ESOF 2014 Copenhagen, Denmark Addictions & Brain Reward Systems Dr. Delon HUMAN Secretary-General: Africa Medical Association President, Health Diplomats

ESOF 2014 Copenhagen, Denmark OUTLINE Addiction – the medical view Impact on Individuals and Society Example 1: Alcohol Example 2: Tobacco Preferred future

1,3 billion Kills up to half of its users

In UK 1 death per day from alcohol poisoning, 3 with other drugs 5 from alcohol-related RTAs Nutt 2006 Journal of Psychopharmacology editorial

2,5 million deaths per year due to the harmful use of alcohol and world’s 3 rd largest risk factor for disease burden

ESOF 2014 Copenhagen, Denmark OUTLINE Addiction – the medical view Impact on Individuals and Society Example 1: Alcohol Example 2: Tobacco Preferred future

ESOF 2014 Copenhagen, Denmark Persistent, compulsive DEPENDENCE on a behaviour or substance SUBSTANCES: E.g. Smoking, alcohol, drugs PROCESS ADDICTIONS: E.g. Overeating, gambling, video games, shopping, sexual activity What is ADDICTION?

ESOF 2014 Copenhagen, Denmark “Over consumption” Unable to stop Time spent on procuring, using and recovering Cravings Continued use despite problems Anti-social behaviour Use despite danger Use despite physiological problem Tolerance Withdrawal symptoms DSM V Symptoms of ADDICTION

ESOF 2014 Copenhagen, Denmark Tobacco Alcohol Cannabis Caffeine Hallucinogens (e.g. phencyclidine) Inhalants, Opoids, Sedatives Stimulants (e.g. amphetamine-type) Unknown substances DSM V: 10 Classes of Addictive Substances

The Orphan of Public Health: Mental Illness Set of medical conditions that affect a person’s thinking, feeling, mood, ability to relate to others and daily functioning In 2002, 154 million people suffered from depression globally, 25 million people from schizophrenia and over 100 million people suffered from alcohol or drug abuse disorders (WHO, 2011a) Close to 900,000 people die from suicide each year.

ESOF 2014 Copenhagen, Denmark OUTLINE Addiction – the medical view Impact on Individuals and Society Example 1: Alcohol Example 2: Tobacco Preferred future

Stigmatization of Addiction

Simplistic view:

Negative Cycle of Psychological Addiction

ESOF 2014 Copenhagen, Denmark OUTLINE Addiction – the medical view Impact on Individuals and Society Example 1: Alcohol Example 2: Tobacco Preferred future

Alcohol

Can lead to addictive disorder = Alcoholism Alcoholism a chronic, relapsing disorder UK: Harm to self and others inflicted by alcohol exceeds that caused by heroin or cocaine 10% of disability-adjusted years lost due to harmful use of alcohol (Industrialized countries) 3,3 million deaths, or 5,9% of all global deaths, were attributable to alcohol consumption (2012) USA: 12% of population affected by alcoholism at some point

Alcohol Statistics Alcohol-related: 50% of stranger violence 50% of domestic violence 30% of child abuse Alcohol Liver Disease in Ireland (15 to 34 year olds) increased by 247% between 1995 and % of alcohol related ill health in the poorest 10% of the population Civil disorder, anti social behaviour and petty crime

Alcohol Most of us have a relationship with alcohol Unlike nicotine, alcohol causes cognitive change “Once addicted always addicted” A continuum where all are at risk Dichotomy of health based approach when many of the related problems are behaviour driven

Current Issues WHO advises no safe level of drinking. NCD action plan: 10% target reduction of alcohol use by 2025 “Less is better” advice to young women Measurement of alcohol consumption: units or grams of ethanol? Minimum pricing policies Access to treatment

ESOF 2014 Copenhagen, Denmark OUTLINE Addiction – the medical view Impact on Individuals and Society Example 1: Alcohol Example 2: Tobacco Preferred future

Approximately 1,3 billion cigarette smokers Up to half of of world’s cigarette smokers will die prematurely from tobacco-related disease Nearly 80% of world’s smokers live in low and middle income countries In poorest households, more than 10% of expenditure on cigarettes Single most preventable cause of death Tobacco (Cigarette) Dependence

Source: Matrix for the European Commission Nicotine delivery

Banning snus in the EU ethical?

Public Health Perspective Smoking Prevalence & Lung Cancer Mortality in the EU

Cancer Rates in Sweden vs EU

Is it ethical to deny cigarette smokers the choice to switch to E-cigarettes? 2% use in 2010, while 30% of smokers tried E-cigs in 2012

CONCERNS Perpetuates addiction Gateway effect Decrease in cessation Increased relapse rates Renormalization of smoking

Why people use E-cigarettes Health: Perceived as less toxic than tobacco products Cessation: To aid in quit smoking or to avoid relapsing Cravings: To deal with cravings or other tobacco withdrawal symptoms Cost: Cheaper than cigarettes Enjoyment No second hand smoke Cutting down: To reduce combustible tobacco intake

Aids used in most recent quit attempt N=4,164 adults who smoke and tried to stop or who stopped in the past year

Tobacco / Nicotine Research Needed Clear product safety and quality standards Differentiation of risk between different nicotine- containing products Debunking ‘equivalence’ between smoking and e- cigarette use Rectifying misconceptions about the toxicity of nicotine Behavioural studies on nicotine using behaviour Health economic studies Developing appropriate marketing, pricing and tax mechanisms Testing the gateway effect

ESOF 2014 Copenhagen, Denmark OUTLINE Addiction – the medical view Impact on Individuals and Society Example 1: Alcohol Example 2: Tobacco Preferred future

We have failed to decrease the morbidity and premature mortality from addiction and mental illness The path to better health outcomes in addiction is through better science More people are getting worse on today’s treatment, and too few new diagnostics and treatment (only 3 new medications approved by the FDA in the last 10 years) Inconvenient truths about addiction

Accept harm reduction as basis for regulation Pragmatic rather than absolutist solutions

Nutt et al Lancet 2007 tobacco alcohol

Preferred future: Risk basis for regulation & use

Where Do We Need to Go From Here? Where Do We Need to Go From Here? We Need to… Advance the SCIENCE Erase the STIGMA and to… Erase the STIGMA and to…

ESOF 2014 Copenhagen, Denmark WHO Role Preventing disease Preventing premature death Promoting health Mental Health Action Plan ( )

42 Developing Evidence-Based Policy SCIENCE POLITICS / DIPLOMACY GOVERNANCE

1st Consideration: How best to save lives & prevent disease Differentiation of product, risk, consumer and science Invest in science to support evidence-based policy (balance between individual and population-based science) Scientifically accurate, precise health & risk communication Roadmap to preferred regulatory future

ESOF 2014 Copenhagen, Denmark THANK YOU !!