Piecing+the+Puzzle+of+Addiction+Together

//The nature of addiction, and why our understanding of it needs to change.// **Cultural Artefact: //video (//**[]**//)//** Russell Brand is the well-known comedian and actor from films such as “Forgetting Sarah Marshall”, and has recently become guest-editor of the very popular British left-wing political magazine the //New Statesman//. On the 23rd of October 2013 Brand went on //BBC// //Newsnight// for a talk with Jeremy Paxman, an infamously combative interviewer. Issues discussed ranged from the working class’ apathy towards current government, the current ‘futility’ of voting, and the potential need for revolution (with jabs being thrown by both opponents). The interesting point relevant here comes up around 2:47 into the interview, when Paxman incredulously questions Brand about his failure to vote since the age of 18: **Brand**: “Well I was busy being a drug addict at that point because I come from the kind of social conditions that are exacerbated by an indifferent system that really just administrates for large corporations and ignores the population that voted it in…” **Paxman**: “You’re blaming the political class for the fact that you had a drug problem?” **Brand**: “No no no, I’m saying that I was part of a social and economic class that is underserved by the current political system, and drug addiction is one of the problems it creates when you have huge, underserved, impoverished populations. People get drug problems and also don’t feel that they want to engage with the current political system … The apathy doesn’t come from us, the people, the apathy comes from the politicians: they are apathetic to our needs.” In essence, Brand is stating that drug addiction (both in his specific case and in general) is caused by prevailing socio-political conditions exploiting the working class, and that a change in these conditions will change the prevalence of addiction. **Central Public Health Issue:** “For every complex problem there is an answer that is clear, simple, and wrong.”--H.L. Mencken The central issue being examined here is that while a multitude of journal articles exist on the social, political, biochemical and neurological factors which potentially contribute to the development of a drug addiction, to date the prevailing attitude has been largely to study these in isolation of any wider context of the problem. A neuroscientist studies chronic drug use in relation to the brain, and proposes treatments based on their observations, without consideration of the social scientist’s observations on social conditions and how these both contribute to addiction and could be harnessed to cure the problem. It is important for these factors to be understood, and for experts to research their individual fields, but treatment programs devised to treat addiction from these solitary approaches have so far had limited efficacy, as seen in the literature. In effect, by trying to simplify addiction and its causative factors in an attempt to solve the problem, we end up with this:
 * Piecing the Puzzle of Addiction Together: Understanding addiction and its many, many parts. **



**Literature Review:** Addiction is a complex problem, and will not have a simple answer. Recent moves have been made to encourage conversation between experts of the different fields concerning addiction, but more work remains and the effect this has on treatment models remains to be seen. The Australian Institute of Health and Welfare reports an increase in drug use in Australia between 2006 and 2010. In 2006 38% of Australians 14 years and over had tried an illicit substance (cannabis, heroin, ecstasy etc) at some stage in their lives (AIHW, 2007), while the 2011 report notes that 60% of the same defined group had not (AIHW, 2011), showing a 2% increase over the four years. Other sources agree: Moore and Fraser (2013, p. 916) comment that the scale of drug addiction in Australia appears to be growing rather than shrinking, while as of 2010 in the US numbers have risen to the point where approximately 15.6% of the population (29 million) will engage in illicit drug use at some stage in life, with around 2.9% (5.4 million) going on to develop substance abuse (Koob & Volkow, 2010, p. 217). The AIHW reports appears to rely on self-reporting and detections/arrest made by police (AIHW, 2006), meaning that these numbers could be inaccurate. The reports also make no attempt to explain the reasoning behind the noted increase. Moore and Fraser, on the other hand, note that current government episode-of-care treatment systems operating in Australia are bureaucratically bound to provide services only to those who present as “addicts” (Moore & Fraser, 2013, p. 918), indicating that individuals with general social welfare or health issues outside of addiction are choosing to present as addicts in order to obtain access to required services. This could further skew results, as “the system produces ‘addicts’ as an effect of policy imperatives” (Moore & Fraser, 2013, p. 916), and could also explain the AIHW’s finding that those living in socioeconomically disadvantaged areas constitute a ‘vulnerable group’ when it comes to addiction (AIHW, 2011). These individuals are more likely to require access to social resources, and so interact with these programs. Regardless of exact numbers, addiction remains a significant problem within Australia, one relatively unchanged since at least 1991 when prevalence rates were similar to 2004 (AIHW, 2007) and 2010 data (AIHW, 2011). The literature is increasingly recognising that a lack of understanding of how the wider spectrum of factors contributing to the development of drug addiction interrelate could explain why methods to address this problem have to date had little impact. Dunbar, Kushnar and Vrecko (2010, p. 3) recognize a “biology/culture dualism” affecting the understanding of drug addiction - many studies focus exclusively on the social, cultural and political aspects of addiction, at the expense of any consideration of the physiologic, biochemical and neurobiological considerations. The understanding that drug addiction is a loss of control over whether or not to take a drug as compared to recreational use purely for enjoyment at the whim of the user is clear (Li, Mao & Wei, 2008, p. 31; Koob & Volkow, 2010, p. 17), and the range of individual factors contributing to the development of an addiction is equally evident in the literature. Social factors include place-based factors such as a geographical area’s socioeconomic status (Thomas, Richardson & Cheung, 2008), the access a potential problem user has to social aid services (Lingford-Hughes et al, 2003, p. 211; Dunbar et al, 2010), and the overarching policies of the various governing jurisdictions (Thomas et al, 2008). Psychological factors are described by a cycle of evolving drug addiction, where a user gradually moves away from controlled drug use for pleasure towards a negative reinforcement compulsive state as they seek to avoid unpleasant withdrawal symptoms and have little control over their own use (Koob & Volkow, 2010, p. 219; Matthews, 2010, p. 23-24). The presence or absence of support nets (friends and family) and any coexisting disorders will also contribute (Robinson & Berridge, 2003). Finally, physiological factors include the drug-induced dopamine incentive arousal cycle of self-reinforcement (Di Chiara et al, 2004; Dunbar et al, 2010), and the physical restructuring of neural pathways (Koob & O’Brien, 2010) towards drug-seeking behaviours that occurs with sustained drug use (Gould, 2010; Kuhar, 2010). Research into genetic predisposition towards addiction is still in the early stages, but is also likely to constitute as a contributory factor (Li et al, 2008, p. 33; Welburg, 2010; Volkow & Muenke, 2012, p. 774-775). These factors are all well established in the literature, but what is missing is an understanding of how these all tie together to cause addiction. Addiction cannot be reduced to a single domain; social, psychological and biological factors all interrelate to cause it. The “Addiction, the Brain and Society” conference held in Atlanta on Feb 2009 was an interdisciplinary discussion on drug addiction and the many factors contributing to it, and was held as a direct recognition of this problem. The papers presented ranged from historical epidemiologies of addiction in society (Berridge, 2009; Acker, 2010), the neuroscience of addiction (Gabriel, 2009; Campbell, 2010; Courtwright, 2010), to social perspectives (Kushner, 2006; Kusher, 2010) and political economic impacts on addiction (Rasmussen, 2010; Vrecko, 2010). A critique of all these papers is beyond the scope of this review, and is beside the point: the conference was designed to expose single-focused experts on particular factors of addiction, and the greater literature, to the wider context of the problem, in an attempt to reconcile disparate approaches and bridge the gap between medical and social scientists (Dunbar et al, 2010, p. 6). It appears at this early stage to be working. Windle’s ‘Multilevel Developmental Contextual Approach’ to substance use and abuse actively attempts to move beyond the concept of “simple, single-cause explanations” (Windle, 2010, p. 9) for substance use disorders towards a consideration of the multiple and dynamic factors behind the development of an addiction. This model attempts to consider genetic, biochemical, physiological, cognitive, social and societal factors behind the development of an addiction, while also recognizing that the expression and prevalence of an addiction will vary across individuals and times. Verster, Brady and Galanter (2012) take an even deeper look, dedicating individual chapters to the neuroscientific, genetic, epidemiological and social aspects of drug addiction and how they influence each other. Both are theoretical at this stage, and are yet to be proven practically through real-world application, but reflect the recognition that the current understanding and treatment of drug addictions and the dynamic factors contributing to them is inadequate. A broader understanding of addiction is still in its nascent stages, and any application to real-world treatment programs even more so, but with data suggesting that Australian drug use has remained relatively unchanged for several decades (AIHW, 2007; AIHW, 2011) and the problem recognised in the literature (Dunbar et al, 2010; Windle, 2010) **Cultural and Social Analysis:** The problem is obvious in the data; percentages of the Australian population using drugs remaining fairly steady since at least 1991 coupled with the growing population over that time, with a 1.9 million resident increase between 2007 and 2012 alone (Australian Bureau of Statistics, 2013), indicates a steadily growing problem. Attempts so far to treat drug addiction through a single approach are having limited effect, and Moore & Fraser (2013) show that some programs designed to treat addiction can in fact be at the least clouding the results and at worst contributing to the problem rather than alleviating it. As a single-focus approach isn’t working, the next logical step would be a review of the current understanding and approach to addiction, making use of an ever-growing body of knowledge. Interdisciplinary understanding and treatments aimed at dealing with //all// the factors contributing to an individual’s disorder could contribute to a definitive mode of treatment for problem users. This requires more communication between experts and fields, a process whose beginnings can already be seen in events like the “Addiction, the Brain and Society” conference mentioned earlier (Dunbar et al, 2010) and the WHO Commission on Social Determinants of Health calling for multisectoral research and policy on the recognized multiple and interlinking factors shaping health outcomes (Ward et al, 2011, p. 630), as well as recent works by authors like Windle (2010) and Verster, Brady and Galanter (2012). Data on individual success rates of programs incorporating a multifactorial approach combined with the overall picture of drug use in Australia from institutions like the AIHW and the ABS will be an interesting indicator of whether this approach is having its intended effect. **Analysis of Artefact and Own Learning Reflections:** So how does the Russell Brand interview tie in with all this? It demonstrates the above point concerning a focus on single factors being attributed to having a drug problem. Brand here blames his past addiction problems on prevailing social conditions perpetuated by society. No mention is made of psychological vulnerability or physiological processes, and in effect Brand is blaming the system over any personal decisions or weaknesses. Obviously in the context of the interview this was to make a point, but it still highlights and epitomises many of the current views towards addiction, what contributes to it, and how it can be treated. As a paramedic I will likely come across addiction quite frequently and so a proper understanding of the situation will be essential, influencing my assessment and treatment (both professionally and personally) of any problem users I may come in contact with. My traditional reaction, when I’ve ever thought about addiction at all, was to attribute blame to the individual. While this is still a factor, other considerations at a larger structural level also play a part, something I’ll be keeping in mind for the future. **Reference List: (APA Print)** Acker, C. (2010). “How crack found a niche in the American ghetto: the historical epidemiology of drug-related harm”, //BioSocieties, 5//(1): 70-88. doi:10.1057/biosoc.2009.1 Australian Bureau of Statistics. (2013). Regional population growth, Australia, 2012. Canberra: ABS. Retrieved from [|http://www.abs.gov.au/ausstats/abs@.nsf/Products/3218.0~2012~Main+Features~Main+Features?OpenDocument#PARALINK0] Australian Institute of Health and Welfare. (2007). “Statistics on drug use in Australia 2006”. //Cat. no. PHE 80//. Canberra: AIHW. “ Retrieved from [] Australian Institute of Health and Welfare. (2011). “Drugs in Australia 2010: tobacco, alcohol and other drugs”. //Drug statistics series. Cat. no. PHE 154//. Canberra: AIHW. Retrieved from []. Berridge, V. (2009). “Smoking and the ‘discover of addiction’. Paper presented at the Addiction, the Brain and Society Conference, Emory University, Atlanta, GA. Retrieved from [] Campbell, N. (2010). “Towards a critical neuroscience of ‘addiction’”, //BioSocieties, 5//(1). 89-104. doi:10.1057/biosoc.2009.2 Courtwright, D. (2010). “The NIDA brain-disease paradigm: History, resistance, and spinoffs”, //BioSocieties, 5//(1). 137-147. doi:10.1057/biosoc.2009.3 Di Chiara, G., Bassareo, V., Fenu, S., De Luca, M.A., Spina, L., Cadoni, C., … Lecca, D. (2004). “Dopamine and drug addiction: the nucleus accumbens shell connection”, //Neuropharmacology, 47//(Supp 1). 227-241. doi: 10.1016/j.neuropharm.2004.06.032 Dunbar, D., Kushner, H.I. & Vrecko, S. (2010). “Drugs, addiction and society”, //BioSocieties, 5//(1). 2-7. doi: 10.1057/biosoc.2009.10 Foddy, B. & Savulescu, J. (2010). “A liberal account of addiction”, //Philosophy, Psychiatry & Psychology, 17//(1). 1-22. Retrieved from http://search.proquest.com/docview/347842731?accountid=13380 Gabriel, J. (2009). “Consuming subjects: Interpretive flexibility, historicity, and biopower in addiction research”, //BioSocieties, 5//(1). Retrived from [] Gould, T.J. (2010). “Addiction and cognition”, //Addiction Science and Clinical Practice 2010, 5//(2). 4-14. Retrieved from [] Kalivas, P.W. & O’Brien, C. (2008). “Drug addiction as a pathology of staged neuroplasticity”, //Neuropsychopharmacology 2008//(33). 166-180. doi: 10.1038/sj.npp.1301564 Koob, G.F. & Volkow, N.D. (2010). “Neurocircuitry of addiction”, //Neuropsychopharmacology 2010//(35). 217-238. doi: 10.1038/npp.2009.110 Kuhar, M. (2010). “Contributions to basic science to understanding addiction”, //BioSocieties, 5//(1). 25-35. doi: 10.1064/biosoc.2009.10 Kushner, H. (2006). “Taking biology seriously: The next task for historians of addiction?”, //Bulletin of the History of Medicine, 80//(7). 114-143. doi: 10.1353/bhm.2006.0025 Kushner, H. (2010). “Toward a cultural biology of addiction”, //BioSocieties, 5//(1). 25-35. Retrieved from [] Li, C-Y., Mao, X. & Wei, L. (2008). “Genes and (common) pathways underlying drug addiction”, //PLoS Computational Biology, 4//(1). 28-34. doi: 10.1371/journal.pcbi.0040002 Lingford-Hughes, A.R., Davies, S.J.C., McIver, S., Williams, T.M., Dalglish M.R.C. & Nutt, D.J. (2003). “Addiction”, //British Medical Bulletin 2003//(65). 209-222. doi: 10.1093/bmb/ldg65.209 Matthews, E. (2010). “Explaining addiction”, //Philosophy, Psychiatry, & Psychology, 17//(1). 23-27. doi: 10.1353/ppp.0.0276 Moore, D. & Fraser, S. (2013). “Producing the “problem” of addiction in drug treatment”, //Qualitative Health Research 23//(7). 916-923. doi: 10.1177/1049732313487027 Rasmussen, N. (2010). “Maurice Seevers, the stimulants, and the political economy of addiction in American medicine”, //BioSocieties, 5//(1). 105-123. doi: 10.1057/biosoc.2009.7 Renthal, W. & Nestler, E.J. (2008). “Epigenetic mechanisms in drug addiction”, //Trends in Molecular Medicine, 14//(8). 341-350. doi: 10.1016/j.molmed.2008.06.004 Ritzer, G. (2000), //Modern Sociological Theory// (5th ed.), McGraw-Hill. Robinson, T.E. & Berridge, K.C. (2003). “Addiction”, //Annual Review of Psychology 2003//(54). 25-53. doi: 10.1146/annurev.psych.54.101601.145237 Thomas, Y.F., Richardson, D., & Cheung, I. (2008). //Geography and drug addiction// [EBL]. Washington, D.C: Springer Verster, J.C., Brady, K. & Galanter, M. (2012). //Drug abuse and addiction in medical illness// [EBL]. Washington, D.C.: Springer Volkow, N.D. & Wise, R.A. (2005). “How can drug addiction help us understand obesity”, //Nature Neuroscience, 8//(5). 555-560. doi: 10.1038/nn1452 Volkow, N.D. & Muenke, M. (2012). “The genetics of addiction”, //Human Genetics 2012//(131). 773-777. doi: 10.1007/s00439-012-1173-3 Vrecko, S. (2010). “’Civilizing technologies’ and the control of deviance”, //BioSocieties, 5//(1). 36-51. doi:10.1057/biosoc.2009.8 Wagner, M.G. & Wagner, M.G. (1974). //A treatment program for drug addicted youth in Denmark// [EBL]. Washington, D.C.: ERIC Clearinghouse. Retrieved from [] Ward, P.R., Meyer, S.B., Verity, F., Gill, T.K. & Luong, T.C. (2011). “Complex problems require complex solutions: the utility of social quality theory for addressing the social determinants of health”, //BMC Public Health 2011//(11). 630-639. doi: 10.1186/1471-2458-11-630. Welberg, L. (2010). “Cracking the code of addiction”, //Nature Reviews Neuroscience, 11//(1). 29. doi: 10.1038/nrn2921 Windle, M. (2010) “A multilevel developmental contextual approach to substance use and addiction”, //BioSocieties,// //5//(1). 124-136. doi: 10.1057/biosoc.2009.9. http://healthcultureandsociety2013.wikispaces.com/page/messages/%27Rip+%26+Roll%27+Exploring+the+Prevalence+of+HIV+AIDS+in+Gay+Men+of+Australia
 * Reflection:**

http://healthcultureandsociety2013.wikispaces.com/page/messages/%27The+Junkie%27s+Prayer%27+-+Illicit+Substance+Use%2C+Criminalisation+and+the+Overlooked+Cycle

Jacob Serena n8382476