For the 17thtime, the world has seen the meeting of the International Society of Addiction Medicine (ISAM) in Dundee, Scotland. The congress covered Addiction from biology to recovery with the aim of translating research evidence to improve clinical practice and community resilience. Here, I note my thoughts from three out of the eight keynotes that I attended.
Monday 5 October: Raju Hajela and Ken Roy talked about addiction’s past, present and future (Chair: Kathleen Brady). Dr Hajela opened his talk with photos from his tour of the Edinburgh castle. He combined the treatment of alcohol and drug dependence as a doctor in the Canadian armed forces. At the age of 15, he moved to Canada. From his experience, episodical treatment has been the model. Today, episodic treatment still persists, but punishment, as a form of treatment receded. We have to be careful about how we define disease, remission and cure. Is addiction like diabetes? Before insulin has been discovered, diabetes was a mystery. Insulin replacement is not treatment for all types of diabetes. The state of addiction is not the same as the state of intoxication. Simply put, addiction is not a desired condition.
Dr Roy claimed that recovery is necessary for abstinence. It is important to recognise that my addiction is stronger than I am. According to the Betty-Ford expert opinion recovery is a voluntary maintained lifestyle. There is no medication for immaturity. Craving is only one part of the whole gestalt of who this recovering person is; yet, most treatment has concentrated on it.
Monday 5 October: Elizabeth Sáenz introduced UNODC’s global projects on drug use prevention and the treatment of drug use disorders. Is it the type and patterns of drug users that we are interested in? What are the challenges? To date, human rights of people with substance use disorders are violated. Many countries don’t accept addiction treatment in prisons. Respect first is key for the mentality of the change in the community. Many countries spend prevention money on cups and pens. Are these interventions effective? What are we really doing? Training people in prevention and treatment is very difficult when the training materials haven’t been translated into local languages.
Dr Howard Moss covered the heterogeneity of alcohol dependence and the role of polysubstance misuse. The key point of is talk was that “alcoholic is not an alcoholic.” He described the distinctly different type of a person who uses multiple drugs. Simply using the phenomenology to understand dependence, we’re missing the boat. Who comes to treatment? People with the chronic, severe dependence and multiple other (substance-use) disorders. How did they do in the treatment? Not well. These are the people who present in our problems. The people who have most success treatment are the group who doesn’t present in treatment and who doesn’t experiences the psychosocial consequences of addiction. The saying “drinkers smoke and smokers drink,” seems to be true from the epidemiological perspective. If there are distinct differences between single- and poly-drug users, is it because of exposure to multiple drugs or are we looking at a pre-morbid risk factor. We clearly don’t know the answer to that question. Because clinical trials almost never include poly-drug users, we don’t know much about them. This topic is of utmost importance also for our Cochrane Systematic Review of literature.
Tuesday 6 October Dr Wim van den Brink talked about the addiction and comorbid ADHD. What is the prevalence of adult ADHD among people who have addiction? According to Dr van den Brink’s meta-analysis, it was 23% on average (range 10-50%). The method of assessment and the primary substance of use could explain this variability. Differences between the countries are huge. Which children with ADHD develop addiction? The literature showed that the single most important factor was the age of starting treatment of ADHD. The treatment of treatment fades out over time, especially if the treatment is discontinued. Whether the treatment decreases the risk or increases the risk is unknown mainly due to the heterogeneity of the literature. The impulsivity aspects seem to be responsible for the association between addiction and ADHD.
Dr Brink didn’t enjoy walking in the mountains and by this he demonstrated how some people might be born with a vulnerability to addiction similar to hyperactive nervous system. You just want to do something nice, including drug taking, which in itself may not be bad, but if combined with ADHD – the problems occur. Delay discounting plays an important role in addiction. The comorbidity between the conditions goes in both directions. Van Den Brink thinks we shouldn’t be keeping the medication away from patients who need it. It seems though that at certain stage, the impulsive behavior, it might become an autonomic automatic behavior.
Wednesday 7 October: “Brief interventions started in Scotland,“ Dr Nick Heather opened his morning talk discussing addiction as a disorder of choice. “I am a former addict,” he apologized for using the term addict; we shouldn’t be labelling people. He quit smoking three years ago. Is addiction a choice or a disease? Recently, the research suggested that the truth is somewhere in the middle. Carl Hart’s book The High Price has caused big stir in this debate. Also, the fact that Dr Alexander’s Rat Park work has been replicated and the rats did not choose morphine if they had structured-environment reinforces is of great significance. As Dr Humphreys suggested, the rat park, and the evidence of former Vietnam veterans quitting after return to US, should have changed our views of addiction.
Wednesday 7 October Keith Humphreys started with how met a person who bought his book on mutual help and recovery. Does that really help? The difference is in how people refer. The warm hand-off trial with an impressive follow-up rate of 85% found people randomized to self-help intervention had about 60% better outcomes than treatment as usual. Active coping, motivation to change, changes in friendship networks (specifically encouraging to stop using) seem to be the most active ingredients of, or the mediators of, change that occurs in mutual help groups. Giving people helps is strongly associated with better outcomes. Intensive referral that includes even just calling the person in the session increases people’s chances of going to the group. Transitions are challenging for people. Furthermore, the recovery movement had a huge impact on the expansion of the so-called Obama care to include full coverage for all substance use disorders. During some of these fights, the recovery movement put so many calls to the White House that the line had to be shut down. You can never measure that impact scientifically, but there’s good amount of hope to believe that a group of well-meaning people can influence policy. In conclusion, apart the psychological and social factors of mutual help groups; we really need more choices, more groups for people. We also need more good quality studies, even though we could guess that self-help works given the evidence from other areas where it had impact.
Have you attended the Plenary at the 14th Centre for Addiction Research and Education Scotland (CARES) Conference on Thursday? Post your thoughts below.