Why should addiction medicine be an attractive field for young physicians?

Aims The clinical practice and science of addiction are increasingly active fields, which are attracting professionals from diverse disciplines such as psychology and neurobiology. Our scientific knowledge of the pathophysiology of addiction is rapidly growing, along with the variety of effective treatments available to clinicians. Yet, we believe that the medical specialties of addiction medicine/psychiatry are not attracting the interest and enthusiasm of young physicians. What can be done? Methods We offer the opinions of two experience addiction psychiatrists. Results In the US, there has been a decline in the number of psychiatrists seeking training or board certification in addiction psychiatry; about one‐third of graduates with such training are not practicing in an addiction psychiatry setting. There is widespread neglect of addiction medicine/psychiatry among the medical profession, academia and national health authorities. This neglect is unfortunate, given the enormous societal costs of addiction (3–5% of the gross domestic product in some developed countries), the substantial unmet need for addiction treatment, and the highly favourable benefit to cost yield (at least 7:1) from treatment. Conclusions We believe that addiction medicine/psychiatry can be made more attractive for young physicians. Helpful steps include widening acceptance as a medical specialty or subspecialty, reducing the social stigma against people with substance use disorders, expanding insurance coverage and increasing the low rates of reimbursement for physicians. These steps would be easier to take with broader societal (and political) recognition of substance use disorders as a major cause of premature death, morbidity and economic burden.     

Reflections and best practice recommendations for interdisciplinary working: a case study on the identification of the determinants of addiction from the Addiction and Lifestyles In Contemporary Europe Reframing Addictions Project (ALICE RAP)

BackgroundStudies on the determinants of the development of substance use disorders are done across the natural and social sciences. However, research is usually conducted by individual or closely related disciplines, so evidence on how determinants from multiple disciplines interact has been slow to emerge. Within the Addiction and Lifestyles In Contemporary Europe Reframing Addictions Project (ALICE RAP) we have brought together experts from 11 disciplines in the humanities, social sciences, and medical sciences to identify the determinants of risky and harmful substance use and gambling. The aim of the present research was to explore ALICE RAP members' experiences of working with experts from diverse disciplines and to make recommendations for best practice in such projects.MethodsAll members of the interdisciplinary team (n=18) were invited to participate in an in-depth interview in early 2014. The aims were to explore the experience of working in an interdisciplinary manner; to identify perceived strengths and weaknesses in our approach; and to provide recommendations for future interdisciplinary collaborations. 14 experts representing ten disciplines participated. Data were analysed thematically, and recommendations were derived from suggestions made by participants and discussion among the authors on the implications of the findings. Ethics approval for this study was granted by the ScHARR Research Ethics Review Committee at the University of Sheffield in December, 2013.FindingsParticipants described five strengths of our approach: inclusiveness, generosity and openness of experts, flexibility, diverse forms of interaction, and the value of a dedicated facilitator or facilitators. However, the widespread view was that we had underestimated the challenge of interdisciplinary working. Specific concerns were diverse approaches to scientific evidence, differing expectations of discipline experts, ambiguity of some disciplines' roles, conflicting commitments, and a vague project endpoint. We have identified four recommendations for interdisciplinary working: to have a blueprint for the integration of disciplines, to be clear about expectations, to ensure resilient project staffing, and to talk frequently to maintain relationships and progress work.InterpretationInterdisciplinary work is challenging; however, our recommendations for interdisciplinary collaborations, identified through expert interviews, could be used to facilitate the successful planning and management of interdisciplinary work in the specialty of substance use disorders and beyond.FundingThe European Union's Seventh Framework Programme for Research, technological development and demonstration under grant agreement no 266813: ALICE RAP.     

Future medicine shaped by an interdisciplinary new biology

The projected effects of the new biology on future medicine are described. The new biology is essentially the result of shifts in the way biological research has progressed over the past few years, mainly through the involvement of physical scientists and engineers in biological thinking and research with the establishment of new teams and task forces to address the new challenges in biology. Their contributions go well beyond the historical contributions of mathematics, physical sciences, and engineering to medical practice that were largely equipment oriented. Over the next generation, the entire fabric of the biosciences will change as research barriers between disciplines diminish and eventually cease to exist. The resulting effects are starting to be noticed in front-line medicine and the prospects for the future are immense and potentially society changing. The most likely disciplines to have early effects are outlined and form the main thrust of this paper, with speculation about other disciplines and emphasis that although physics-based and engineering-based biology will change future medicine, the physical sciences and engineering will also be changed by these developments. Essentially, physics is being redefined by the need to accommodate these new views of what constitutes biological systems and how they function.     

Introduction to health economics and decision-making: Is economics relevant for the frontline clinician?

In a climate of escalating demands for new health care services and significant constraints on new resources, the disciplines of health economics and health technology assessment (HTA) have increasingly been turned to as explicit evidence-based frameworks to help make tough health care access and reimbursement decisions. Health economics is the discipline of economics concerned with the efficient allocation of health care resources, essentially trying to maximize health benefits to society contingent upon available resources. HTA is a broader field drawing upon several disciplines, but which relies heavily upon the tools of health economics and economic evaluation. Traditionally, health economics and economic evaluation have been widely used at the political (macro) and local (meso) decision-making levels, and have progressively had an important role even at informing individual clinical decisions (micro level).The aim of this paper is to introduce readers to health economics and discuss its relevance to frontline clinicians. Particularly, the content of the paper will facilitate clinicians' understanding of the link between economics and their medical practice, and how clinical decision-making reflects on health care resource allocation.     

How psychological framing affects economic market prices in the lab and field

A fundamental debate in social sciences concerns how individual judgments and choices, resulting from psychological mechanisms, are manifested in collective economic behavior. Economists emphasize the capacity of markets to aggregate information distributed among traders into rational equilibrium prices. However, psychologists have identified pervasive and systematic biases in individual judgment that they generally assume will affect collective behavior. In particular, recent studies have found that judged likelihoods of possible events vary systematically with the way the entire event space is partitioned, with probabilities of each of N partitioned events biased toward 1/N. Thus, combining events into a common partition lowers perceived probability, and unpacking events into separate partitions increases their perceived probability. We look for evidence of such bias in various prediction markets, in which prices can be interpreted as probabilities of upcoming events. In two highly controlled experimental studies, we find clear evidence of partition dependence in a 2-h laboratory experiment and a field experiment on National Basketball Association (NBA) and Federation Internationale de Football Association (FIFA World Cup) sports events spanning several weeks. We also find evidence consistent with partition dependence in nonexperimental field data from prediction markets for economic derivatives (guessing the values of important macroeconomic statistics) and horse races. Results in any one of the studies might be explained by a specialized alternative theory, but no alternative theories can explain the results of all four studies. We conclude that psychological biases in individual judgment can affect market prices, and understanding those effects requires combining a variety of methods from psychology and economics.     

The relationship of Axis II personality disorders to other known predictors of addiction treatment outcome.

This study evaluated the prevalence of Axis II disorders in substance abuse patients and the relationship between Axis II psychopathology and two other known predictors of adverse addiction treatment outcomes, i.e., Axis I psychiatric comorbidity and illegal drug use, specifically cocaine. 232 patients with cocaine and/or alcohol dependence were admitted to either inpatient or outpatient addiction recovery programs at Carrier Foundation, a nonprofit, private-pay hospital in New Jersey. Axis II disorders were more prevalent in cocaine than alcohol dependence and in patients with Axis I psychiatric comorbidity. When all three predictors were evaluated in one prediction model, the combination of Axis I and II psychopathology was the best predictor of a return to substance use at one year post-treatment, compared to the three factors alone. These findings highlighted the importance of the interrelationship of the relative prognostic value of three known predictors of addiction treatment.     

Under what conditions is it ethical to offer incentives to encourage drug‐using women to use long‐acting forms of contraception?

Aims To stimulate debate by examining ethical issues raised by Project Prevention, a US‐based organization that offers $US300 to addicted individuals who agree to either undergo surgical sterilization or use long‐acting forms of contraception. Method An analysis of key ethical questions raised by Project Prevention. Results The important issues for debate are: (i) what are the reproductive rights of drug‐using women; (ii) does a substantial cash incentive undermine the ability of addicted women to make free and informed decisions about long‐term contraception; and (iii) how can we best assist addicted women to access good reproductive health care and obtain treatment for their addiction? Conclusions We need more research on ways in which small non‐cash incentives for reversible methods of contraception could be used in a morally acceptable and effective way to promote the sexual, reproductive and general health of addicted women.     

Addiction and its sciences-philosophy

Philosophers have been writing about addiction continually since the 1990s, and a number of much older, broader philosophical theories are of direct relevance to the study of addiction. Yet the developments in the philosophical study of addiction have seldom been incorporated into the science of addiction. In this paper I focus upon two issues in the scientific literature: the disease classification of addiction and the claim that addictive behaviour is compulsive. While each of these views is open to debate on empirical grounds, there is a long history of philosophical work which must be engaged if these claims are to be justified in a philosophical sense. I begin by showing how the conceptual work of philosophers such as Boorse and Nordenfelt can be used to critique the claim that addiction is a disease. Following this, I demonstrate how deep philosophical concepts of freedom and willpower are embedded into scientists' claims about compulsion in drug addiction. These concepts are paradoxical and difficult, and they have consumed numerous contemporary philosophers of mind, such as Audi, Arpaly, Frankfurt, Mele, Wallace and Watson, among many others. I show how problems can arise when scientists sidestep the work of these philosophers, and I explain where scientists should seek to include, and sometimes exclude, philosophical concepts. CONCLUSIONS: Many philosophical concepts and theories can be of use to addiction science. The philosophical work must be understood and acknowledged if the science is to progress.     

Should the Reorganization of Addiction‐Related Research Across All the National Institutes of Health Be Structural?—The Devil Is Truly in the Details

The recent proposal to dissolve the National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse and create a new institute for substance use, abuse, and addiction will require significant effort by the staff of both institutes, the Advisory Councils, and outside experts to overcome complex challenges that could threaten its success. Although integration of the grants portfolios can be achieved, harmonization of goals and policies related to legal use of alcohol versus illegal consumption of drugs will present serious challenges. Consolidating the infrastructure of the 2 existing institutes would entail avoiding encroachment on grant funding. A new institute for substance use, abuse, and addiction would require an enormous amount of cooperation from other institutes as the portfolios of research on alcohol, tobacco, and other drug abuse should logically be transferred to the new institute. In the near term, a structural reorganization would be less efficient and more costly than the individual institutes are currently. Increasing efficiency and reducing costs over time will necessitate careful strategic planning. Success in this difficult task would be made easier and less costly by first implementing carefully placed building blocks of increasing functional reorganization. The newly created institute should increase opportunities for specialization within disorders of addiction, attract new leadership, and build a novel strategic plan that will energize scientists and staff and incorporate ideas of stakeholders to advance the public good in preventing and treating alcohol, tobacco, and all addictions. Attention must be paid to the devil in the details.     

Are there ecological limits to population?

Policy on population and environment in the United States and abroad has been vacillating, unsure of its course; it would be more decisive if the several disciplines could agree on the nature of the problems and their urgency. The two disciplines principally concerned are biology and economics, and the contribution of this paper is to identify eight of the many axes or directions on which the methods and traditions of the two are different. For example, the first of the axes runs between contingency and orderly progress, with biology tending to seek out the former and economics the latter; thus biologists can more easily comprehend catastrophes, such as the demise of the dinosaurs or widespread desertification. The third axis concerns indefinite market-driven substitutability, seen by economists as resulting from scientific discovery; natural scientists, including biologists, whose discoveries make possible the substitutions, are skeptical. Axis 7 results from the fact that economics concentrates on goods that are on the market, and so deals with a truncated part of the commodity cycle, while ecology aims at the whole; because goods disappear from economic statistics once they pass into the hands of consumers many of their ecological effects are invisible. I believe that from similar further study of the two disciplines a common set of policy recommendations will ultimately emerge.     

The economics of ideas and intellectual property

Innovation and the adoption of new ideas is fundamental to economic progress. Here we examine the underlying economics of the market for ideas. From a positive perspective, we examine how such markets function with and without government intervention. From a normative perspective, we examine the pitfalls of existing institutions, and how they might be improved. We highlight recent research by us and others challenging the notion that government awards of monopoly through patents and copyright are "the way" to provide appropriate incentives for innovation.     

How can we conceptualize behavioural addiction without pathologizing common behaviours?

Following the recent changes to the diagnostic category for addictive disorders in DSM‐5, it is urgent to clarify what constitutes behavioural addiction to have a clear direction for future research and classification. However, in the years following the release of DSM‐5, an expanding body of research has increasingly classified engagement in a wide range of common behaviours and leisure activities as possible behavioural addiction. If this expansion does not end, both the relevance and the credibility of the field of addictive disorders might be questioned, which may prompt a dismissive appraisal of the new DSM‐5 subcategory for behavioural addiction. We propose an operational definition of behavioural addiction together with a number of exclusion criteria, to avoid pathologizing common behaviours and provide a common ground for further research. The definition and its exclusion criteria are clarified and justified by illustrating how these address a number of theoretical and methodological shortcomings that result from existing conceptualizations. We invite other researchers to extend our definition under an Open Science Foundation framework.     

Food addiction and bariatric surgery: a systematic review of the literature

Emerging research suggests that rates of food addiction are high among individuals seeking bariatric surgery, but little is known about associated features and the prognostic significance of pre‐operative food addiction. Thus, this article provides a systematic review and synthesis of the literature on food addiction and bariatric surgery. Articles were identified through PubMed and SCOPUS databases, resulting in a total of 19 studies which assessed food addiction among pre‐bariatric and/or post‐bariatric surgery patients using the Yale Food Addiction Scale. Most studies were cross‐sectional, and only two studies prospectively measured food addiction both pre‐operatively and post‐operatively. The presence of pre‐surgical food addiction was not associated with pre‐surgical weight or post‐surgical weight outcomes, yet pre‐surgical food addiction was related to broad levels of psychopathology. The relationship between food addiction and substance misuse among individuals undergoing bariatric surgery is mixed. In addition, very few studies have attempted to validate the construct of food addiction among bariatric surgery patients. Results should be interpreted with caution due to the methodological limitations and small sample sizes reported in most studies. Future rigorous research with larger and more diverse samples should prospectively examine the clinical utility and validity of the food addiction construct following bariatric surgery.     

Drug Interactions between Antiretroviral Medications and Medications Used in the Treatment of Drug Addiction: Research Needs

Today substance dependence is one of the major public health problems in the world with millions of people abusing legal and illegal drugs. In addition, almost one‐third of the world's population suffers with one or more infections. Both drugs of abuse and infections are associated with serious medical and health consequences, some of which may be exacerbated by the occurrence of pharmacokinetic and/or pharmacodynamic interactions between medications used in the treatment of these conditions when they co‐occur. This review briefly discusses issues surrounding clinical management related to drug interactions experienced by substance abusing patients. The emphasis of this paper is on the research needed to further study the extent, nature, and underlying molecular/genetic mechanism(s) of interactions between drugs of abuse, medications used in the treatment of drug addiction, and co‐occurring infections. (Am J Addict 2009;19:96–100)     

Disentangling the Role of Astrocytes in Alcohol Use Disorder

Several laboratories recently identified that astrocytes are critical regulators of addiction machinery. It is now known that astrocyte pathology is a common feature of ethanol (EtOH) exposure in both humans and animal models, as even brief EtOH exposure is sufficient to elicit long‐lasting perturbations in astrocyte gene expression, activity, and proliferation. Astrocytes were also recently shown to modulate the motivational properties of EtOH and other strongly reinforcing stimuli. Given the role of astrocytes in regulating glutamate homeostasis, a crucial component of alcohol use disorder (AUD), astrocytes might be an important target for the development of next‐generation alcoholism treatments. This review will outline some of the more prominent features displayed by astrocytes, how these properties are influenced by acute and long‐term EtOH exposure, and future directions that may help to disentangle astrocytic from neuronal functions in the etiology of AUD.     

Food Addiction and Bulimia Nervosa

In individuals with obesity and binge eating disorder (BED), eating patterns can show addictive qualities, with similarities to substance use disorders on behavioural and neurobiological levels. Bulimia nervosa (BN) has received less attention in this regard, despite their regular binge eating symptoms. The Yale Food Addiction Scale (YFAS) was developed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for substance use disorders, and food addiction can be diagnosed when at least three addiction symptoms are endorsed and a clinically significant impairment or distress is present. Although the prevalence of food addiction diagnoses is increased in individuals with obesity and BED, recent studies which used the YFAS showed that there are also individuals with normal weight who can be classified as being ‘food addicted’. Based on self‐reported eating disorder symptoms, women with current (n = 26) or remitted (n = 20) BN, and a control group of women matched for age and body mass index (n = 63) completed the YFAS and other measures. Results revealed that all patients with current BN received a food addiction diagnosis according to the YFAS while only six (30%) women with remitted BN did. None of the women in the control group received a food addiction diagnosis. Results provide support for the notion that BN can be described as addiction‐like eating behaviour and suggest that food addiction most likely improves when BN symptoms remit. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.     

Heroin addiction in Bahrain: 15 years experience

This study describes the development and outcome of a new treatment programme for the management of heroin addiction in Bahrain. The problem reached its peak in the early 1980s with several reported deaths and with the involvement of many disciplines in the overall response. In 1983, treatment of all addicts was restricted by law to the government psychiatric hospital. The newly established specialized drug unit was overwhelmed by the number of patients seeking treatment. The lack of sufficient resources and suitably trained staff forced the unit to adopt an outpatient maintenance therapy approach for most of its clients. In 1987, a new comprehensive treatment programme was introduced that relies on a clear philosophy, safe detoxification (using objective scales for withdrawal manifestations) rather than maintenance therapy, followed by psychological and social rehabilitation. A national committee for drug addiction leas formed and an intensive programme of education was started at ail levels. The results indicate an initial increase at inpatient level but a marked drop of outpatient attendance. The use of the Opioid Objective Withdrawal Manifestations Scale (OOWMS) revealed that only a small number of our patients developed moderate or severe signs of withdrawal that required detoxification, and the rate of dispensed controlled medication was reduced by 99%. The effect of this approach is discussed, with special reference to the need for a collaborative effort from all disciplines in planning, implementing, continuously evaluating and modifying the national programmes for handling the serious problem of addiction.