The 10 most important things known about addiction

Enthusiastic young colleagues new to the addiction treatment field not infrequently ask a question something like this: 'What are the most important things I need to know about addiction and how to treat it that I can read about over the next month or two?'. This paper documents a list of 10 things about addiction that have emerged over the last three or four decades that form an overview of the most important things known about addiction that I think would be useful for new colleagues to get to grips with quickly as they embark on their career in addiction treatment. It may also be useful for established colleagues to compare with their own list in the ongoing process of freshening up clinical practice and as a prelude to considering the most fruitful areas to research that will bring about the greatest treatment improvements for addicted people. This summary is not intended to be an exhaustive catalogue of addiction treatment knowledge. It focuses upon addiction treatment in dedicated addiction treatment settings and is naturally biased towards the work of key figures in the international field who have had a significant influence on the thinking of our group at the National Addiction Centre (NAC) Aotearoa, New Zealand. If you were limited to listing the 10 most important things known about addiction, would your list be similar to what follows? . . . .

Read Full Text (PDF)

_________________________________________

WHAT WE DO AND DO NOT KNOW ABOUT ADDICTION

truly enjoyed reading Doug Sellman's paper . These types of paper, which summarize the literature briefly and, even more importantly, review it critically, are needed, especially right now, as there are increasing numbers of scientific outlets for papers and it becomes increasingly difficult to gain an overview of the field—not only for young scholars, who have just entered the field, but also for 'old and wise' researchers who have been in the field for a long time. The paper is an eye-opener, not so much because of the discussed empirical evidence for the 10 important insights, but through the combination and order of the 10 things. It makes one think about where we stand and what the next endeavours should be.

However, the question is not whether or not I agree with Sellman on the selection of 10 most important 'things'. Such a list is driven by personal experience, expertise and motivations. In fact, I fully agree with many of his statements; for instance, the neuropsychological processes related to addictive behaviours such as cue-signalling and reactivity, that go outside conscious awareness, the recent trends in thinking about addiction as complex gene–environment interactions and the statement that addictive behaviours occur mainly with other psychiatric disorders—which has huge complications for studying treatment effects. I also agree with the relevance of scrutinizing treatment alliances, and the dynamic developmental interactions between therapist and patient, rather than testing differences exclusively between treatments.

Read Full Text (PDF)

_______________________________________

CAN SCIENCE HELP CLOSE THE TREATMENT GAP?

In his paper, Sellman divides the scientific evidence that impacts treatment for addictions into 10 principles. It is easy to follow and is a most welcome guide for those interested in treatment and a useful translation of scientific evidence for both the specialist and the non-specialist responsible for making decisions related to the funding of services and training of specialists and so on.

The paper marshals evidence against mistaken conceptions about the nature of addiction and the effectiveness of treatment. It is often thought that one episode of treatment is enough and that relapse constitutes failure, conceptions that must be corrected if we want to reduce the treatment gap. This issue is reflected in the statement: 'Addiction is a chronic relapsing disorder in the majority of people who present for help'. To this very interesting review of the issue I would add that treatment should be readily available because, as Sellman correctly states, 'Change takes time'.

Read Full Text (PDF)

_____________________________________________

CULTURE, TREATMENT AND THE CULTURE OF TREATMENT

I read Doug Sellman's distilled wisdom for the next generation with appreciation. I suspect that we, the old men, need the enthusiasm of the young more than they need our wisdom. Cynicism and despair are the concomitants of addiction, and clinicians risk being infected, for our work has many frustrations. Training young doctors (and nurses, psychologists, counsellors) has been one of the joys, an antidote to burnout.

There is a fault line beneath addiction treatment, between the 'moral–spiritual' and the 'empirical, social sciences' traditions. The dominant paradigm is moral–spiritual, in which conversion (the 'epiphany') is the basis of recovery. In so far as therapists can promote change it is slow, fluctuating, and lacks the black-and-white clarity that fits the dominant paradigm. Worse, we are in a bind—we must engender 'hope', while avoiding 'unrealistic expectations'. Unrealistic expectations of cure contribute to frustration in the lives of addicts and their families, and corrupt the practitioners who seek to meet those expectations. Young practitioners, you must avoid the lure of being a charismatic healer; the 'first step' towards helping people is to admit that we are powerless to cure our patients.

Read Full Text (PDF)

_________________________________________

MISSING THE CONTINUUM

Sellman's provocative paper makes several excellent (e.g. 'different psychotherapies appear to produce similar outcomes') and sometimes contentious (e.g. 'compulsive drug seeking is initiated outside of consciousness') points In this commentary, we offer some general reactions to Sellman's paper and then discuss an important area in the addictions field about which little is known.

One of the most important points raised by Sellman, also discussed by Orford is that rivalries between explanatory models seem to have been more important to practitioners and researchers than to clients. Another important point raised by Sellman is that therapists can play a critical role in increasing a client's motivation for change. We found it puzzling, however, that Sellman's paper focused almost exclusively on substance abusers whose problems are severe. Such a focus raises two concerns. First, the references Sellman cites about alcohol problems are decades old, and there are no references to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Data from the NESARC survey suggest that long-term stability of outcomes is achieved by many alcohol abusers, with about equal proportions of abstinent and low-risk drinking outcomes Secondly, Sellman's focus on substance abusers who present for treatment ignores the majority of individuals with alcohol and other drug problems, as they do not seek treatment. In this regard, any comprehensive conceptualization of substance use disorders must apply to all cases, not just those in treatment. This point, made repeatedly by others, including Orford & Edwards , Vaillant , Cahalan and Robins, is best captured in the following statement: 'addiction looks very different if you study it in a general population than if you study it in treated cases';

Read Full Text (PDF)
______________________________________
-

PERHAPS IT IS THE DODO BIRD VERDICT THAT SHOULD BE EXTINCT

Dr Sellman's excellent synthesis and common-sense conclusions regarding the addiction treatment field will doubtless become required reading in many addiction training centres, and deservedly so . However, Professor Sellman makes one point that appears to us to misrepresent some of the evidence and reflects a line of thinking which, if broadly accepted, has some potential to reverse some of the important, and very hard-won, progress we have made in improving the quality of addiction treatment. The premise that 'Different psychotherapies appear to produce similar results', reminiscent of the 'Dodo Bird verdict', overlooks some of the recent evidence and results in some misconceptions. Following Professor Sellman's lead, we will limit ourselves to 10 points, as follows. . . . .

Read Full Text (PDF)

_______________________________________

SCIENCE WILL UNCOVER THE MYSTERIES OF ADDICTION IN THE END

Standing back from the research trenches from time to time to take a wide view of past horizons on what is already known about addiction is vital to scientific progress. 'The 10 most important things known about addiction' has stimulated discussion and debate amongst senior colleagues, as hoped, and contributes to broad reflection on where we are at in our knowledge and strategically direct future research energy.

Rutger Engels wants us to come up with a hundred things known about addiction, ordered according to the ten most important addictions, to capture important detail about separate compulsive disorders. He suggests addiction to tobacco smoking has unique features that inclusion in the broad category of 'addiction' does not give justice to the topic. While acknowledging there are important specific aspects of tobacco addiction, nevertheless, as with other addictions,

'. . . . involves a genetically influenced set of behaviours that become increasingly compulsive with repetition, although consciousness is not particularly required for the learning to take place. Most people who present for help have multiple problems, the majority of whom subsequently run a chronic relapsing course of their [tobacco addiction]. Various psychological treatments appear to produce similar results but the more individualised and broad-based the whole input is, the better the outcomes will be. Empathic listening is central to the beginning of the change process but consolidated lifestyle change takes time, even in those who recover from [tobacco] addiction following a seemingly miraculous life-changing experience'.

Read Full Text (PDF)

____________________________________________

An Animal Model of Genetic Vulnerability to Behavioral Disinhibition and Responsiveness to Reward-Related Cues: Implications for Addiction

Rats selectively bred based on high or low reactivity to a novel environment were characterized for other behavioral and neurobiological traits thought to be relevant to addiction vulnerability.

The two lines of animals, which differ in their propensity to self-administer drugs, also differ in the value they attribute to cues associated with reward, in impulsive behavior, and in their dopamine system.

When a cue was paired with food or cocaine reward bred high-responder rats (bHRs) learned to approach the cue, whereas bred low-responder rats (bLRs) learned to approach the location of food delivery, suggesting that bHRs but not bLRs attributed incentive value to the cue.

Moreover, although less impulsive on a measure of 'impulsive choice', bHRs were more impulsive on a measure of 'impulsive action'— ie, they had difficulty withholding an action to receive a reward, indicative of 'behavioral disinhibition'.

The dopamine agonist quinpirole caused greater psychomotor activation in bHRs relative to bLRs, suggesting dopamine supersensitivity. Indeed, relative to bLRs, bHRs also had a greater proportion of dopamine D2^high receptors, the functionally active form of the receptor, in the striatum, in spite of lower D2 mRNA levels and comparable total D2 binding.

In addition, fast-scan cyclic voltammetry revealed that bHRs had more spontaneous dopamine 'release events' in the core of the nucleus accumbens than bLRs.

Thus, bHRs exhibit parallels to 'externalizing disorders' in humans, representing a genetic animal model of addiction vulnerability associated with a propensity to attribute incentive salience to reward-related cues, behavioral disinhibition, and increased dopaminergic 'tone.'

Read Full Abstract

Request Reprint E-Mail: sflagel@umich.edu
____________________________________________

Validation of the Alcohol Use Identification Test in a Prison Sample Living in the Arabian Gulf Region

The purpose of this study was to assess the utility of the Arabic translation of the Alcohol Use Disorders Identification Test (AUDIT) among a sample of male Muslim prisoners (N = 107) in Dubai, United Arab Emirates (UAE).

Confirmatory factor analysis indicated a two-factor model to be the best fit of the data. Good internal reliability ( =.91) and predictive validity were also observed. While the limitations of the study are observed, these promising results suggest that the Arabic version of the AUDIT is a reliable and sound measure of alcohol use disorders among prisoners in the UAE

Read Full Abstract

Request Reprint E-Mail: tayyibaalmarri@gmail.com
____________________________________

Workplace Responsibility, Stress, Alcohol Availability and Norms as Predictors of Alcohol Consumption-Related Problems Among Employed Workers

The objectives of this study were to determine the prevalence of alcohol use and problems among employed individuals in Alberta, Canada (N = 1,890), and to conduct a multivariate examination of predictors of alcohol consumption-related problems.

General alcohol problems were identified by 10%, although very few workers described any specific work-related alcohol problems (1%).

Structural equation modeling revealed that, as hypothesized, workplace alcohol availability predicted general alcohol problems. Job responsibility and workplace norms also predicted alcohol problems but only for men. Perceived work stress did not predict alcohol problems.

Results support the development of interventions that focus on re-shaping alcohol use norms.

Read Full Abstract

Request Reprinxt E-Mail: dhodgins@ucalgary.ca
___________________________________________

Talking to Ourselves: A Dialogical Exploration of Consumption Experiences

This article introduces the dialogical nature of self to study consumers’ inner dialogs in order to understand consumers’ marketplace decisions and conflicts.

The authors explore the meaning of consumption at multiple self levels and dialogical relationships to manage differences.

The study uses mixed methods including in‐depth interviews, multidimensional scaling, cluster analysis, and metaphors to distill important voices in their informants.

They find that the consumption stories vary across self levels. The meta‐self level reflects a dispassionate representation of the primary I‐positions in consumers and does not explain what the consumers experience at the time of actual consumption. An examination of inconsistent consumption preferences at the level of I‐positions reveals that dialogical relationships labeled compartmentalization, compassion, negotiation, and coalition can avoid and manage conflicts, while relationships involving opposition and domination reflect unresolved conflicts.

Suggestions to use the dialogical self model for addressing issues of negative selves, addictions, and domination in future research are provided.

Read Full Abstract

Request Reprint E-Mail: shalini@iam‐bc.com
________________________________________

Roxon rejects advice on drinking age

THE Health Minister, Nicola Roxon, has rejected a call from the Prime Minister's advisory body on drugs to consider lifting the drinking age.

The Australian National Council on Drugs declared that there was evidence that lifting the legal drinking age did decrease the number of young people drinking alcohol and being harmed as a result.

The council said there was a need to ''explore the options'' to break the connection between the drinking age, getting a full driver's licence and leaving school, which all occurred around the 18th birthday. Their verdict follows calls for the drinking age to be lifted to 19. . . . . . .

Read More

___________________________________________

Editorial - Neurocircuitry: A Window into the Networks Underlying Neuropsychiatric Disease

Understanding the neurocircuitry that underlies normal and adaptive behaviors is a foundation for elucidating the pathology and pathophysiology of psychiatric diseases. The rich history of anatomical observations forms the backbone for what we now consider to be the key structures and pathways associated with aberrant behaviors and psychiatric disorders. Given the focus of psychiatry on the interface of motivation, emotion, and cognition, psychiatric neuroscience has progressively highlighted brain networks that subserve these functional domains and their interactions. The convergence of findings from the variety of techniques in animal studies to human postmortem, neurosurgical, and brain imaging methods have led to major advances that constitute the groundwork for the neurocircuitry pertinent to psychiatric diseases.

The goal of this volume is to outline the circuitries that are thought to underlie psychiatric disorders, with a particular focus on recent work in the field, as it relates to normal and abnormal behaviors. One of the first key anatomical contributions was the development of the idea that specific connected brain regions control emotion (the limbic system). Although the concept of the limbic system as originally conceptualized may be outdated, a constellation of brain structures appears to be at the core of most neuropsychiatric disorders. The key structures include the prefrontal cortex, the striatum, the hippocampus, the amygdala (including the extended amygdala), and the ascending monoaminergic modulatory transmitter systems, particularly the midbrain dopamine system. Clearly, this is not an exhaustive list, but one that is essential. . . . . . .

Read Full Text (PDF)
______________________________________

Exploring the molecular basis of addiction: drug-induced neuroadaptations

Abuse of a number of psychoactive substances can eventually control an individual's behavior by producing dependence and/or addiction. Recent surveys estimate that there are about 200 million users of illegal drugs worldwide, which represent 3.4% of the world population. An ever-increasing number of neuroscientists are searching for clues regarding the molecular determinants of addictive behavior. The low-hanging fruit would be to study dopamine receptors and transporters in the nucleus accumbens (NAc); however, scientists are now exploring mechanisms far beyond dopaminergic targets.

For example, some scientists have chosen to target molecular mechanisms within the hippocampus because of its role in encoding and retrieving information in the central nervous system. In addition, this brain region sends and receives projections from the mesolimbic dopamine system so often implicated in addiction (Bannerman et al, 2004). Further, the hippocampus has been directly implicated in addiction behavior (Vorel et al, 2001), likely because of the fact that there is increasing evidence suggesting that drug addiction represents a conditioning phenomenon that is largely dependent on associations between drug effects and environmental cues (Berke and Hyman, 2000.

. . . . . .

Read Full Text (PDF)

___________________________________________

Separable Roles of the Nucleus Accumbens Core and Shell in Context- and Cue-Induced Alcohol-Seeking

Conditioned responding to drug-predictive discrete cues can be strongly modulated by drug-associated contexts.

We tested the hypothesis that differential recruitment of the nucleus accumbens (NAc) core and shell mediates responding to drug cues in a drug vs non-drug context.

Rats were trained to discriminate between two 10-s auditory stimuli: one stimulus (CS+) was paired with ethanol (10% v/v; 0.2 ml; oral) whereas the other (CS-) was not. Training occurred in operant conditioning chambers distinguished by contextual stimuli, and resulted in increased entries into the ethanol delivery port during the CS+ when compared with the CS-.

In experiment 1, port entries were then extinguished in a second context by withholding ethanol, after which context-induced renewal of ethanol-seeking was tested by presenting both stimuli without ethanol in the previous training context.

This manipulation stimulated strong responding to the CS+ in rats pretreated with saline in the core (n=9) or shell (n=10), which was attenuated by pharmacologically inactivating (muscimol/baclofen; 0.1/1.0 mM; 0.3 l/side) either subregion pretest. In experiment 2, after discrimination, training rats were habituated to a different context in which ethanol and both stimuli were withheld. Cue-induced ethanol-seeking was then elicited by presenting the CS+ and CS- without ethanol in the different context. Saline-pretreated rats responded more to the CS+ than the CS- (core n=8; shell n=9), and inactivating the core but not shell attenuated this effect.

These data highlight an important role for the core in cue-induced ethanol-seeking, and suggest that the shell is required to mediate the influence of contexts on conditioned ethanol-seeking.

Read Full Abstract

Request Reprint E-Mail: nchaudhri@gallo.ucsf.edu
______________________________________

Externalities from Alcohol Consumption in the 2005 US National Alcohol Survey: Implications for Policy

A subsample (n = 2,550) of the 2005 US National Alcohol Survey of adults was used to estimate prevalence and correlates of six externalities from alcohol abuse—family problems, assaults, accompanying intoxicated driver, vehicular accident, financial problems and vandalized property—all from another‘s drinking.

On a lifetime basis, 60% reported externalities, with a lower 12-month rate (9%).

Women reported more family/marital and financial impacts and men more assaults, accompanying drunk drivers, and accidents.

Being unmarried, older, white and ever having monthly heavy drinking or alcohol problems was associated with more alcohol externalities.

Publicizing external costs of drinking could elevate political will for effective alcohol controls.


Read Full Text (PDF)
______________________________________

Is expectancy reality? Associations between tension reduction beliefs and mood following alcohol consumption.

The present study investigated whether tension reduction expectancies were uniquely associated with self-reported mood following in-lab alcohol administration, given that little research has addressed this association. We also tested whether level of experience with alcohol, which may influence the learning of expectancies, moderated expectancy-mood associations.

Regularly drinking college students (N = 145) recruited through advertisements completed self-report measures of positive alcohol expectancies, alcohol involvement, demographics, and pre- and post-drinking mood, and then consumed alcohol ad libitum up to four drinks in the laboratory.

Regression analyses controlling for pre-consumption mood, blood alcohol concentration, and all other positive expectancies showed tension reduction expectancies to be a marginally significant positive predictor of negative mood post-drinking. This association was significant only for those who achieved lower blood alcohol concentrations in lab and those who reported less involvement with alcohol (i.e., lower typical quantity, heavy episodic drinking frequency, and years of regular drinking).

Findings suggest that associations between expectations for mood and actual post-drinking mood outcomes may operate differently for less versus more involved drinkers.

Clinical implications pertain to early intervention, when expectancies may be less ingrained and perhaps more readily modified.

Read Full Abstract

Request Reprint E-Mail: merrill7@buffalo.edu
________________________________________

Reliability and validity of a demand curve measure of alcohol reinforcement.

Recent clinical research suggests that several self-report behavioral economic measures of relative reinforcing efficacy (RRE) may show utility as indices of substance abuse problem severity.

The goal of the present study was to evaluate the reliability and validity of the Alcohol Purchase Task (APT), a RRE measure that uses hypothetical choices regarding alcohol purchases at varying prices (demand curves) to generate several indices of alcohol-related reinforcement.

Participants were 38 college students who reported recent alcohol consumption. Both the raw alcohol purchase/consumption values and several of the computed reinforcement parameters (intensity & Omax) showed good to excellent 2-week test–retest reliability. Reinforcement parameters derived from both a linear-elasticity (Hursh, Raslear, Bauman, & Black, 1989) and an exponential (Hursh & Silberberg, 2008) demand curve equation were generally less reliable, despite the fact that both equations provided a good fit to participants’ reported consumption data.

The APT measures of demand intensity (number of drinks consumed when price = 0), Omax (maximum expenditure), and elasticity (a) were correlated with weekly drinking, alcohol-related problems, and other self-report RRE measures (relative discretionary monetary expenditures toward alcohol and/or relative substance-related activity participation and enjoyment).

Demand intensity was uniquely associated with problem drinking in a regression model that controlled for weekly consumption.

These results provide support for the reliability and validity of the RRE indices generated with the APT.

Read Full Abstract

Request Reprint E-Mail: jgmurphy@memphis.edu
______________________________________

Alcohol-induced changes in the brain as assessed by MRI and CT

This review provides an overview of structural magnetic resonance imaging and computed tomography findings of direct and indirect alcohol-related toxic effects on the brain. In addition to ethanol-related changes to the brain, this article will also describe imaging findings in the acute setting of methanol and ethylene glycol poisoning.

Alcohol will lead to brain atrophy, osmotic myelinolysis, Marchiafava–Bignami disease and, especially when related to malnutrition, may also cause Wernicke encephalopathy. Brain atrophy can be reversible if alcohol abuse is stopped. If not treated, Wernicke encephalopathy can lead to coma and death and an early diagnosis is important for immediate initiation of thiamine substitution.

As clinical symptoms are often unspecific, the radiologist plays an important role in the detection of alcohol abuse and its related clinical conditions.

Read Full Abstract

Request Reprint E-Mail: timo.krings@uhn.on.ca
_______________________________________

The impacts of substance abuse and dependence on neuropsychological functions in a sample of patients from Saudi Arabia

A lot of studies were directed to explore the relation between drug abuse and neuropsychological functions. Some studies reported that even after a long duration of disappearance of withdrawal or intoxication symptoms, many patients have obvious deterioration of cognitive functions. The aim of this study was to explore the relationship between the substance use disorders and the executive functions.

The study showed that the group of drug-dependent subjects performed significantly worse than the comparison group on all measures Also, there were significant differences among the subgroups as the alcoholic group was much worse followed by the amphetamine then the opioids groups. Patients with longer duration of dependence and multiple hospital readmissions were much worse in comparison to patients with shorter duration of dependence and less readmission.

The study confirmed that the functions of specific brain regions underlying cognitive control are significantly impaired in patients of drug addiction. This impairment was significantly related to type of substance, duration of use and number of hospitalization and may contribute to most of behavioral disturbances found in addicts and need much attention during tailoring of treatment programs.

Read Full Text (PDF)
______________________________________