The appliance of science

The first pan-European multi-disciplinary conference on addictive behaviours looked at how science and research can translate into policy and practice. DDN reports

‘Addictions, above all, are a health problem – but they can’t be solved by health interventions alone,’ state secretary to the Portuguese Ministry of Health, Fernando Leal Da Costa, told delegates at the opening session of Lisbon Addictions 2015. Portugal’s groundbreaking policy of decriminalising personal drug possession was one that other countries could learn from, he said. ‘We acknowledge that it’s not perfect, but we do believe that it’s a sensible and rational approach.’

The policy had been fully monitored and the plan was now to further develop it in cooperation with other Portuguese-speaking countries, he said – ‘a way to expand our interventions’. However, Portugal was struggling with the reintegration of people who’d had drug problems, particularly in terms of employment opportunities in the current economic climate, and was aware that more needed to be done in terms of prevention. ‘Much more also needs to be done, Europe-wide, on the issue of alcohol,’ he stated. ‘We need to revisit the alcohol strategy in terms of the whole continent.’

Even defining addiction could present problems, said Robert West of University College London. ‘It’s a complicated subject, with a lot of different components. But we do know that it arises out of learning, which means there’s a huge overlap between neuroscience and behavioural science.’ The question was how to get the best return on investment – not necessarily in monetary terms, but in terms of benefit to society, he said.

There was a tendency for people in the field to compartmentalise their favourite model of addiction, he pointed out, whether that related to ‘reward, self-medication, relief from withdrawal, habit, acquired drive’ or other models. ‘All of them have some validity, and in terms of interventions we can educate, persuade, coerce, incentivise, enable, restrict and more. They’re broad-brush things, but all will be relevant at some point.’

For any behaviour to occur, three things had to be in place, he said – capability, motivation and opportunity. ‘So if we do ever manage to crack the problem of addiction, that would be quite a scary thought – it means someone will have a very powerful behaviour-change tool at their disposal.’ Policies and interventions could be informed by neuroscience, he said, and it was now time for a ‘major review of the research strategy underpinning the approaches we take to combatting addiction. I don’t mean a bunfight about where the money goes – just an analysis of how we do it.’

‘There are many levels of ongoing research that are essential to understanding addiction and effective interventions,’ added neuroscientist Marina Picciotto of Yale University. ‘But we do need research that determines the efficacy of the interventions out there.’ One example was Alcoholics Anonymous, she told delegates. ‘Are there options that aren’t being used because there’s this dominant paradigm?’

Neuroscience research had permeated the study of addiction, and public policy, to the extent that it was now ‘practically invisible’ she said, and had been highly successful in developing new interventions. ‘It can identify the primary molecular targets for drugs of abuse, as well as defining circuits, neurotransmitter systems and the really long-term changes that can explain cue and use and so on. It’s even defined the exact molecules in the brain that nicotine binds to.’

However it was important to remember that neurobiology and holistic approaches were not mutually exclusive, she stressed. ‘We do need hybrid neurobiological and behavioural interventions based on what we know about neural systems, and we need to get beyond the “one pill will fix it” philosophy.’

‘The world is a very complicated place,’ agreed Robert West. ‘It’s about finding the right angles to approach things from.’

On the issue of whether treatment was even the correct first response to addiction problems, Mark Kleiman of UCLA’s Luskin School of Public Affairs told the conference that ‘most people who use habit-forming substances do not go on to form bad habits, with the exception of nicotine. With all other substances, rates from initiation to problem use are low. Addiction is not a characteristic property of the use of addictive materials, and I’d also say that most people recover spontaneously – that is, without formal interventions.’

However, spontaneous recovery was usually a reaction to outside events, he stressed – ‘getting a job, pressure from loved ones, things like that. Most people who seek help do so through voluntary self-help programmes such as AA, and the outcomes tend to be just as good as paid treatment. So if you’re a clinician the people you’re going to see are those who didn’t recover spontaneously. But spontaneous recovery is based on a range of external conditions, so we need to make sure the right external conditions are in place.’

This was very different from addiction being a chronic relapsing disorder, he argued, ‘so when we require treatment of someone who’s been arrested for drug possession, for example, we’re making a mistake that can start a cycle of unjustified and ineffective punishment. Involuntary treatment should not be a first resort, as it is in too many cases. If one definition of addiction is to continue to use in the face of adverse circumstances – for example, very intense enforced treatment – then your diagnosis is made. In the US a very large percentage of people with drug problems are under criminal supervision.’

However, the outcomes of treatment were ‘multi-dimensional’, he said. ‘One way to think about treatment is to think about the other problems that people have – treatment should be measured by overall outcomes, not just drug outcomes. The goal should be achieving the best available outcomes for people with substance problems, and the people around them, by whatever means.’

‘Do we need treatment as a first response? Yes,’ countered Gabriele Fischer of the University of Vienna. ‘It reduces deaths, reduces use, reduces HIV and HCV risk and saves money. Some say, “why spend the money when people relapse?” Well, relapse isn’t limited to drug treatment – it also applies to the treatment of chronic conditions like diabetes, asthma, hypertension. And when people talk about dependence on methadone, remember that people are also dependent on drugs for diabetes, asthma, hypertension. What’s unique in our population is the percentage of people who are ending up in the criminal justice system.’

In terms of whether those polices would change, Mark Kleiman told the conference that, ‘I’m sure cannabis will be fully legalised in the US in ten years. But I’m only moderately happy about that. If you were going to pick a country to legalise cannabis in you wouldn’t choose one where the courts had ruled that any legal activity can be advertised and promoted without limits. I think we will lurch from prohibition – which admittedly doesn’t work – to the most extreme version of legalisation, and you only have to look to alcohol to see the model for what we’ll have.’

When it came to whether academics should even try to influence policy, views varied, said Linda Bauld of the University of Sterling. ‘It’s very context-specific, and we have to show that there’s a positive impact on society or the economy.’ A great deal had been written about the gaps between research and policy, she said, and addictions research often responded to policy ambiguity by ‘trying to improve the supply of evidence – but that tends to ignore the importance of other factors. It’s very often a long game.’

Alcohol policy was a case in point, she said, where research findings came up against the power of the drinks industry, government indifference, media hostility, low levels of public awareness and other factors. ‘So research alone isn’t enough, but being an advocate for the evidence certainly helps.’

Research into new psychoactive substances (NPS), however, had helped to both inform policy and practice and challenge myths, said Felix Carvalho of the University of Porto. ‘Those myths included that NPS are safer than street drugs, contain fewer contaminants and are associated with lower health risks – general addiction pathways are the same.’ However, researchers tended to publish their findings in scientific journals, he said. ‘And politicians don’t read those. So we do need the mass media.’

Things had changed dramatically for people with addiction issues in the US over the last few years, said former White House ‘drug czar’ Keith Humphreys, now at Stanford University’s School of Medicine (DDN, June 2012, page 16). The 2010 Affordable Care Act – or ‘ObamaCare’ – had defined mental health and substance use as an ‘essential healthcare benefit’, as well as allowing parents to keep their children on their private insurance plans until the age of 26 – and ‘almost all substance use problems have an onset early in life,’ he said. ‘So access to, and insurance coverage for, substance treatment has never been better in the US.’

This meant the law was driving the integration of previously ghettoised specialities into the mainstream, ‘where they belong’, he said. ‘But is science supposed to define policy by itself? Science is very good at identifying emerging problems, and it can also suggest new polices and determine whether existing policies are working. But it can’t tell us what we care about.’ Ultimately, politicians had to make value judgements, he said. ‘You can’t fund everything. Just because we’re experts in science doesn’t make us experts in government.’

The main routes through which findings eventually translated into policy were media coverage, professional and grass-roots organisations, scientists engaging the bureaucracy – both formally and informally – and scientists in policy-making roles themselves, he said.

‘US healthcare policy around substance use has changed dramatically. Scientists did not cause that to happen – they shouldn’t expect to, and no one should expect them to. But when you have political will combined with good research and evidence – that’s when you can really make a difference.’