Current Issue: May–June 2012

Interventions and Assessments

• Illicit-Drug Brief Intervention Reduced Risk Score among Some Patients in a Randomized Trial
• Brief Intervention Reduces Drinking among Emergency Department Patients with Nondependent Unhealthy Use
• Alcohol and Other Drug Discussions in Primary Care: Not Rare, but Numerous Challenges
• Naloxone Distribution Programs for Opioid Overdose Prevention: Time to Scale Up?
• Naltrexone Implants Reduced Opioid Use in People with Co-occurring Heroin and Amphetamine Dependence
• Adding Telephone Support to Office-Based Buprenorphine Treatment for Opioid Dependence Has Modest Effects

Health Outcomes

• Ongoing Use of Analgesics after Low-Risk Surgery
• Severity of Alcohol Problems Predicts Recurrence and Persistence of Alcohol Dependence
  
• Change in Heavy Drinking among Alcohol-Dependent Individuals
  
• Light Alcohol Consumption Prior to and Following Myocardial Infarction Is Associated with Lower Risk of Mortality

HIV and HCV

• Rates of HCV Reinfection Are Low among People with Injection Drug Use Who Receive HCV Treatment
• Availability of Viral Hepatitis Services in US Drug Treatment Programs
• Providing Directly-Observed Hepatitis C Treatment at a Methadone Maintenance Program is Feasible and May Improve Treatment Outcomes
• People with Injection Drug Use Who Also Use Noninjecting Routes of Drug Administration Are Less Likely to Be HIV Positive

Resource Alert

• BAP Releases New Guidelines on the Pharmacologic Management of Substance Use Disorders

Slide Presentations

• Update on Alcohol, Other Drugs, and Health
• Journal Club

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Resources for the prevention and treatment of substance use disorders

The global burden of disease attributable to alcohol and illicit drug use amounts to 5.4% of the total burden of disease. Effective interventions and strategies exist to prevent and treat substance use disorders. The Global Information System on Resources for the Prevention and Treatment of Substance Use Disorders maps and monitors health system resources at the country level to respond to the health problems due to substance use. Data from 147 countries (88% of the world population), collected in 2008, show that the main location for treatment of substance use disorders is the specialist substance abuse system, followed by the mental health system, the general health system, and primary care.

View interactive graph

MORE DATA PRODUCTS ON RESOURCES FOR THE PREVENTION AND TREATMENT OF SUBSTANCE USE DISORDERS

• Maps
• Atlas on substance use (ATLAS-SU) report
• Country profiles
• Indicator book
  pdf, 214kb
• Management of Substance Abuse web pages
• Global Information System on Alcohol and Health (GISAH)

Addiction Medicine: Closing the Gap between Science and Practice

WHAT'S IN THIS REPORT:

CASA Columbia’s new five year national study reveals that addiction treatment is largely disconnected from mainstream medical practice. While a wide range of evidence-based screening, intervention, treatment and disease management tools and practices exist, they rarely are employed. The report exposes the fact that most medical professionals who should be providing treatment are not sufficiently trained to diagnose or treat addiction, and most of those providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to provide the full range of evidence-based services, including pharmaceutical and psychosocial therapies and other medical care.

This landmark report examines the science of addiction--a complex disease that involves changes in the structure and function of the brain--and the profound gap between what we know about the disease and how to prevent and treat it versus current health and medical practice.

HIGHLIGHTS FROM THE REPORT:

• Forty million Americans ages 12 and older (16 percent) have the disease of addiction involving nicotine, alcohol or other drugs, a disease affecting more Americans than heart conditions, diabetes or cancer; another 80 million people are risky substance users – using tobacco, alcohol and other drugs in ways that threaten health and safety.
• About 7 in 10 people with diseases like hypertension, major depression and diabetes receive treatment; only about 1 in 10 people who need treatment for addiction involving alcohol or other drugs receive it while the number receiving treatment for nicotine is not even known.
• Addiction treatment facilities and programs are not adequately regulated or held accountable for providing treatment consistent with medical standards and proven treatment practices.
• In 2010 only $28 billion was spent to treat the 40 million people with addiction. In comparison, the United States spent:
  • $44 billion to treat diabetes which affects 26 million people;
  • $87 billion to treat cancer which affects 19 million people;
  • $107 billion to treat heart conditions which affect 27 million people.

  
  

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Sequence of Alcohol Involvement from Early Onset to Young Adult Alcohol Abuse: Differential Predictors and Moderation by Family-Focused Preventive Int

This study tests risk factors for four dimensions of alcohol use in the sequence from (a) early onset prior to age 13 to (b) adolescent alcohol use and (c) alcohol problems to (d) young adult alcohol abuse. It also examines whether family-focused preventive interventions buffer predictive relationships.

Data were from a randomized prevention trial extending from ages 11 to 21.

Families of sixth graders enrolled in 33 rural schools in the Midwestern United States were invited to participate.

Families (N = 667) were pretested and randomly assigned to a control group (n = 208) or to family interventions (n = 459). The average age of participating youth was 11.3 years when the study began (52% female). Measurements: Questionnaire data were collected on alcohol dimensions during adolescence (early onset, alcohol use, alcohol problems) and young adulthood (alcohol abuse), and on risk factors in early adolescence (male gender, impulsive behaviors, aggression-hostility, peer deviance, and parent problem drinking).

Impulsive behaviors predicted early onset, peer deviance predicted alcohol use, and parent problem drinking predicted alcohol problems (p <.05). Aggression-hostility and alcohol problems predicted alcohol abuse in the control group (p <.05), but not in the family interventions group (p >.05).

Different dimensions of alcohol use and problems from before age 13 to young adulthood are predicted by different risk factors. Family-focused preventive interventions can reduce the influence of some of these risk factors, including early adolescent aggression-hostility and late adolescent alcohol problems.

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Request Reprint E-Mail: masonwa@boystown.org

Alcohol dependence a significant predictor for depression and anxiety disorders

The British Journal of Psychiatry (BJP) has published research which suggests that alcohol dependence is a significant predictor of future episodes of anxiety or depressive disorders, whereas alcohol abuse is not.

The study explored whether the course of depression or anxiety disorders were conditional upon the type and severity of alcohol problem. Severe dependency was linked to the persistence of anxiety and depressive disorder incidences at 2 year follow-up. However, the study found no significant difference in people with alcohol abuse (or moderate problems), compared to people with no lifestyle problems at a 2 year follow- up.

This study is the latest in a long line of research aimed at teasing out the complex nature of the links between alcohol and depression/anxiety disorders. A 2005 study by Haynes et al found that alcohol was not a significant risk factor for the onset of anxiety and depression, whereas abstinence was associated with a lowered risk of onset. A study in 2011 by Liang et al found that common mental health disorders, such as anxiety and depression, may increase the risk of alcohol dependency and misuse. > > > > Read More

Effects of Intoxicating Free-Choice Alcohol Consumption During Adolescence on Drinking and Impulsivity During Adulthood in Selectively Bred High-Alcoh

Abuse of alcohol during adolescence continues to be a problem, and it has been shown that earlier onset of drinking predicts increased alcohol abuse problems later in life. High levels of impulsivity have been demonstrated to be characteristic of alcoholics, and impulsivity has also been shown to predict later alcohol use in teenage subjects, showing that impulsivity may precede the development of alcohol use disorders. These experiments examined adolescent drinking in a high-drinking, relatively impulsive mouse population and assessed its effects on adult drinking and adult impulsivity.

Experiment 1: Selectively bred high-alcohol preferring (HAPII) mice were given either alcohol (free-choice access) or water only for 2 weeks during middle adolescence or adulthood. All mice were given free-choice access to alcohol 30 days later, in adulthood. Experiment 2: Adolescent HAPII mice drank alcohol and water, or water alone, for 2 weeks, and were then trained to perform a delay discounting task as adults to measure impulsivity. In each experiment, effects of volitional ethanol (EtOH) consumption on later behavior were assessed. We expected adolescent alcohol exposure to increase subsequent drinking and impulsivity.

Mice consumed significant quantities of EtOH, reaching average blood ethanol concentrations (BECs) of 142 mg/dl (adolescent) or 154 mg/dl (adult) in Experiment 1. Adolescent mice in Experiment 2 reached an average of 108 mg/dl. Mice exposed to alcohol in either adolescence or adulthood showed a transient increase in EtOH consumption, but we observed no differences in impulsivity in adult mice as a function of whether mice drank alcohol during adolescence.

These findings indicate that HAPII mice drink intoxicating levels of alcohol during both adolescence and adulthood and that this volitional intake has long-term effects on subsequent drinking behavior. Nonetheless, this profound exposure to alcohol during adolescence does not increase impulsivity in adulthood, indicating that long-term changes in drinking are mediated by mechanisms other than impulsivity.

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Request Reprint E-Mail: ngrahame@iupui.edu

Sensitivity and Specificity of Urinary Ethyl Glucuronide and Ethyl Sulfate in Liver Disease Patients

It is important to monitor alcohol use in the care of patients with liver disease, but patient self-report can be unreliable. We therefore evaluated the performance of urine ethyl glucuronide (EtG) and ethyl sulfate (EtS) in detecting alcohol use in the days preceding a clinical encounter.

Subjects (n = 120) were recruited at a university-based hepatology clinic or during hospitalization. Alcohol consumption was ascertained by validated self-report measures. Urine EtG (cutoff 100 ng/ml) and EtS (cutoff 25 ng/ml) concentrations were assayed by a contracted laboratory using tandem mass spectrometry. The sensitivity and specificity of each biomarker in the detection of drinking during the 3 and 7 days preceding the clinic visit were determined, as well as the influence of liver disease severity on these results.

Urine EtG (sensitivity 76%, specificity 93%) and urine EtS (sensitivity 82%, specificity 86%) performed well in identifying recent drinking, and liver disease severity does not affect biomarker performance. After elimination of 1 false-negative self-report, urine EtG > 100 ng/ml was 100% specific for drinking within the past week, whereas 9% of the subjects without evidence of alcohol drinking for at least 1 week had EtS > 25 ng/ml.

Urine EtG and EtS can objectively supplement the detection of recent alcohol use in patients with liver disease. Additional research may determine optimal methods for integrating these tests into clinical care.

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Request Reprint E-Mail: stewarsh@musc.edu

Dynamic and Persistent Effects of Ethanol Exposure on Development: An In Vivo Analysis During and After Embryonic Ethanol Exposure in Caenorhabditis e

Defects caused by ethanol (EtOH) exposure during development can be different depending on the time of observation. To investigate this temporal component of developmental delay, we use the fast-developing nematode model Caenorhabditis elegans. We first defined the longitudinal effects of EtOH on development using age-appropriate markers and then closely followed embryonic development before, during, and after EtOH exposure.

C. elegans embryos were bathed in 0 to 20% EtOH (w/w in ddH₂O) for 8 hours or were left untreated during embryonic development. Development was followed longitudinally and scored as embryonic stage at the end of the exposure, hatch time, hatching probability (mortality), body length, postembryonic stage, and egg-laying pattern. The rate of in vivo embryonic development was observed hourly for 24 hours covering times before, during, and after EtOH exposure.

After exposure to 10% EtOH, embryos were at younger embryonic stages, hatched later, and had higher mortality compared to unexposed controls. Embryos exposed to 5% EtOH were at normal embryonic stages, showed no change in mortality, but hatched later than controls. Both EtOH groups showed shorter mean body lengths and slower postembryonic development; however, the 5% group recovered to control levels faster than the 10% group. The pattern of egg laying was delayed in the 10% group, but not in the 5% group. Hourly in vivo observations revealed that a developmental delay was first visible a few hours into 10% EtOH exposure and that the delay increased after the removal of EtOH exposure.

Developmental delays occurred during and immediately after exposure and were not uniform but rather dynamic. This article highlights the importance of investigating EtOH-induced defects using different markers and at multiple time points. Attention to temporal effects during and immediately after EtOH exposure can provide understanding of these sensitive time points for observation and treatment.

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Request Reprint E-Mail: crankin@psych.ubc.ca

Vascular Effects of Maternal Alcohol Consumption

Maternal alcohol consumption during pregnancy is a significant field of scientific exploration primarily because of its negative effects on the developing fetus which is specifically defined as Fetal Alcohol Spectrum Disorders (FASD).

Though the effects on the mother are less explored compared to those on the fetus, alcohol produces multiple effects on the maternal vascular system. Alcohol has major effects on systemic hemodynamic variables, endocrine axes and paracrine factors regulating vascular resistance, as well as vascular reactivity. Alcohol is also reported to have significant effects on the reproductive vasculature including alterations in blood flow, vessel remodeling, and angiogenesis.

Data presented in this Review will illustrate the importance of the maternal vasculature in the pathogenesis of FASD and that more studies are warranted in this field.



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Request Reprint E-Mail: jaramado@utmb.edu

Neurochemical Heterogeneity of Rats Predicted by Different Measures to be High Ethanol Consumers

Alcoholism is a heterogeneous disease, with subjects possibly differing both in the best measure that predicts their excess consumption and in their most effective pharmacotherapy. Two different measures, high novelty-induced activity and high-fat-induced triglycerides (TGs), are known to identify subgroups of animals prone to consuming higher amounts of ethanol (EtOH). The question investigated here is whether these subgroups are, in fact, similar in their neurochemical phenotype that may contribute to their overconsumption

EtOH-naïve, Sprague–Dawley rats were subgrouped based on the 2 predictor measures of activity or TG levels, and then quantitative real-time polymerase chain reaction and digoxigenin-labeled in situ hybridization were used to measure their expression of hypothalamic peptides that affect EtOH intake. In additional subgroups subsequently trained to drink 9% EtOH, the opioid antagonist and alcoholism medication, naltrexone, was tested at a low dose (0.02 mg/kg, s.c.) to determine the rats' sensitivity to its effects.

The 2 measures, while both effective in predicting amount of EtOH intake, were found to identify distinctive subgroups. Rats with high compared to low activity exhibited significantly greater expression of galanin and enkephalin in the paraventricular nucleus (PVN) and of orexin in the perifornical lateral hypothalamus (PFLH), but no difference in melanin-concentrating hormone in PFLH or neuropeptide Y in arcuate nucleus. This contrasts with rats having high TG, which exhibited greater expression only of PVN galanin, along with reduced PFLH orexin. The high-activity rats with elevated enkephalin, but not high-TG rats, were also unusually sensitive to naltrexone, which significantly reduced their alcohol intake.

In addition to revealing differences in endogenous peptides and drug responsiveness in predicted high EtOH drinkers, this study demonstrates that these disturbances differ markedly between the 2 at-risk subgroups. This indicates that simple tests may be effective in identifying subjects most responsive to a specific pharmacotherapy.

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Request Reprint E-Mail: leibow@rockefeller.edu

Chronic Ethanol Consumption Alters All-Trans-Retinoic Acid Concentration and Expression of Their Receptors on the Prostate: A Possible Link Between Al

Ethanol (EtOH) alters the all-trans-retinoic acid (ATRA) levels in some tissues. Retinol and ATRA are essential for cell proliferation, differentiation, and maintenance of prostate homeostasis. It has been suggested that disturbances in retinol/ATRA concentration as well as in the expression of retinoic acid receptors (RARs) contribute to benign prostate hyperplasia and prostate cancer. This study aimed to evaluate whether EtOH consumption is able to alter retinol and ATRA levels in the plasma and prostate tissue as well as the expression of RARs, cell proliferation, and apoptosis index.

All animals were divided into 4 groups (n = 10/group). UChA: rats fed 10% (v/v) EtOH ad libitum; UChACo: EtOH-naïve rats without access to EtOH; UChB: rats fed 10% (v/v) EtOH ad libitum; UChBCo: EtOH-naïve rats without access to EtOH. Animals were euthanized by decapitation after 60 days of EtOH consumption for high-performance liquid chromatography and light microscopy analysis.

EtOH reduced plasma retinol concentration in both UChA and UChB groups, while the retinol concentration was not significantly different in prostate tissue. Conversely, plasma and prostate ATRA levels increased in UChB group compared with controls, beyond the up-regulation of RARβ and -γ in dorsal prostate lobe. Additionally, no alteration was found in cell proliferation and apoptosis index involving dorsal and lateral prostate lobe.

We conclude that EtOH alters the plasma retinol concentrations proportionally to the amount of EtOH consumed. Moreover, high EtOH consumption increases the concentration of ATRA in plasma/prostate tissue and especially induces the RARβ and RARγ in the dorsal prostate lobe. EtOH consumption and increased ATRA levels were not associated with cell proliferation and apoptosis in the prostate.

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Request Reprint E-Mail: martinez@ibb.unesp.br

Resting-State Synchrony in Long-Term Abstinent Alcoholics

Alcohol dependence is a disorder with an impulsive and compulsive “drive” toward alcohol consumption and an inability to inhibit alcohol consumption. Neuroimaging studies suggest that these behavioral components correspond to an increased involvement of regions that mediate appetitive drive and reduced involvement of regions that mediate executive control within top-down networks. Little is known, however, about whether these characteristics are present after long periods of abstinence.

Resting-state functional magnetic resonance imaging data were collected to examine resting-state synchrony (RSS) differences between 23 long-term abstinent alcoholics (LTAA; 8 women, age: M = 48.46, SD = 7.10), and 23 nonsubstance abusing controls (NSAC; 8 women, age: M = 47.99, SD = 6.70). Using seed-based measures, we examined RSS with the nucleus accumbens (NAcc) and the subgenual anterior cingulate cortex (sgACC). All participants were assessed with the intra/extradimensional set shift task outside of the scanner to explore the relationship between RSS and cognitive flexibility.

Compared to NSAC, LTAA showed (i) decreased synchrony of limbic reward regions (e.g., caudate and thalamus) with both the anterior cingulate cortex seed and the NAcc seed and (ii) increased synchrony of executive control regions (e.g., dorsolateral prefrontal cortex) with both the NAcc seed and the sgACC seed. RSS differences were significantly correlated with task performance.

The results are consistent with an interpretation of an ongoing compensatory mechanism in LTAA evident during rest, in which decision-making networks show reduced synchrony with appetitive drive regions and increased synchrony with inhibitory control regions. In addition, RSS differences were associated with cognitive flexibility. These resting-state findings indicate an adaptive mechanism present in long-term abstinence that may facilitate the behavioral control required to maintain abstinence.

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Request Reprint E-Mail: jcamchong@nbresearch.com

Voluntary Alcohol Drinking Enhances Proopiomelanocortin Gene Expression in Nucleus Accumbens Shell and Hypothalamus of Sardinian Alcohol-Preferring Ra

Evidence obtained in humans and rodents indicates that beta-endorphin (encoded by the proopiomelanocortin [POMC] gene) is critical in the regulation of alcohol drinking behavior. However, the alcohol effect on POMC gene expression has not been studied in rodent mesolimbic regions, such as the nucleus accumbens (NAc).

In this study, we first utilized POMC-enhanced green fluorescent protein (EGFP) transgenic mice to visualize POMC neurons and found that POMC-EGFP cells were modestly distributed throughout the NAc shell and core, in addition to the hypothalamic arcuate nucleus. POMC mRNA expression in the NAc of mice and rats was confirmed using reverse transcriptase-polymerase chain reaction and solution hybridization assays. We then investigated whether there are genetically determined differences in basal mRNA levels of POMC and mu opioid receptor (MOP-r) between selectively bred Sardinian alcohol-preferring (sP) and nonpreferring (sNP) rats, and whether these mRNA levels are altered in sP rats after alcohol drinking (10%, unlimited access) for 17 days.

Alcohol-naïve sP rats had higher basal POMC mRNA levels than sNP rats only in hypothalamus. Alcohol drinking increased POMC mRNA levels in both the NAc shell (by 100%) and the hypothalamus (by 50%) of sP rats. Although sP rats had lower basal levels of MOP-r mRNA and GTPγS binding in NAc shell than sNP rats, voluntary alcohol consumption had no effect on MOP-r mRNA levels in the NAc shell.

Our results define the distribution of POMC-expressing neurons in the NAc of mice and rats. Higher POMC expression at basal levels in sP rats (genetically determined), along with increases after drinking (alcohol-induced) in the NAc shell and hypothalamus, suggests that the POMC systems play a role in high alcohol preference and consumption.

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Request Reprint E-Mail: yan.zhou@rockefeller.edu

Drinking History Associations with Regional White Matter Volumes in Alcoholic Men and Women

Critique 083: Higher indices of quality of life are seen among persistent moderate drinkers than among abstainers — 20 June 2012

Kaplan MS, Huguet N, Feeny D, McFarland BH, Caetano R, Bernier J, Giesbrecht N, Oliver L, Ross N. Alcohol Use Patterns and Trajectories of Health-Related Quality of Life in Middle-Aged and Older Adults: A 14-Year Population-Based Study. J. Stud. Alcohol Drugs,2012;73, 581–59l

Key results of paper: Key results of the study were that the majority of subjects remained in their respective alcohol categories for over 6 years (as seen in most studies). However, 31.4% of their subjects decreased their intake over the follow-up period. In the model using baseline consumption data, lifetime abstainers and former drinkers had lower quality of life (HUI3) scores at baseline (poorer quality of life) than did moderate drinkers. Lifetime abstainers, former drinkers, and infrequent drinkers experienced a greater decline in HUI3 compared with moderate drinkers.

In a separate model incorporating changes in drinking patterns that was limited to subjects consistently reporting good health, trajectories of the quality of life were similar for all groups. The persistent moderate drinkers had higher HUI3 scores at the start of their follow up, but alcohol patterns only affected baseline HUI3 scores and not the rates of change. As stated by the authors, “The findings suggest that alcohol-consumption patterns are associated with HRQL, but the rate of decline in HRQL is similar for all drinking patterns except for persons who decreased their consumption.” > > > > Read Full Critique

Association of genetic copy number variations at 11 q14.2 with brain regional volume differences in an alcohol use disorder population

This study investigates the relationship between genetic copy number variations and brain volume differences in an alcohol use disorder (AUD) population.

We hypothesized that copy number variations may influence subject's risk for alcohol use disorders through variations in regional gray and white matter brain volumes. Since genetic influences upon behavior are the result of many complicated interactions we focus on differences in brain volume as a putative intermediate phenotype between genetic variation and behavior.

Copy number variation, alcohol use assessments and brain structural magnetic resonance images from 283 subjects, 199 male and 84 females who were enrolled in two AUD studies were obtained and analyzed using a combination of the Freesurfer image analysis suite and independent component analysis. Because brain volume varies by age we compared participant's volume variation with that derived from a control cohort of 75 subjects. In addition we also regressed out the possible brain volume changes induced by long term alcohol consumption.

Small cerebral cortex, cerebellar and caudate along with large cerebral white matter and 5th ventricle volumes are shown to be significantly associated with increased AUD severity. When these volume variations are compared with control subject volumes; the variations seen in subjects with AUD are markedly different from normal aging effects.

CNVs at 11 q14.2 are marginally (p < 0.05 uncorrected) correlated with such brain volume variations and the correlation holds true after controlling for long-term alcohol consumption; deletion carriers have smaller cerebral cortex, cerebellar, caudate and larger cerebral white matter and 5th ventricle volumes than insertion carriers or subjects with no variation in this region.

Similarly, deletion carriers also demonstrate higher AUD severity scores than insertion carriers or subjects with no variation.

The results presented here suggest that copy number variation and in particular the variation at chromosome 11 q14.2 may have an impact in brain volume variation, potentially influencing AUD behavior.

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Request Reprint E-Mail: dboutte@mrn.org

News Release - Summer drive to stop alcohol blighting children's lives

Children’s lives are being ruined by alcohol-fuelled violence, says charity CHILDREN 1ST, as new research suggests almost a quarter of people living in Scotland (23 per cent) have seen someone who’s been drinking being aggressive or violent towards a child.

Launching the summer campaign today the charity revealed that more than half of people surveyed (52 per cent) have witnessed a person drunk in charge of a child. Alarmingly more than one in four people (27 per cent) did nothing to help the child because they weren’t sure what to do or felt it was none of their business. > > > > Read More

In the Cave: Philosophy and Addiction

Philosophy is one of the oldest areas of inquiry. Out of control behavior fueled by alcohol and other drugs is one of the world’s oldest problems. What could these old timers offer each other? Philosophy has a long, stable relationship with reason and more specifically, the relationship between reason, emotions and the will. Addiction seems to involve a total abdication of reason, a messy tangle of emotions and a lack of will.

I introduce the notion of addiction as a subject of philosophical inquiry here for a reason. I am a philosopher, yes, but I am also an alcoholic who has been sober for more than 24 years ― only the last four of them as part of a recovery program. I am often asked how I got and stayed sober for those first 19 years; it was because of philosophy, which engendered in me a commitment to living an examined life, and gave me the tools and concepts to do so. My training in moral philosophy made it natural for me to wrestle with issues of character, responsibility, freedom, care and compassion in both work and life.

Philosophy has always been about the pursuit of knowledge, but one that included the higher aim of living a good and just life. This pursuit has involved examining the nature of just about everything. Socrates’s guiding question was “what is it?” The “it” in question could be justice, piety, beauty, courage, temperance, or knowledge. For Socrates, these are the crucial virtues around which life should turn. Socrates’s agenda was to draw the line between what appears to be just or pious and what justice or piety really is. In the person of Socrates, Plato provides the powerful tools of conceptual analysis and allegory that can be fruitfully applied to the questions about addiction.

In his pursuit of knowledge about the nature of virtues, Socrates first had to debunk popular opinions about them. The debunking took the form of a dialogue but in reality more closely resembled a cross examination. Socrates looked for the essence, necessary property or ineliminable trait that made particular acts pious or just. Socrates interrogated every definition offered to him by asking for examples, pushing and pulling against those definitions, turning them inside out and upside down, stretching that definition to see if weird things followed, exploring what follows when a particular definition is put into practice and excavating hidden assumptions behind those definitions. > > > > Read More

The Purpose in Chronic Addiction

I argue that addiction is not a chronic, relapsing, neurobiological disease characterized by compulsive use of drugs or alcohol. Large-scale national survey data demonstrate that rates of substance dependence peak in adolescence and early adulthood and then decline steeply; addicts tend to “mature out” in their late twenties or early thirties. The exceptions are addicts who suffer from additional psychiatric disorders.

I hypothesize that this difference in patterns of use and relapse between the general and psychiatric populations can be explained by the purpose served by drugs and alcohol for patients. Drugs and alcohol alleviate the severe psychological distress typically experienced by patients with comorbid psychiatric disorders and associated problems.

On this hypothesis, consumption is a chosen means to ends that are rational to desire: Use is not compulsive. The upshot of this explanation is that the orthodox view of addiction as a chronic, relapsing neurobiological disease is misguided.

I delineate five folk psychological factors that together explain addiction as purposive action: strong and habitual desire; willpower; motivation; functional role; and decision and resolve.

I conclude by drawing lessons for research and effective treatment.



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Request Reprint E-Mail: h.pickard@gmail.com