Have we got the balance right? Return on investment from brain, behavioural and social sciences in the field of addiction Robert West University College 1

2 Declaration of interests I undertake research and consultancy for companies that develop and manufacture smoking cessation medications I am a trustee of QUIT I am co-director of the NHS Centre for Smoking Cessation and Training My salary is funded by Cancer Research UK

Outline 1.Definitions 2.Models of addiction 3.A strategy for developing and evaluating behaviour change interventions 4.Where can we best deploy future resources? 3

Defining addiction An individual is addicted to an activity (characteristically ingestion of a drug) to the extent that he or she experiences repeated strong motivation to engage in it as a result of learning, with potentially harmful consequences 1 4 StrengthThe relative strength of motivation to engage in the addictive behaviour relative to other activities SeverityThe degree of current or expected harm arising from the addictive behaviour 1Developed from West and Brown 2013 Theory of Addiction. Oxford: Wiley- Blackwell

Neuroscience and behavioural science Neuroscience a branch of the life sciences that deals with the anatomy, physiology, biochemistry, or molecular biology of nerves and nervous tissue and especially with their relation to behaviour and learning Behavioural science a branch of science (drawing on psychology, neuroscience, economics, sociology, or anthropology) that deals primarily with human action and often seeks to generalize about human behaviour in society 5

Neuroscience and behavioural science 6 Neuroscience Behavioural science

Defining return on investment Return on investment from scientific study of a problem is the benefit to society arising from that study This may involve Creating a societal and/or professional level of understanding that generates more adaptive ways of thinking about that problem Developing better specific interventions for addressing the problem 7

Models of addiction ModelCause of addiction Powerful rewardEnjoyment or satisfaction Self-medicationAttempted alleviation of distress or dysfunction Withdrawal reliefRelief from adverse effects of abstinence Acquired driveStrong learned biologically generated wants and needs Impaired executive function Low self-control in the face of internally and externally generated motivational pressures HabitStrong learned stimulus impulse associations Social constructLabel used by individuals and social groups to serve particular functions 8 What is causing the high relative strength of motivation? 1 1 West (2014) Models of Addiction. Lisbon: EMCDDA

Focusing on specific interventions to combat addiction: ‘Intervention functions’ Education (inform) Persuasion (promote) Incentivisation (provide material rewards) Coercion (imprison, tax, fine, disapprove) Training (develop life skills) Restriction (set rules) Environmental restructuring(reduce access, restrict marketing) Modelling (set an example) Enablement (medicate, counsel, support) 9 Michie et al 2013 The Behaviour Change Wheel Guide to Intervention Development. London: Silverback

Strategy for developing behaviour change interventions 1.Define behavioural target 2.Behavioural diagnosis 3.Identify potentially useful broad intervention functions 4.Develop and implement more specific behaviour change techniques (BCTs) 5.Cycle through development, implementation and testing as required 10

The COM-B Model of behaviour (Rev 1) 11 Capability Motivation Opportunity Behaviour Psychological Physical Reflective Automatic Physical Social Influences Moderate influence 1 Michie et al 2013 The Behaviour Change Wheel Guide to Intervention Development. London: Silverback

Behavioural diagnosis in addiction What needs to change in order to combat addiction in a given context for a given population? 12 Psychological capability Improve effectiveness of self-regulatory processes and activities Reflective motivation Induce greater perceived cost and lower perceived benefit, or more effective plans Automatic motivation Reduce the addictive want, need, or habit, and/or strengthen competing wants, needs or habits Physical opportunity Restrict access and physical cues Social opportunityReduce supporting norms and social cues and/or increase conflicting norms

Ontology of behaviour change interventions Intervention Mechanism of action Outcome UsageContext Michie and West 2015 Manuscript under review Mechanisms of action cannot be seen in isolation Population Setting Other behaviours Reach Engagement Content Delivery Effect size Confidence

Neuroscience and mechanisms of action Identify relevant Neuro-anatomical structures Neurochemical activity Goal is to Find better drug targets Inform psychological and social interventions Improve understanding of the brain 14

Contribution of neuroscience to specific interventions Contribution An intervention or intervention strategy that has been developed from, or informed by, theories and models in neuroscience 15 Addictive behaviourContribution 1 TobaccoVarenicline, nicotine replacement therapy, bupropion, cytisine Stimulants? AlcoholAcamprosate, Naltrexone OpiatesMethadone, Buprenorphine Cannabis? Gambling? 1 Based on Cochrane reviews

Contribution of psychological and social sciences 16 Addictive behaviourContribution 1 TobaccoPrice increases, social marketing, brief advice, financial incentives, behavioural support for cessation, refusal skills training StimulantsContingency management AlcoholPrice increases, access restriction, brief advice, online support Opiates? Cannabis? Gambling? 1 Based on Cochrane reviews

The future Need a major review of research strategy underpinning approaches to combating addiction It needs to Set clear criteria against which to assess potential contribution Use a comprehensive, coherent framework for understanding behaviour change Involve a reflective approach in which all options are considered against the relevant criteria Make recommendations to funders for research priorities in terms of amounts and topics 17