Addiction research

ADDICTION RESEARCH: BELIEVING IN THE FUTURE1 In global terms, alcohol research has been a growth industry in recent decades, as Tom Babor has recently documented, and I believe the same could be documented for illicit drugs, forpsychopharmaceuticals, and for tobacco research. There is some reason to believe that the periodof growth may be coming to an end. The growth has, in any case, been highly uneven. Research on the problems of alcohol, tobacco and other drugs has been largely concentrated in Northern Europe and the English-speaking countries -- the countries that Harry Levine has referred to as"temperance societies". While there has been some growth also in other developed societies, themap of research effort remains highly uneven.
By and large, the research effort has been mission-oriented, that is, funding it has been motivated by the promise that it will point to or test solutions of health or social problems.
Certainly in Ontario, and perhaps also elsewhere, there is a greater insistence these days that theresearch should have a pay-off in useful and usable information. In my view, as researchers weshould and indeed must be responsive on the issue of relevance. But I think it is also appropriatefor us to insist that some of our effort be directed to longer-term goals, to knowledge which maychange how we think about a problem, as well as knowledge which is predicated on existing waysof thinking about the problem.
A discussion of future needs and opportunities in addiction research, then, is appropriately set in a frame of the present situation and trends in alcohol, tobacco and other drug problems.
Let me start by enumerating some of those trends. To know how to interpret what you see on thehorizon, it helps to know where you stand and where you are heading.
We have seen a substantial net growth in the use of psychoactive drugs in recent decades,although for some drugs in some places -- including tobacco and alcohol -- the rate of usehas stabilized or is slowly declining.
We have seen a substantial erosion of control regimes for psychoactive drugs, particularlyfor plant-derived drugs.
We are witnessing substantial and in some places increasing social responses to drug use.
The form of these responses have been varied: at the political level, within the community, 1Presented at the 1994 National Addiction Centre Scientific Meeting, "Addiction ResearchHorizons: An International One Day Conference", London, England, 28 April 1994.
within the family, and through mutual help movements.
Reflecting an interaction of rates of use and problems with increased social responses,rates of experience of addiction have been rising.
There has been a growth in use of harm reduction strategies -- decoupling the use of thedrug from the potential harm from drug use -- but these strategies are often in competitionwith an addiction model of drug use.
In many societies, there has been a substantial growth in the provision of treatmentspecifically for alcohol and illicit drug addiction. There is frequently a coercive element Now let us consider each of these trends in turn and some of the research agendas which Let us start with the substantial net growth in psychoactive substance use. As I have already noted, the growth has not been everywhere and on all fronts. In particular, tobacco andalcohol consumption have both dropped somewhat in many industrial countries in the last decade.
But on a global basis, psychoactive substance use seems to have been growing, and certainly theillicit traffic in substances covered by the international drug conventions has grown.
One issue for research underlined by these trends is the study of interactions and combinations in drug use. There is a striking passage in Marlatt and Gordon's Relapse Preventionwhere they take one of their clients through his daily round of drug use, titrating against eachother coffee, marijuana, tobacco, alcohol and prescription drugs. While we know a fair bit aboutthe overlap of user populations for different psychoactive drugs, we know very little about whenand how drugs are used together at the same time or in succession. We know anecdotally that useof one drug may provide a cue for use of another, so that tobacco smoking may be more likelyor more heavy in a drinking situation, but it is time that our knowledge of these patterns ofinteraction and combination is put on a more systematic basis.
Let me turn now to the erosion of control regimes for psychoactive drugs. There are four main methods presently in use for controlling the market in psychoactive drugs. One is outrightprohibition, as for example is true in most places for LSD. A second method is through aprescription control system, where particular health professions control and ration access tosupply. A third, used mostly for alcohol, is a specific control structure for the drug, with thegovernment sometimes monopolizing some aspects of the supply. And the fourth is a licensingsystem for manufacture and distribution, often with very little differentiation from the licensingsystem for food or other commodities. Crosscutting particularly the third and fourth methods maybe a pricing policy, where the level of taxes or prices may be set in part to discourage use.
These control mechanisms have been put in place mostly in the last century, and have often served as effective restraints on a free market in psychoactive drugs. Now many of them arebeing eroded. In part, the erosion reflects the growth of international travel and trade. This makes, for instance, the operation of the international narcotics control regime less and less successful. In part, the erosion is a byproduct of the triumph of free market ideologies and of thedoctrine of consumer sovereignty -- the idea that consumer choice should be limited only byability to pay. The vanloads of alcoholic beverages now coming back to Britain from Sainsbury's and other supermarkets in Calais are a local example of the erosion of a control regime -- in this case, Britain's high-tax policy on alcohol. In Canada we recently experienced a more dramaticfailure of a control policy, when the extent of cigarette smuggling from the U.S. forced theCanadian government to reduce cigarette taxes to a point where the cost of a pack of cigarettes We presently understand entirely too little about how, under what circumstances, and to what extent these control systems work. Even with respect to pricing policies, where there is areasonably strong tradition of economic work on elasticity, too little is known about thedifferential effects of price on different subpopulations and in different circumstances. Thealcohol literature has seen a flowering in the last 15 years of studies of the effects of aspects ofalcohol control. Ironically, the strongest studies in this tradition are of the effects of policychanges which weakened controls on availability. Whatever may be the public health significanceof the erosion of control regimes, from a researcher's point of view these changes offer unusualopportunities for quasi-experimental studies of the impact of controls. This tradition of studiesof the effects of control measures needs to be strengthened and, as opportunities arise, broadenedin its application to other psychoactive drugs.
The erosion of control measures also underlines the need for explanatory research on public attitudes to control measures. The erosion of market controls does not necessarily reflectpublic sentiment. In Ontario, in fact, we have found that public support for the present level ofrestrictions on availability remains strong even while the ratchet-mechanism of market and fiscalpressures wears them away. But it is clear that in the long run control structures for psychoactivedrug markets must be responsive to public opinion, and we need to know more about what liesbehind public attitudes in this area, and how such attitudes may be changed.
A third trend for discussion is the substantial and often increasing social responses to drug use. These can take many forms. One form is that of overt sociopolitical movement for changesin criminal laws or government policies, such as Mothers Against Drunk Driving, or the moretop-down approach of Gorbachev's 1985 alcohol reforms. Religion-based movements such asIslamic fundamentalism can also be seen as falling into this category. While there has been bynow very substantial work on the social history of the 19th and early 20th century temperancemovement in a number of countries, there is a need for more social historical research coveringa wider range of organizations and movements against drug problems, and particularly a need for more research work on the functioning and social effects of contemporary organizations andmovements.
A second form of social response to drug use is directed at self- and mutual help rather than directly at social change. Since the flowering of the Washingtonians in the 1840s, theexperience of addiction to drugs has been a fertile ground for the organization both of lay- organized mutual-help movements and of professionally guided self-help movements. While these movements have conventionally been treated in the research literature as treatment modalities,joining one is usually both less than and more than an episode of treatment. The nature andfunctioning of the movements and the conditions under which they flourish are properly topics A third form of social response to drug use takes the form of informal reactions to problematic drug use by family members and friends of the user. In the U.S., at least, we found evidence that such informal reactions to drinking had increased during the 1980s, in a period inwhich the per-capita consumption of alcohol had been declining. The task of mapping theseinformal efforts at social control and understanding the conditions for their effectiveness has only been begun for alcohol, and even more remains to be done for other drugs. A next step willinvolve experiments in strengthening and backing up these informal reactions to problematic druguse.
A fourth form of social response to drug use lies at the level of community institutions and organizations. Problems of drug use usually impact in the first instance on the family andassociates of the drug user, but in the second instance on the peace and wellbeing of thecommunity. There is a nascent tradition of evaluated community action studies, particularly inthe alcohol field, which needs to be nurtured and strengthened.
From considering these several kinds of social responses to drug use, let us turn to a fourth trend, towards increases in the rate of experience of addiction. In North America at least, thistrend can be seen statistically for alcohol addiction in two forms: in reported rates of dependence-related experiences in general population surveys, and in the increasing membership in groups likeAlcoholics Anonymous. There is evidence, also, of an increase in the experience of tobaccoaddiction, primarily as a result of redefining a tobacco smoking habit as an addiction.
You will notice that my emphasis in defining addiction is on experience and on popular conceptions. In the society at large, it seems to me that addiction has retained a fairly constantcore meaning. At the heart of it is an experienced inability to control drug-using behaviour, andalso often an experience of inability to control one's life because of this. I think we need to takethis experience more seriously and to study and understand it better. With all the clarification thatconcepts like the dependence syndrome have brought to the field, they have not encouraged ussufficiently to examine the empirical relations between the dimensions the concepts bring together.
Empirically, how do withdrawal and tolerance relate to the experience of impaired control of druguse, and how for that matter does continued use despite harm, or the dropping of usual pleasuresand activities, relate to it? My plea here is to take the phenomenology of experience seriously asa matter for study.
Addiction is an experience, but it is also a classification assigned to others. One finding of the WHO study of the cross-cultural comparability of diagnostic terms is how widespread indifferent societies an extremely negative connotation of addiction or alcoholism is. The social positioning of addiction in the U.S. can be gathered by the current struggle of tobacco manufacturers to avoid their product being defined as addictive -- a more derogated term, in theirview, than simply being a prime cause of cancer and other diseases. We still understand too littleabout the structure of popular conceptions of addiction and their relation to other governing images by which problematic behaviour is defined and understood. Scientific and professional definitions of dependence or addiction should not be constructed in ignorance of or isolation fromthe structure of everyday thinking in the society.
A fifth trend has been towards the adoption of harm reduction strategies to reduce the levels of problems related to psychoactive drug use. The most noted aspects of this trend havebeen the adoption of such measures as needle exchanges and methadone maintenance to reduce the risk of HIV infection from opiate use. But the strategy has also been applied in a much widerframe. Nicotine patches and nicotine chewing gum are examples of the application of a harmreduction strategy to tobacco smoking. In the field of alcohol problems, there has been a longhistory of strategies that reduce the harm from drinking without necessarily changing the drinkingbehaviour -- of "making the world safer for (and from) drunks". It should be noted thatcountermeasures which do not attempt to influence the drug use behaviour potentially leave anaddiction to the drug in place, and the strength of addiction as a governing image means that harmreduction strategies are always somewhat in question. Nicotine patches, for instance, have beenapproved in North America only for use in a tapering-off procedure lasting a few weeks, whilea straightforward harm reduction perspective would see their indefinite use as preferable tocontinued cigarette smoking.
A clear imperative for research from a harm reduction perspective is to improve our measurements of drug-related harm. In alcohol epidemiology, there has long been a tradition ofdirect measurement of the problems related to drinking. But for illicit drugs, asking about andanalyzing reports of harm related to the drug use has been rare; the pattern of drug use has beenregarded as the problem in itself. Sustained work is needed on the measurement of different kindsof harm in different frames - for the individual, for family members and friends, for thecommunity, and so on - for different drugs and circumstances.
A second need is for research which maps in detail the relation between particular consumption patterns and specific problems or harm, taking into account the circumstances ofconsumption. Such risk curves for consumption have long been used by medical epidemiologywith respect to potential chronic health consequences of consumption, and analogous curves havebeen used in the drinking driving literature to map the relation between the amount of alcohol inthe blood on a specific occasion and the risk of traffic casualties. But such approaches need tobe applied systematically on a much broader scale for the whole range of problems and for allclasses of psychoactive drugs. From the perspective of developing strategies for harm reductionor prevention, careful attention should be paid to the influence of the circumstances of andfollowing drug use.
The logical further development of this line of work, in fact, is toward controlled trials of harm reduction interventions based on findings about the relations of consumption patterns, circumstances and particular types of harm. Such approaches hold particular promise where the drug user has a vested interest in avoiding the problem -- as with victimization by crime, or withcasualties.
The last trend for discussion is the increase in alcohol- and drug-specific treatment.
Substantial provision of such treatment has been a relatively recent phenomenon in most societiesproviding it, a phenomenon of the last 20 or 25 years. By and large, such drug-specific treatment services have been focused on alcohol or illicit drugs or both, while treatment for tobacco or prescription psychoactive dependence or problems, if provided at all, has been primarily a taskfor general health or therapy services.
While the study of the effectivenes of specific alcohol and drug treatment modalities is well under way, the study of the functioning of alcohol and drug services as a treatment system, andof their relation to other health and social service systems, is not yet well developed. In my view,we need not only to push such research forward, but to use findings from it to inform our furtherresearch on treatment modalities.
In a North American context, for instance, it seems clear that referral between agencies and systems occurs much less often than might be expected from treatment ideologies. This posesa challenge for policy and for action-oriented research: either we must develop and infuse intothe system effective methods of referral, or we need to rethink the emphasis on a continuum andprogression of care in present ideologies of the treatment system.
Another issue posed for treatment research by studying the actual social ecology of treatment is the influence of coercion on the treatment process. We have usually thought aboutthis dimension in terms of a dichotomization between voluntary and compulsory treatment. Infact, however, most people coming to treatment for alcohol or drug problems are under informalpressure from family or friends, and often also more formal pressure from the workplace. In theU.S., almost all in public treatment for drug problems, and probably a majority of those in publictreatment for alcohol problems, are there under pressure from the criminal courts, ofteninformally as a condition of probation rather than through a formal diversion procedure. This isless true in Canada, though treatment under court pressure is not uncommon. But most of thealcohol treatment outcome literature, and much of the equivalent drug literature, assumes avoluntary contract between the therapist and the client. We urgently need to infuse into theliterature on treatment modalities and outcomes a detailed attention to these real-world conditionsof treatment.
In the same vein, there is a need to start on the process of thinking and research concerning the actual use in treatment and prevention of potential breakthroughs inpsychopharmacology and molecular biology. Experience with pharmacological agents in alcoholand drug treatment teaches us that establishing the therapeutic efficacy of the agent is only the first issue of a series to be faced. A drug or other intervention which makes a temporary change indesire for drug use may often not in fact be used by the client. If the intervention makes a more lasting change, there will be serious ethical issues to be faced. Where an intervention detaches continued drug use from the risk of harm, it may be seen as fostering denial, and therapists maythus be reluctant to use it. These cautions are suggested, for instance, by the complex history ofuse -- or nonuse -- of disulfiram for alcohol dependence, of methadone for opiate dependence, and of propylthiouracil (PTU), a thyroid drug, for alcoholic liver disease. These experiences suggest that future research efforts in psychopharmacology and molecular biology need to becoupled with work on the eventualities of use of the innovations in human societies.
In this presentation, I have briefly considered a variety of research questions raised by some current trends in alcohol, tobacco and other drug problems. In terms both of societal needsand of interesting research questions, addictions research has a promising future. In a field which operates at the interstices of many important social issues and institutions, we have the opportunityto build a science which addresses significant scientific questions, and at the same time contributesto the solution of pressing practical problems in our societies. As scientists, we could not ask foranything more.



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