1. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 Tackling the World’s Addiction Problems: Global Insights Dr. Delon HUMAN Secretary-General: Africa Medical Association

2. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 OUTLINE What is Addiction ? Impact on Individuals and Society Ethics – the blind spot Preferred regulatory futures

3. Opium Den 1850s LONDON

5. 1,3 billion Kills up to half of its users

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

7. 3,3 million deaths per year due to the harmful use of alcohol (WHO 2014) and world’s 3 rd largest risk factor for disease burden

8. 2,5% of world population (147 million)

12. 13-15 million intravenous drug users

13. Havelock Slum, Durban, South Africa Biggest menace: WHOONGA drug (ARV, Cannabis, Battery acid)

14. 1,4 Billion overweight (20 yrs or older)

16. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 OUTLINE What is Addiction ? Impact on Individuals and Society Ethics – the blind spot Preferred regulatory futures

17. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 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?

18. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 “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

19. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 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

20. 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.

21. Drugs of Abuse Engage Systems in the Motivation and Pleasure Pathways of the Brain Drugs of Abuse Engage Systems in the Motivation and Pleasure Pathways of the Brain

22. Where in the brain is addiction localised? Different areas of the brain subserve different functions PET/SPECT and fMRI scanning can now test these theories

23. Kinetics = Speeding up brain entry Chewing tobacco Snuff Cigarettes Coca leaves Coca paste Cocaine Crack Opium Morphine Heroin Snorted heroin i.v./smoked heroin Faster brain entry  more effects  more addiction

24. Addiction – 3 elements Social factors Personal biological factors Drug factors

25. Negative Cycle of Psychological Addiction

27. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 OUTLINE What is Addiction ? Impact on Individuals and Society Ethics – the blind spot Preferred regulatory futures

28. Alcohol Statistics 3,3 million deaths, or 5,9% of all global deaths, were attributable to alcohol consumption (2012) Alcohol-related: 50% of stranger violence 50% of domestic violence 30% of child abuse 80% of A&E admissions (UK Alcohol Harm Reduction Strategy) Alcohol Liver Disease in Ireland (15 to 34 year olds) increased by 247% between 1995 and 2007 80% of alcohol related ill health in the poorest 10% of the population Civil disorder, anti social behaviour and petty crime

29. , Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 230 million people current users -just under 5% of the global adult population (UNODC, 2012) and 208,000 fatalities per year 200 substances: cannabis most commonly used, then amphetamines, heroin and cocaine HIV Infection: 3 million users per year New substances present a challenge (280 new synthetics in recent years) Illegal Drugs

30. 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

31. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 OUTLINE What is Addiction ? Impact on Individuals and Society Ethics – the blind spot Preferred regulatory futures

32. Stigmatization of Addiction

33. Simplistic view:

34. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 Are ethical values applied in addiction? Autonomy: Patients’ right to self-determination Beneficence: Serve the best interests of individual patients Non-maleficence: "First, do no harm” Justice: Distribution of scarce health resources Dignity: Right to dignity Truthfulness and honesty

35. Principle of proportionality in Public Health Ethics Constraining policies should be proportionate to the harms being controlled and the benefits produced Ongoing assessment needed Examples : > Methadone used in heroin addiction > Snus ban in Europe > Current example of E-cigarettes

36. 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

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

38. 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

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

40. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 OUTLINE What is Addiction ? Impact on Individuals and Society Ethics – the blind spot Preferred regulatory futures

41. 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

42. 42 Developing Evidence-Based Policy SCIENCE POLITICS / DIPLOMACY GOVERNANCE

43. Addiction: Regulatory approaches Public Health Approach - disease - disease - treatment - treatment -precautionary principle -precautionary principle Public Safety Approach - illegal behavior - illegal behavior - punish - punish

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

45. 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…

47. “Electronic cigarettes are aggravating the tobacco epidemic among youth” BUT - Correlation between E-cig use and higher and more sustained levels of smoking -This was a cross-sectional study, so not possible to detemine which came first LESSON DO NOT CONFUSE CORRELATION WITH CAUSATION !!! Glantz Report on E-cigarettes (March 2014, JAMA Pediatrics)

48. Preferred future: Risk basis for regulation & use

49. Nutt et al Lancet 2007 tobacco alcohol

50. Addiction: Our Compulsions & Brain Reward Systems AAAS Chicago, Friday 14 February, 2014 WHO Role Preventing disease Preventing premature death Promoting health Mental Health Action Plan (2013- 2020)

51. 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

52. Addiction: Ethics, Integrity & The Policy-Maker Brussels, Tuesday 10 June 2014 THANK YOU !!