tag:theconversation.com,2011:/ca/topics/addiction-421/articlesAddiction – The Conversation2024-03-26T16:40:09Ztag:theconversation.com,2011:article/2242542024-03-26T16:40:09Z2024-03-26T16:40:09ZWant to quit vaping? There’s an app for that<figure><img src="https://images.theconversation.com/files/579066/original/file-20240229-21-z0wh8.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-tattoos-on-arms-hands-2271193519">SeventyFour/Shutterstock</a></span></figcaption></figure><p>More Australians than ever are vaping, according to recently released data.</p>
<p>The National Drug Strategy Household Survey <a href="https://www.aihw.gov.au/getmedia/b8b298cc-6d3f-4ab0-a238-9bd63f300c09/national-drug-strategy-household-survey-2022-2023.pdf?v=20240229072409&inline=true#:%7E:text=interpreted%20with%20caution.-,Use%20of%20illicit%20drugs%20increases%2C%20driven%20by%20hallucinogens,million%20people%20had%20done%20so.">shows</a> the proportion of Australians aged 14 and over who, in 2022–2023, said they currently vaped was 7%. In 2019 it was just 2.5%. Users are most likely to be aged 18-24.</p>
<p>As we learn more about the potential harms of vaping, <a href="https://www.mdpi.com/2673-995X/4/1/3">many</a> will be keen to quit.</p>
<p>But because vapes have only been widespread in recent years, there is <a href="https://www.sciencedirect.com/science/article/abs/pii/S0306460321000836">limited evidence</a> on how to go about quitting. With the addictive nature of nicotine-containing vapes, it can also be hard to stop vaping on your own.</p>
<p>Could apps be the answer? The <a href="https://www.statista.com/statistics/730101/australia-smartphone-ownership-by-age/">vast majority</a> of young people have a smartphone. And we know apps have helped people <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2770816">quit smoking</a>. So why not use apps to help people quit vaping?</p>
<p>But which apps are best? And which app <a href="https://mhealth.jmir.org/2019/7/e11926/">features</a> should you look for? Our <a href="https://mhealth.jmir.org/2024/1/e55177">recently published study</a> gives us some clues.</p>
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Read more:
<a href="https://theconversation.com/could-messages-from-social-media-influencers-stop-young-people-vaping-a-look-at-the-governments-new-campaign-224621">Could messages from social media influencers stop young people vaping? A look at the government's new campaign</a>
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<h2>We tested 30 apps</h2>
<p>We searched the Apple iTunes and Google Play stores in May 2023 to identify apps available in Australia claiming to help people quit vaping.</p>
<p>We then made a shortlist of 20 iOS apps and ten Android apps to assess for:</p>
<ul>
<li><p><a href="https://mhealth.jmir.org/2015/1/e27/">quality</a> (including ease of use, how it engaged users, appearance, and the information it conveyed)</p></li>
<li><p>the potential to <a href="https://mhealth.jmir.org/2019/1/e11130">change behaviour</a> (including setting goals, making an action plan, identifying barriers, monitoring progress and giving feedback).</p></li>
</ul>
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Read more:
<a href="https://theconversation.com/my-teen-is-addicted-to-vaping-how-can-i-help-them-quit-and-manage-their-withdrawal-symptoms-208586">My teen is addicted to vaping. How can I help them quit and manage their withdrawal symptoms?</a>
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<h2>Here’s what we found</h2>
<p>The highest rated app overall was the iOS app <a href="https://apps.apple.com/au/app/quit-smoking-stop-vaping-app/id1641262016">Quit smoking. Stop vaping app</a>. This had 19 out of 21 features known to help people change behaviour.</p>
<p>The highest rated app for Android devices was <a href="https://play.google.com/store/apps/details?id=com.despdev.quitsmoking&hl=en_US">Quit Tracker: Stop Smoking</a>, with 15 behaviour change features. </p>
<p>The highest rated app for both <a href="https://play.google.com/store/apps/details?id=org.instaquit.app&hl=en_US">Android</a> and <a href="https://apps.apple.com/us/app/quitsure-quit-smoking-smartly/id1523992725">iOS users</a> was the QuitSure Quit Smoking Smartly app. This had 15 behaviour change features for iOS users and 14 for Android users.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/579068/original/file-20240229-20-gjbt99.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Quit vaping app" src="https://images.theconversation.com/files/579068/original/file-20240229-20-gjbt99.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579068/original/file-20240229-20-gjbt99.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=308&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579068/original/file-20240229-20-gjbt99.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=308&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579068/original/file-20240229-20-gjbt99.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=308&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579068/original/file-20240229-20-gjbt99.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=387&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579068/original/file-20240229-20-gjbt99.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=387&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579068/original/file-20240229-20-gjbt99.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=387&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">This ‘Quit smoking. Stop vaping app’ had the most features known to help people change behaviour.</span>
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Read more:
<a href="https://theconversation.com/my-teens-vaping-what-should-i-say-3-expert-tips-on-how-to-approach-the-talk-196205">My teen's vaping. What should I say? 3 expert tips on how to approach 'the talk'</a>
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<h2>So what should I look for?</h2>
<p>There are key <a href="https://mhealth.jmir.org/2019/7/e11926/">app features</a> to look for in an app that could help you change your behaviour. These features also apply to apps helping people to quit alcohol, or to take more exercise, for instance. These features include:</p>
<ul>
<li><p><strong>full customisability</strong>, allowing individuals to tailor the app to their needs</p></li>
<li><p><strong>goal setting</strong>, allowing individuals to create their own goals, monitor their progress, then update them over time. This is <a href="https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2017.00915/full">more likely</a> to lead to positive behaviour change</p></li>
<li><p><strong>external help</strong>, allowing users to access more help or advice, directly from the app</p></li>
<li><p>apps that are <strong>easy to use</strong> or navigate, so users are more likely to stick with the app.</p></li>
</ul>
<p>But not all apps we assessed scored highly on these. On average, apps only had about nine out of 21 behaviour change features. And only 12 of the 30 apps included a goal-setting feature.</p>
<p>The overall quality of the apps was moderate – scoring about three out of five. While apps were easy to use and navigate, we found they were not always transparent in who funded or developed them.</p>
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<strong>
Read more:
<a href="https://theconversation.com/how-apps-and-influencers-are-changing-the-way-we-sleep-for-better-or-for-worse-211749">How apps and influencers are changing the way we sleep, for better or for worse</a>
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<h2>Future apps</h2>
<p>Earlier research shows quit smoking apps <a href="https://mhealth.jmir.org/2019/7/e11926/citations">rate higher</a> for their potential to change behaviour than ones to quit vaping.</p>
<p>In one study, researchers found more than half of users of one quit smoking app were still not smoking <a href="https://formative.jmir.org/2023/1/e51658">after a month</a>.</p>
<p>So app developers could look at quit smoking apps to identify strategies and features to develop or update quit vaping apps.</p>
<p>App developers need to create apps with comprehensive goal-setting features. These apps need to be trialled or tested by the developer, users or an external party. This is important as, to our knowledge, no publicly available app has undergone such testing.</p>
<p>As many young people vape to <a href="https://www.sciencedirect.com/science/article/abs/pii/S0306460322001319?via%3Dihub">relieve stress or anxiety</a>, future apps could provide extra features, such as meditation, cognitive behaviour therapy and relaxation.</p>
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<p>Apps need to align with current <a href="https://www.health.nsw.gov.au/tobacco/Publications/e-cigarette-young-people-guide.pdf">guidelines</a> on how to quit vaping, so evidence-based messaging is consistent. Unfortunately, information and guidelines on quitting vaping are in their infancy and vary across different countries or jurisdictions.</p>
<p>Developers also need to ensure they disclose who owns and paid for the app. Is it a commercial company, a research group, a government agency, or a not-for-profit? We found it difficult to tell during our analysis.</p>
<p>Last of all, quit vaping apps need to be updated and improved over time, to iron out bugs, make improvements as the evidence changes, and to respond to changes in how users behave.</p>
<p>In an ideal world, we’d see partnerships between app developers, people who vape, researchers and experts in health behaviour change to develop and update quit vaping apps – ones with the highest chance of actually shifting people’s behaviour.</p>
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<p><em>We wish to thank Lilian Chan, Rebecca Cerio, Sandra Rickards, Phillipa Hastings, Kate Reakes and Tracey O’Brien from Cancer Institute NSW for their assistance with this research.</em></p><img src="https://counter.theconversation.com/content/224254/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fiona McKay has previously received funding from Cancer Institute NSW (which funded this study) and VicHealth.</span></em></p><p class="fine-print"><em><span>Matthew Dunn has previously received funding from Cancer Institute NSW and VicHealth, and currently receives funding from VicHealth. </span></em></p>Here’s what to look for when you’re browsing for apps.Fiona McKay, Associate Professor of Health Equity, Deakin UniversityMatthew Dunn, Senior Lecturer in Public Health, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2235392024-02-27T17:35:27Z2024-02-27T17:35:27ZGovernments must avoid policies that stigmatize those recovering from addiction<p>British Columbia is experiencing an <a href="https://app.powerbi.com/view?r=eyJrIjoiMmIzN2UyYTItNmM0Yi00MGZhLWI1NDUtOTRhZGNjYTBhZDJlIiwidCI6IjZmZGI1MjAwLTNkMGQtNGE4YS1iMDM2LWQzNjg1ZTM1OWFkYyJ9">unprecedented opioid crisis</a>. Drug overdoses are the <a href="https://www.timescolonist.com/bc-news/overdoses-the-leading-cause-of-death-in-bc-for-those-aged-for-10-to-59-coroner-7908352#:%7E:text=Opinion-,Overdoses%20the%20leading%20cause%20of%20death%20in%20B.C.%20for%20those,ten%20months%20of%20this%20year">leading cause of death</a> in the province for those aged 10 to 59. B.C., and all of Canada, are <a href="https://www.canada.ca/en/health-canada/services/substance-use/canadian-drugs-substances-strategy.html">trying hard to help</a> those with substance abuse problems and addictions. </p>
<p>Among the responses are <a href="https://www2.gov.bc.ca/gov/content/overdose/reducing-stigma">calls to destigmatize addiction</a>. Mostly, these calls encourage us to consider how the language we use can stigmatize people struggling with addiction. Language does of course have a powerful impact, but not as powerful as policy.</p>
<p>I am the executive director of a <a href="https://www.fraserhealth.ca/Service-Directory/Services/mental-health-and-substance-use/substance-use/bed-based-treatment-services">bed-based treatment facility</a> in Metro Vancouver. We help people dealing with substance abuse get better. My doctoral research is on addiction stigma. It gives me a unique perspective on the roadblocks to getting out of addiction. </p>
<p>In my work, we often come across B.C. government policies requiring a minimum amount of sobriety, usually a year, before enrolment. Most commonly, these are associated with educational programs for those doing work connected to mental health and addictions. It also occurs in provincial programs aimed at employment or re-training. </p>
<p>We say we want to destigmatize addictions. But if we are refusing to help people in recovery get back to work or school, what are we actually doing?</p>
<h2>Policies discouraging recovery</h2>
<p>These policies <a href="https://doi.org/10.1080/07347324.2021.1917323">stigmatize</a> people in <a href="https://doi.org/10.1080/1556035X.2010.523364">early recovery</a> by essentially telling them they aren’t sober enough to invest in. This discourages them from staying in recovery. We are saying they aren’t good enough and, in some cases, they hear that they’ll <a href="https://doi.org/10.1007/s11673-017-9784-y">never be good enough</a>.</p>
<p>These policies are, in part, about risk aversion. Why put money into helping someone re-train if they are at high risk of relapsing? The average taxpayer may even agree that we should restrict who can access government programs along these lines. However, these policies are <a href="https://doi.org/10.1097/yco.0000000000000351">rooted in stigma</a>. They <a href="https://doi.org/10.1177/0261018319839158">fundamentally change how people experience the programs</a>, and risk aversion does more harm than good.</p>
<p>Let’s say, on average, the policy is that someone needs to be clean and sober for a year before they can access certain government services. This means the people who access the services will generally be pretty successful in completing those programs, considering they already have been sober a year. People get to school or work, agencies get a completion statistic, and we all get to feel good for helping someone get back on their feet. The policy means that people with a year sober get the help they deserve.</p>
<p>It also means <a href="https://doi.org/10.1080/10826080701681473">fewer people</a> will reach that year mark. <a href="https://doi.org/10.1080/10826080802289762">Recovery capital</a> is a concept that says having more support makes overcoming addiction easier. These supports are holistic and can include things like counsellors or mental health supports, but also hobbies, friends, and life fulfilment. School and work are big parts of recovery capital. People in recovery want to <a href="https://doi.org/10.1080/02791072.2018.1517909">feel like they are moving forward</a>. A rolling stone gathers no moss.</p>
<p>If someone is unable to count in their recovery capital the social support and life-meaning that school and work provide, they are less likely to succeed. We weaken people’s recovery capital when we exclude them from pursuing fulfilment. It can mean the difference between someone staying in recovery and <a href="https://doi.org/10.1080/16066359.2022.2039912">going back to their old ways</a>. </p>
<h2>Destigmatizing language</h2>
<p>B.C.’s strategy for destigmatizing addiction focuses on considering the language that we use. Stigmatizing language is damaging. It is mean and <a href="https://doi.org/10.1097/yco.0000000000000351">stops people from asking for help</a>. But part of my doctoral research asks: what is the worst of the worst? The answer I have so far is that stigmatization is at its worst when it <a href="https://doi.org/10.1111/j.1468-2435.1992.tb00776.x">marginalizes an individual</a>.</p>
<p>In terms of addiction and treatment, marginalization means socially separating someone who has nowhere else to go. When someone who has grappled with addiction throughout their entire life makes an effort to break free from its grip, only to encounter rejection, they experience marginalization. They don’t want to go back to addiction, but because of policies on sobriety, they cannot move forward.</p>
<p>Recovery requires <a href="https://www.routledge.com/Addiction-Behavioral-Change-and-Social-Identity-The-path-to-resilience/Buckingham-Best/p/book/9781138934085">re-learning how we see ourselves</a>. It is taking the jump from <a href="https://doi.org/10.3109/16066359.2015.1075980">one life to another</a>. It means getting vulnerable and asking for help. I’ve seen firsthand how important it is for people to feel accepted. It makes sense, considering they are putting themselves out there to start a new life. This feeling of insecurity is something we can all relate to. </p>
<p>We can destigmatize addictions and support people in recovery by creating policies that recognize the <a href="https://doi.org/10.1016/j.drugpo.2022.103609">difference between addictions and recovery</a>. We should not just tell people they are good enough; we should help them see themselves as worthy. </p>
<h2>Find balance in policy</h2>
<p>I’m not saying to completely do away with policies on sobriety requirements that provide structure for government services. There are <a href="https://www.worksafebc.com/en/health-safety/hazards-exposures/substance-use-impairment#:%7E:text=Impairment%20from%20substance%20use%20can,reaction%20time%2C%20and%20sensory%20perception">safety concerns</a> that agencies are not specialized in accommodating. But we need to recognize the impact that these policies have and seek balance. </p>
<p>In my experience, someone with three months of sobriety starting to get back into work or school is just as steadfast in their recovery as someone who has stayed sober for a year. This begs the question of who these policies are actually helping. Is someone who has been sober for months still struggling with addiction? Are we inadvertently marginalizing someone new to recovery by labeling them by their past rather than present? </p>
<p>We should not be afraid to give people in recovery a chance at getting a new life. By reconsidering these policies, we stand a better chance at destigmatizing addiction in a meaningful way. Hopefully, we can even save lives. </p>
<p>If you or someone you know is struggling with substance abuse, <a href="https://www.canada.ca/en/health-canada/services/substance-use/get-help-with-substance-use.html">know that there is help available</a>. Do not be afraid to ask for it.</p><img src="https://counter.theconversation.com/content/223539/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Max Weselowski is affiliated with InnerVisions Recovery Society of BC, a non-profit bed-based treatment provider. He is also affiliated with InnerStart Training & Education, which provides addictions-specific training programs. </span></em></p>Calls to destigmatize language around drug addiction must be combined with action to change policies that stigmatize people in early recovery.Max Weselowski, Doctoral student, College of Interdisciplinary Studies, Royal Roads UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2206552024-01-24T19:06:29Z2024-01-24T19:06:29ZHow Dostoevsky overcame his gambling addiction<figure><img src="https://images.theconversation.com/files/570509/original/file-20240121-27-zvcxdt.png?ixlib=rb-1.1.0&rect=4%2C4%2C3190%2C2045&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fyodor Mikhailovich Dostoevsky – Vasily Perov (1872).</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Vasily_Perov_-_%D0%9F%D0%BE%D1%80%D1%82%D1%80%D0%B5%D1%82_%D0%A4.%D0%9C.%D0%94%D0%BE%D1%81%D1%82%D0%BE%D0%B5%D0%B2%D1%81%D0%BA%D0%BE%D0%B3%D0%BE_-_Google_Art_Project.jpg">Public domain, via Wikimedia Commons</a></span></figcaption></figure><p>Dostoevsky had to write <a href="https://en.wikisource.org/wiki/The_Gambler_and_Other_Stories/The_Gambler">The Gambler</a> in two months. He had no choice. He had accepted 3,000 roubles from a publisher named Stellovsky to keep his creditors at bay. If he failed to deliver a work of not less than ten printer’s sheets (160 pages) by November 1, 1866, Stellovsky would receive the rights and income for all of Dostoevsky’s previous and future work for nine years. </p>
<p>Dostoevsky broke off writing <a href="https://www.gutenberg.org/ebooks/2554">Crime and Punishment</a> to take on the seemingly insurmountable task of completing a novel in such a sort period of time. He drew on his experience of being addicted to gambling.</p>
<p>His gambling mania had first seized him in 1863 on a tour of Europe, where he developed a passion for roulette. Dostoevsky soon fell into a pattern of chasing his losses, telling himself that his fortunes would change and he would redeem himself: </p>
<blockquote>
<p>…one turn of the wheel, and all will be changed, and those very moralists will be the first (I am convinced of that) to come up to congratulate me with friendly jests. And they will not all turn away from me as they do now. But, hang them all! What am I now? Zero. What may I be tomorrow? Tomorrow I may rise from the dead and begin to live again! There are still the makings of a man in me.</p>
</blockquote>
<h2>Boundless egoism</h2>
<p>In Crime and Punishment, an impoverished student named Rodion Raskolnikov murders an elderly pawnbroker with an axe. The reader follows his dialogue with himself until he confesses and seeks atonement for his actions. </p>
<p>In The Gambler, there is only a spiral downward with no landing point. Alexei Ivanovich, a tutor working for the family of a once wealthy general, initially shows no interest or desire to gamble. By the end, he is totally addicted to roulette. His character is transformed. From what Dostoevsky calls an aristocratic disinterest in winning (or losing), Alexi becomes a person with a plebeian willingness to lose his very last coin. </p>
<p>The “aristocratic” type gambles only for pure pleasure. The “plebeian” embraces the risk of gambling in the hope of changing his life – if only he can win big enough. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/570510/original/file-20240121-15-3rmndw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/570510/original/file-20240121-15-3rmndw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/570510/original/file-20240121-15-3rmndw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=923&fit=crop&dpr=1 600w, https://images.theconversation.com/files/570510/original/file-20240121-15-3rmndw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=923&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/570510/original/file-20240121-15-3rmndw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=923&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/570510/original/file-20240121-15-3rmndw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1160&fit=crop&dpr=1 754w, https://images.theconversation.com/files/570510/original/file-20240121-15-3rmndw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1160&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/570510/original/file-20240121-15-3rmndw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1160&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>The novel reminds the reader of what it is like to be drawn into a culture of gambling, where the first win at a roulette table (or in any form of gambling) is burned into one’s memory for ever. </p>
<p>The compulsive gambler holds on to the idea that continued gambling will, through improved skills, lead to proportionally higher rewards. But what takes hold in reality is the erroneous belief that they can develop an infallible gambling system, governed simply by the power of reason, which will allow them to conquer the ever-spinning roulette wheel. </p>
<p>Another trait evident in The Gambler is “boundless egoism” – this was <a href="https://www.encyclopedia.com/psychology/dictionaries-thesauruses-pictures-and-press-releases/dostoyevsky-and-parricide#:%7E:text=Source%20Citation,%2C%2021%2C%20173%2D196.">Sigmund Freud’s</a> reading of Dostoevsky. As the gambler becomes addicted, he loses all sense of socially motivated feelings, such as sympathy for family members or friends. </p>
<p>For Alexi, an emotional numbness prevails: </p>
<blockquote>
<p>I am living, of course, in continual anxiety. I play for the tiniest stakes, and I keep waiting for something, calculating, standing for whole days at the gambling table and watching the play; I even dream of playing – but I feel that in all this, I have, as it were, grown stiff and wooden, as though I had sunk into a muddy swamp. </p>
</blockquote>
<p>This is a heartfelt description of the internal experience of fear, hope, defeat and entrapment. Alexei reflects on where he is in life: his hopes and dreams, the “whole days” spent stuck in one spot “watching the play”. He loses all desire for Polina, his romantic interest at the start of the novel. He has “grown stiff” and “stuck”, despite the love, comfort and connection she might provide.</p>
<hr>
<p>
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Read more:
<a href="https://theconversation.com/crime-and-punishment-is-150-and-its-politics-are-more-relevant-than-ever-69259">Crime and Punishment is 150 – and its politics are more relevant than ever</a>
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<h2>Addiction and revelation</h2>
<p>The treatment of gambling addiction is not a topic in The Gambler – only Alexi’s tragic fall from grace. But without psychiatric knowledge, or perhaps in spite of his personal awareness of what he was describing at the time, Dostoevsky tapped into the raw experience of gambling and the issue of how to understand gambling addiction.</p>
<p>Our understanding of gambling addiction is still evolving. Treatments are being explored and developed. From 1980, the <a href="https://www.tandfonline.com/doi/full/10.1080/14459795.2019.1638432">American Psychiatric Association</a> included compulsive gambling in its Diagnostic and Statistical Manual of Mental Disorders as a form of impulse control disorder, alongside kleptomania and pyromania. </p>
<p>In 2013, gambling was reclassified as gambling disorder, within the substance-related and addictive disorders categorisation. This marked, among other things, a turn towards the investigation and use of pharmaceutical treatments, such as <a href="https://www.frontiersin.org/articles/10.3389/fnbeh.2013.00206/full">dopamine</a>, to control the gambling impulse. It is noteworthy, that online gambling or gaming is not classified in this space. </p>
<p>So how does one overcome these challenges when knowledge, while no longer in its infancy, is still expanding? </p>
<p>Dostoevsky offers a potentially valuable example of how one moment or a chance happening can change everything. It might sound counterintuitive to wait for such an event in a modern world such as ours, where advice from professionals or the internet is close to hand, but those cured of gambling addictions have often emphasised the role of chance or sudden revelation in their rehabilitation. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/570538/original/file-20240122-27-va5mdg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/570538/original/file-20240122-27-va5mdg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/570538/original/file-20240122-27-va5mdg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=716&fit=crop&dpr=1 600w, https://images.theconversation.com/files/570538/original/file-20240122-27-va5mdg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=716&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/570538/original/file-20240122-27-va5mdg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=716&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/570538/original/file-20240122-27-va5mdg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=900&fit=crop&dpr=1 754w, https://images.theconversation.com/files/570538/original/file-20240122-27-va5mdg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=900&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/570538/original/file-20240122-27-va5mdg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=900&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Anna Grigoryevna Dostoevsky, née Snitkin (1871).</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Anna_Dostoyevskaya_in_1871.jpg">Public domain</a></span>
</figcaption>
</figure>
<p>Eight days after having completed The Gambler, Dostoevsky proposed marriage to his stenographer, Anna Grigoryevna Snitkin. She accepted and they soon went abroad for a number of years. During this period, Dostoevsky gambled heavily, often pawning their belongings so he could gamble further. He would travel ahead to a town or resort with gaming tables, then write letters back to Anna chastising himself for losing all their money. </p>
<p>Anna believed Dostoevsky needed gambling as a kind of cathartic, physiological release from his daily frustrations. She felt it cleared his mind to concentrate on his writing. By all accounts, she was unsuccessful in reversing the gambling tendency in Dostoevsky. As with most gambling addicts, Dostoevsky oscillated between confessions to his wife, hope for forgiveness, and promises it will not happen again – promises he would then break. </p>
<p>But then, in a letter to Anna in 1871, he shares a life changing epiphany: </p>
<blockquote>
<p>By half past nine I had lost everything and I fled like a madman. I felt so miserable that I rushed to see the priest (don’t get upset, I did not see him, no, I did not, nor do I intend to!) […] But I lost my way in this town and when I reached a church, which I took for a Russian church, they told me in a store that it was not Russian but a synagogue. It was as if someone had poured cold water over me. I ran back home. And now it is midnight and I am sitting and writing to you.</p>
<p>A great thing has happened to me: I have rid myself of the abominable delusion that has tormented me for almost 10 years. For 10 years (or, to be more precise, ever since my brother’s death, when I suddenly found myself weighted down by debts) I dreamed about winning money. I dreamt of it seriously, passionately. But now it is all over! This was the very last time.</p>
</blockquote>
<p>And so it was. Dostoevsky lost all interest in gambling for good. He no longer dreamed of winning. The delusion that he might win enough to transform his life had left him as easily as it had arrived. The change in his character was permanent. </p>
<p>The key moment, with its many spiritual echoes was: “it was as if someone had poured cold water over me”. Worthy of comment, too, is his inability to access the familiarity and reassurance of the Russian Orthodox church. Disoriented, he arrives instead a Jewish synagogue. Arguably, it was this strangeness that made him uneasy and vulnerable to an experience, spiritual or otherwise, that had a lasting effect on his view of gambling and its personal consequences. </p>
<p>There is, however, another account that does not quite line up with the timeline of his cure – one that is less mysterious, but of interest nonetheless. </p>
<p>Gambling had been for Dostoevsky a “kind of obsession”, an experience defined by the thrill of “half-hanging over an abyss so as to peer into its very depths and – in certain, though not frequent cases – flinging oneself headlong into it”.</p>
<p>In 1871, Dostoevsky went abroad to Ems for a cure. He had a bronchial condition, the first symptoms of which had appeared as early as 1868. Could it be that his abandonment of gambling was related to his not being able to endure the excitement of gambling? His health had deteriorated to such an extent that he lacked the necessary physical strength; it was physiologically too much for him. Perhaps physical incapacity had a hand in his cure?</p><img src="https://counter.theconversation.com/content/220655/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Dobson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Dostoevsky’s sudden recovery from his gambling mania is an example of how a chance happening can change everythingStephen Dobson, Professor and Dean of Education and the Arts, CQUniversity AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2201342024-01-22T13:32:06Z2024-01-22T13:32:06ZAlcohol and drugs rewire your brain by changing how your genes work – research is investigating how to counteract addiction’s effects<figure><img src="https://images.theconversation.com/files/569941/original/file-20240117-21-ycbpim.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3600%2C1810&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Alcohol and other drugs can overpower the reward pathways of the brain.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/illustration-of-a-brain-cocktail-isolate-don-a-royalty-free-image/1263367270">Simona Dumitru/Moment via Getty Images</a></span></figcaption></figure><p>Many people are wired to <a href="https://www.penguinrandomhouse.ca/books/306396/the-compass-of-pleasure-by-david-j-linden/9780143120759">seek and respond to rewards</a>. Your brain interprets food as rewarding when you are hungry and water as rewarding when you are thirsty. But addictive substances like alcohol and drugs of abuse can <a href="https://doi.org/10.1016/S2215-0366(16)00104-8">overwhelm the natural reward pathways</a> in your brain, resulting in intolerable cravings and reduced impulse control. </p>
<p>A popular misconception is that addiction is a result of low willpower. But an explosion of knowledge and technology in the field of <a href="https://plato.stanford.edu/entries/molecular-genetics/">molecular genetics</a> has changed our basic understanding of addiction drastically over the past decade. The general consensus among scientists and health care professionals is that there is a <a href="https://www.penguinrandomhouse.ca/books/557515/never-enough-by-judith-grisel/9780525434900">strong neurobiological and genetic basis</a> for addiction.</p>
<p>As a <a href="https://scholar.google.com/citations?user=XgunjGkAAAAJ&hl=en">behavioral neurogeneticist</a> <a href="https://www.kaunlab.com">leading a team</a> investigating the molecular mechanisms of addiction, I combine neuroscience with genetics to understand how alcohol and drugs influence the brain. In the past decade, I have seen changes in our understanding of the molecular mechanisms of addiction, largely due to a better understanding of how genes are dynamically regulated in the brain. New ways of thinking about how addictions form have the potential to change how we approach treatment.</p>
<h2>Alcohol and drugs affect brain gene activity</h2>
<p>Each of your brain cells has your genetic code stored in long strands of DNA. For all that DNA to fit into a cell, it needs to be packed tightly. This is achieved by winding the DNA around “spools” of protein <a href="https://www.genome.gov/genetics-glossary/histone">called histones</a>. Areas where DNA is unwound contain active genes coding for proteins that serve important functions within the cell.</p>
<p>When gene activity changes, the proteins your cells produce also change. Such changes can range from a single neuronal connection in your brain to how you behave. This genetic choreography suggests that while your genes affect how your brain develops, <a href="https://theconversation.com/brains-work-via-their-genes-just-as-much-as-their-neurons-47522">which genes are turned on or off</a> when you are learning new things is dynamic and adapts to suit your daily needs.</p>
<p>Recent data from animal models suggests that alcohol and drugs of abuse directly influence <a href="https://doi.org/10.1523/JNEUROSCI.1649-20.2020">changes in gene expression</a> in areas of the brain that help drive memory and reward responses. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/567627/original/file-20240103-29-mcair4.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram magnifying the nucleus of a neuron, showing spirals of DNA wound around bundles of protein" src="https://images.theconversation.com/files/567627/original/file-20240103-29-mcair4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/567627/original/file-20240103-29-mcair4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=358&fit=crop&dpr=1 600w, https://images.theconversation.com/files/567627/original/file-20240103-29-mcair4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=358&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/567627/original/file-20240103-29-mcair4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=358&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/567627/original/file-20240103-29-mcair4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=449&fit=crop&dpr=1 754w, https://images.theconversation.com/files/567627/original/file-20240103-29-mcair4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=449&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/567627/original/file-20240103-29-mcair4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=449&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Within each neuron in the brain, how tightly DNA is wound around or bound to histones and other proteins determines which genes are expressed and which proteins are produced.</span>
<span class="attribution"><span class="source">Karla Kaun and Vinald Francis</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>There are <a href="https://doi.org/10.1523/JNEUROSCI.1649-20.2020">many ways</a> addictive substances can change gene expression. They can alter which proteins bind to DNA to turn genes on and off and which segments of DNA are unwound. They can change the process of how DNA is read and translated into proteins, as well as alter the proteins that determine how cells use energy to function.</p>
<p>For example, alcohol can cause an alternative form of a gene to be expressed in the memory circuits <a href="https://doi.org/10.1534/genetics.120.303101">in flies</a> <a href="https://doi.org/10.1038/s41598-023-30926-z">and people</a>, resulting in changes in dopamine receptors and transcription factors involved in reward signaling and neuronal function. Similarly, cocaine can cause an alternative form of a gene to be expressed in the <a href="https://doi.org/10.1016/j.neuron.2021.08.008">reward centers</a> <a href="https://doi.org/10.1016/j.biopsych.2017.11.027">of mice</a>, leading them to seek out more cocaine.</p>
<p>Exactly how these drugs cause changes in gene regulation is unknown. However, a direct link between alcohol consumption and changes in gene expression in mice provides a clue. A byproduct of alcohol being broken down in the liver called acetate can cross the blood-brain barrier and <a href="https://doi.org/10.1038/s41586-019-1700-7">unwind DNA from histones</a> in mouse memory circuits. </p>
<p>Alcohol, nicotine, cocaine and opioids also all activate important signaling pathways that are <a href="https://doi.org/10.1111/jnc.12725">central regulators of metabolism</a>. This suggests they can also affect many aspects of neuronal function and consequently affect which genes are expressed.</p>
<h2>Changing brain gene activity with lifestyle</h2>
<p>How addictive substances change cell function is complex. The version of a gene you’re born with can be modified in many ways before it becomes a functional protein, including exposure to alcohol and drugs. Rather than discouraging researchers, this complexity is empowering because it provides evidence that changes to gene expression in your brain aren’t permanent. They can also be altered by medications and lifestyle choices.</p>
<p>Many commonly prescribed medications for mental health disorders also affect gene expression. <a href="https://doi.org/10.1038%2Fs41398-019-0589-0">Antidepressants and</a> <a href="https://doi.org/10.1016/j.jpsychires.2013.05.028">mood stabilizers</a> can change how DNA is modified and which genes are expressed. For example, a commonly prescribed drug for depression called escitalopram affects how tightly wound DNA is and can change the expression of genes important to brain plasticity.</p>
<p>Additionally, <a href="https://theconversation.com/customizing-mrna-is-easy-and-thats-what-makes-it-the-next-frontier-for-personalized-medicine-a-molecular-biologist-explains-216127">mRNA-based therapies</a> can specifically change which genes are expressed to treat diseases like cancer. In the future, we may discover similar therapies for alcohol and substance use disorder. These treatments could potentially target important <a href="https://doi.org/10.1016%2Fj.tins.2021.09.006">signaling pathways linked to addiction</a>, altering how brain circuits function and how alcohol and drugs affect them.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/569945/original/file-20240117-29-n459lb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of person sitting with crossed legs on a yoga mat, hands resting on knees with pointer finger touching thumb" src="https://images.theconversation.com/files/569945/original/file-20240117-29-n459lb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/569945/original/file-20240117-29-n459lb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/569945/original/file-20240117-29-n459lb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/569945/original/file-20240117-29-n459lb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/569945/original/file-20240117-29-n459lb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/569945/original/file-20240117-29-n459lb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/569945/original/file-20240117-29-n459lb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Exercise and other lifestyle choices can affect gene regulation.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/indonesian-woman-is-meditating-in-a-half-lotus-royalty-free-image/1391023941?adppopup=true">Afriandi/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p>Lifestyle choices can also affect gene expression in your brain, though researchers don’t yet know whether they can alter the changes induced by addictive substances. </p>
<p>Like alcohol and drugs, <a href="https://theconversation.com/what-you-eat-can-reprogram-your-genes-an-expert-explains-the-emerging-science-of-nutrigenomics-165867">dietary changes</a> can affect gene expression in many ways. In flies, a high sugar diet can <a href="https://doi.org/10.1126/sciadv.abc8492">reprogram the ability to taste sweetness</a> by tapping into a gene expression network involved in development.</p>
<p><a href="https://doi.org/10.1016/j.cpnec.2022.100152">Intensive</a> <a href="https://doi.org/10.1016/j.psyneuen.2013.11.004">meditation</a>, even after only <a href="https://doi.org/10.1016/j.bbi.2019.11.003">one day</a>, can also affect gene regulation in your brain through similar mechanisms. Attending a <a href="https://doi.org/10.1016/j.cpnec.2022.100152">monthlong meditation retreat</a> reduces the expression of genes that affect inflammation, and experienced meditators can reduce inflammatory genes after just <a href="https://doi.org/10.1016/j.bbi.2019.11.003">one day of intensive meditation</a>. </p>
<p>Work in animal models has also shown that exercise changes gene expression by altering both <a href="https://doi.org/10.1016/j.brainres.2020.147191">histones</a> <a href="https://doi.org/10.1016/j.molmet.2021.101398">and the</a> <a href="https://doi.org/10.1111/j.1460-9568.2010.07508.x">molecular tags</a> directly attached to DNA. This increases the activity of genes important to the activity and plasticity of neurons, supporting the idea that <a href="https://theconversation.com/high-intensity-exercise-improves-memory-and-wards-off-dementia-127001">exercise improves learning and memory</a> and can decrease the risk of dementia.</p>
<p>From <a href="https://doi.org/10.1037/hea0000297">Dry January</a> and beyond, many factors can have profound effects on your brain biology. Taking steps to reduce consumption of alcohol and drugs and picking up healthy lifestyle practices can help stabilize and bring long-lasting benefits for your physical and mental health.</p><img src="https://counter.theconversation.com/content/220134/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karla Kaun receives funding from the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse and the National Institute of General Medical Sciences.</span></em></p>Improved understanding of the molecular mechanisms of addiction can change how researchers and clinicians approach treatments.Karla Kaun, Associate Professor of Neuroscience, Brown UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2179862024-01-18T17:30:42Z2024-01-18T17:30:42ZExcessive social media use during the COVID-19 pandemic exacerbated adolescent mental health challenges<figure><img src="https://images.theconversation.com/files/569404/original/file-20240115-19-cpvqvk.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2695%2C1517&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research shows a strong link between screen time and mental health concerns, including anxiety and depression.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>How does time spent online, and especially social media, affect the brains and behaviours of children and youth?</p>
<p>Social media platforms are seemingly designed to capture the attention of users and produce habitual checking of apps and notifications. In recent years, our lives have become increasingly dominated by social media, either as a source of information, entertainment, or just a way to connect with others. </p>
<p>In Canada alone, <a href="https://madeinca.ca/social-media-statistics-canada/#:%7E:text=Social%20Media%20Statistics%20for%20Canadians,with%20over%2026%20million%20users.">more than 30 million social media accounts</a> are currently registered, with <a href="https://doi.org/10.25318/36280001202100300004-eng">teenagers one of the highest user groups</a>. </p>
<p>During the COVID-19 pandemic, young people were drastically affected by the sudden shift to a digital world and the explosion of a reliance on screens. School closures, coupled with social isolation, led to <a href="https://doi.org/10.1016/j.jadr.2021.100217">dramatic increases in daily screen time use</a> and exacerbated <a href="https://doi.org/10.1186/s40359-023-01240-0">mental health challenges</a> for many young people. </p>
<p>Research shows strong links between screen time and mental health concerns, including <a href="https://doi.org/10.1080/02673843.2019.1590851">anxiety and depression</a>, although few longitudinal studies have been conducted in the pandemic or post-pandemic eras to determine causal relationships. The stress of lockdowns and the absence of typical support networks left adolescents more vulnerable than ever to the negative effects of social media. </p>
<p>Now, in the years following the pandemic lockdowns, it’s imperative that we study and address the impact excessive screen time can have on brain development.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/569606/original/file-20240116-25-l42kqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="a teen girl wearing a face mask makes a peace sign to her phone" src="https://images.theconversation.com/files/569606/original/file-20240116-25-l42kqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/569606/original/file-20240116-25-l42kqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/569606/original/file-20240116-25-l42kqm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/569606/original/file-20240116-25-l42kqm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/569606/original/file-20240116-25-l42kqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/569606/original/file-20240116-25-l42kqm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/569606/original/file-20240116-25-l42kqm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">During the pandemic, social media provided distraction and a way to maintain contact with friends.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Reward and punishment</h2>
<p>A key facet of social media is that it engages brain systems involved in reward and punishment, which could place children and adolescents at risk for <a href="https://doi.org/10.1001/jamapediatrics.2022.4924">adverse brain development</a>. During childhood and adolescence, our brains are still going through <a href="https://doi.org/10.1093/cercor/bhz279">dramatic periods of development</a>, making them more susceptible to the impact of excessive screen time.</p>
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<em>
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Read more:
<a href="https://theconversation.com/how-much-time-do-kids-spend-on-devices-playing-games-watching-videos-texting-and-using-the-phone-210118">How much time do kids spend on devices – playing games, watching videos, texting and using the phone?</a>
</strong>
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<hr>
<p>Children and youth have very active reward systems in the brain. Natural rewards can cause a brief release of “feel good” chemicals in the brain like <a href="https://doi.org/10.1016/j.pneurobio.2021.101997">dopamine</a>. Social media can offer constant levels of rewards that are higher than normal and affect brain chemistry, leading to <a href="https://doi.org/10.1007/s40473-023-00261-8">children seeking out more rewards</a>, even to addictive levels. </p>
<p>The part of our brain that monitors risky but rewarding activity — <a href="https://doi.org/10.1038/s41586-022-04554-y">the prefrontal cortex — does not fully mature until we reach our 30s</a>. The fact that this brain area has not fully developed in children and teens might affect their ability to control scrolling behaviours and monitor emotional triggers.</p>
<p>Coupled with changes in brain chemistry, this could lead to excessive screen time use. The timeline of the prefrontal cortex’s development could also explain why adults are less likely to face the same consequences of the negative effects of social media. </p>
<p>Additionally, some studies have reported <a href="https://doi.org/10.1038/s41467-018-03126-x">changes in cortical and subcortical brain activation and structure in children and teenagers</a> that were associated with high screen time use. These studies have reported changes in the brain’s <a href="https://doi.org/10.1001/jamapediatrics.2022.4924">reward and punishment centres</a>. </p>
<p>Another example of this comes from a <a href="https://doi.org/10.1016/j.dcn.2022.101088">longitudinal study that followed children for three years</a>, showing delayed development of regions involved in social connectedness and understanding the thoughts and feelings of others.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/jR59s2mv24Q?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">CBC News looks at the impact of social media on teens.</span></figcaption>
</figure>
<h2>Different impacts</h2>
<p>However, not all research points to screen time as being associated with changes in brain development. A large-scale imaging study that was designed to examine childhood experiences throughout the United States — including smoking, video games and sleep — in nearly 12,000 children showed <a href="https://doi.org/10.1016/j.cortex.2023.09.009">no association between screen time and brain development</a>. </p>
<p>There may be several explanations for the dissonance between the large-scale child development study and smaller studies that were designed to look at screen time. For example, potentially heavy users of screen time chose to participate in smaller, more focused studies. In turn, children who are most at risk for the adverse effects of screen time may represent a smaller fraction of the data in a large cohort. </p>
<p>Given the widespread use of social media, it’s no surprise that not all children and youth are impacted in the same way. Adolescents and young adults who have pre-existing mental health concerns, particularly anxiety, may be most at risk to the <a href="https://doi.org/10.1016/j.jad.2016.08.040">harmful effects of social media use on the brain and behaviour</a>. </p>
<p><a href="https://doi.org/10.1016/j.jad.2013.06.038">Those who experience anxiety may use social media more frequently</a> to seek validation and reassurance, or as a <a href="https://doi.org/10.1016/j.jad.2013.06.038">maladaptive coping mechanism to avoid in-person interactions and real-world stressors</a>. </p>
<p>More longitudinal research is needed to better understand mental-health risk factors for adverse outcomes associated with excessive social media use as well as the long-term effects on brain development.</p>
<h2>Adapting to a digital world</h2>
<p>As we move forward and adapt to an increasingly digital world, clear guidelines are needed concerning the amounts, types and content of screen time that are most harmful to children’s development, as well as the associated risk and resilience factors, which are informed by science. </p>
<p>For this reason, it is more important than ever that researchers design studies that allow us to understand what is happening to children’s and adolescents’ brains and their behaviours, and how that is affecting long-term outcomes. </p>
<p>In the meantime, educators and parents should engage in open dialogue to help children and teenagers understand the consequences that excessive screen time might have on brain development and mental health. Teenagers should also be given strategies and learn about setting boundaries to help them manage screen time responsibly. </p>
<p>It is crucial that we encourage healthy relationships with technology to minimize the potential for long-term societal issues and concerns in the future.</p><img src="https://counter.theconversation.com/content/217986/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emma Duerden receives funding from the Canada Research Chairs, Brain Canada, and the Children's Health Foundation.</span></em></p><p class="fine-print"><em><span>Michaela Kent does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>During the pandemic, many people relied on social media for distraction and social connection. However, excessive social media use can negatively affect mental health, especially for young people.Emma G Duerden, Canada Research Chair, Neuroscience & Learning Disorders, Assistant Professor, Western UniversityMichaela Kent, PhD Candidate, Neuroscience, Western UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2208512024-01-10T22:10:05Z2024-01-10T22:10:05ZTime for a Weed-Free January? How cannabis users could benefit from a ‘dry’ month<iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/time-for-a-weed-free-january-how-cannabis-users-could-benefit-from-a-dry-month" width="100%" height="400"></iframe>
<p>By now, most are familiar with the idea of Dry January, a voluntary month without alcohol that follows a month when many drink more than usual.</p>
<p>The idea of <a href="https://time.com/6552262/dry-january-origins-alcohol-drinking/">Dry January</a> started in the United Kingdom in 2012, and has become popular internationally since then. The point is to use a date on the calendar that traditionally prompts resolutions to encourage drinkers to make a month-long commitment to giving their bodies a break and resetting their attitudes and habits in a healthier way for the rest of the year and possibly beyond.</p>
<p>For those who use cannabis, the idea of taking a month off is also worth considering, whether it’s January or not.</p>
<h2>1 in 4 use cannabis</h2>
<p>Canadians are among the world’s biggest consumers of cannabis, especially since <a href="https://www.justice.gc.ca/eng/cj-jp/cannabis/">it was legalized</a> in 2018. Prior to legalization, about 15 per cent of adults used cannabis once a year or more. Today, about <a href="https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/research-data/canadian-cannabis-survey-2022-summary.html">one in four</a> adult Canadians use cannabis once a year or more, with a higher concentration among young adults.</p>
<p>Frequency of use varies widely, but there is a sizable group of people who are daily or near-daily users — <a href="https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/research-data/canadian-cannabis-survey-2022-summary.html">about 25 per cent</a>. Within that group, nearly three-quarters report <a href="https://www150.statcan.gc.ca/n1/pub/82-003-x/2023006/article/00001-eng.htm">impaired control over their cannabis use</a>, a key feature of <a href="https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/health-effects/addiction.html">cannabis use disorder</a>, the medical definition of cannabis addiction.</p>
<p>Though daily use and cannabis use disorder are not identical, daily use is nonetheless a reasonable way to identify people who are more likely to experience negative consequences and might benefit from taking a break. </p>
<p>Beyond frequency, the amount of cannabis one uses and the concentration of <a href="https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/about.html">THC, the psychoactive component of cannabis,</a> are important considerations in the likelihood of experiencing harms. Many of the risks and harms from cannabis scale to the amount of THC consumed, so it’s not just a matter of consuming less frequently.</p>
<h2>The benefits of a weed-free month</h2>
<p>A Weed-Free January could do more good than cannabis users may realize. Any month will do, of course, but January is traditionally a time for resolutions and fresh starts, so it may be the most natural time to cut out weed.</p>
<p>Based on the existing evidence, regular cannabis users could expect to experience a number of positive physical and lifestyle changes from a 31-day pause.</p>
<p>Among them:</p>
<ul>
<li><p>Resetting one’s tolerance for cannabis. In response to cannabis use, the body’s <a href="https://www.health.harvard.edu/blog/the-endocannabinoid-system-essential-and-mysterious-202108112569">endocannabinoid system</a> adapts over time, causing users to develop tolerance. Indeed, for heavy users, unpleasant symptoms of withdrawal also follow these adaptations, although cannabis withdrawal is not life-threatening like alcohol withdrawal. Users could expect that taking a month off would be enough for the body to revert to its natural set-points.</p></li>
<li><p>Clearing the mental cobwebs. Cannabis use is associated with <a href="https://doi.org/10.1016/j.biopsych.2015.12.002">reduced cognitive functioning</a>, especially <a href="https://doi.org/10.1073/pnas.1206820109">heavy persistent use</a>. Even short breaks from cannabis have been found to <a href="https://doi.org/10.1001/jamapsychiatry.2018.0335">reduce cognitive consequences</a>, and a month of abstinence has been shown to return cognitive functioning to the level of <a href="https://doi.org/10.1001/archpsyc.58.10.909">non-cannabis users</a>.</p></li>
<li><p>Giving your lungs a break. It’s well established that inhaling combusted cannabis smoke is bad for the lungs <a href="https://doi.org/10.1016/j.rmed.2023.107494">in a number of ways</a>, which may be one of the reasons cannabis has been linked to <a href="https://newsroom.heart.org/news/marijuana-use-linked-with-increased-risk-of-heart-attack-heart-failure">heart attack and stroke risk</a>.</p></li>
<li><p>Developing other habits and routines that take advantage of a clearer mind, such as sports, reading and sober socializing. A rich repertoire of activities without substance use is an important lifestyle counterbalance.</p></li>
<li><p>Saving money. Cannabis is not cheap and adds up quickly if you consume daily. A Weed-Free January could save hundreds of dollars.</p></li>
<li><p>Taking stock of whether you may have a problem. Cannabis use disorder is real and can have serious consequences. A weed-free month can provide a chance to do a self-check and see how hard it is to stop. If quitting for a month is impossible (or feels like torture), it may be time to talk to a health professional. <a href="https://www.psychiatrictimes.com/view/current-treatments-for-cannabis-use-disorder">Effective treatments do exist for cannabis use disorder</a>.</p></li>
</ul>
<p>Importantly, many people have authorizations to use medical cannabis to manage a variety of conditions and this is not to suggest that those individuals should abruptly stop for a month, just as it would be foolhardy to recommend an annual abstinence from cholesterol, blood-pressure, or other medications. For medical cannabis patients who think it might be beneficial to take a break, a chat with their authorizing physician or family doctor would be in order.</p>
<p>Bottom line, though, if you use recreational cannabis regularly, especially daily, having a Weed-Free January could be both good for your health and a good way to promote other healthy resolutions. A real win-win.</p><img src="https://counter.theconversation.com/content/220851/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James MacKillop receives research funding from the Canadian Institutes of Health Research, Health Canada, the National Institutes of Health, and other non-profit funders. He is a principal and senior scientist in Beam Diagnostics, Inc., a technology transfer startup. No Beam products or services are related to this topic. MacKillop has previously consulted to Clairvoyant Therapeutics, Inc. </span></em></p>A Weed-Free January could do more good than cannabis users may realize. Regular cannabis users could expect to experience a number of positive physical and lifestyle changes from a 31-day pause.James MacKillop, Peter Boris Chair in Addictions Research; Director, Peter Boris Centre for Addictions Research; Director, Michael G. DeGroote Centre for Medicinal Cannabis Research; Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2185082023-12-12T23:58:25Z2023-12-12T23:58:25ZProgram at Hamilton Public Library shows how libraries can expand the social services they provide<figure><img src="https://images.theconversation.com/files/565206/original/file-20231212-29-g6jmfe.jpg?ixlib=rb-1.1.0&rect=0%2C44%2C2500%2C1613&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new program at the Hamilton Public Library is making on-site social workers available to the public.</span> <span class="attribution"><span class="source">(Hamilton Public Library)</span>, <span class="license">Author provided</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/program-at-hamilton-public-library-shows-how-libraries-can-expand-the-social-services-they-provide" width="100%" height="400"></iframe>
<p>When we need help or advice, it’s not always clear where to go, what resources are available to us, or who to turn to when we need support. Public libraries are often easily accessible and free to the public. That means the <a href="https://thewalrus.ca/future-of-libraries/">local public library is often the first port of call</a> for people looking for help or advice.</p>
<p>This is changing how community members engage with their library and how staff engage with community members entering their doors. While libraries often act as an informational resource for folks looking to access community and social services, the public’s intensifying needs necessitate an expansion of the library’s role in our communities.</p>
<p>Staff at <a href="https://hpl.ca/">Hamilton Public Library</a>’s (HPL) 23 branches and two bookmobiles increasingly encounter people with a range of complex health and social issues in their library spaces. They include individuals with housing and food insecurity, newcomers to Canada, those dealing with mental-health challenges, substance use and addiction, and individuals who struggle with technology, face language barriers, and income pressures, among other challenges. </p>
<p>Given these growing and varied needs, having social workers in libraries is vital. Library staff often do not have the knowledge or expertise to effectively offer crisis and mental-health support people need. </p>
<h2>What’s happening at Hamilton Public Library</h2>
<p>In November 2022, HPL responded to this challenge. In partnership with Hamilton Public Health Services’ <a href="https://www.hamilton.ca/people-programs/public-health/mental-health-services/mental-health-street-outreach-program">Mental Health and Street Outreach Program</a>, HPL developed a program to provide <a href="https://www.thespec.com/news/hamilton-region/hamilton-public-library-to-hire-a-social-worker-at-its-downtown-branch/article_ec6348b6-22bb-5b31-8911-a98ab38bf12b.html">on-site social work services</a> at its downtown central library, with two part-time social workers being present, visible and accessible on the first floor. </p>
<p>In partnership with Hamilton Public Health Services, HPL staff and social workers working at HPL voiced a need to document and study their social work program. the aim is to identify short- and long-term outcomes, engage with different library members to explore how the social work program is understood and to make these findings available to other public libraries who may be considering their own social work program. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/564559/original/file-20231208-23-8jod9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man gives advice to a woman in a library." src="https://images.theconversation.com/files/564559/original/file-20231208-23-8jod9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564559/original/file-20231208-23-8jod9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564559/original/file-20231208-23-8jod9n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564559/original/file-20231208-23-8jod9n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564559/original/file-20231208-23-8jod9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564559/original/file-20231208-23-8jod9n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564559/original/file-20231208-23-8jod9n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The public library is increasingly the first place people go when they need support or advice.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>With colleagues, I partnered with HPL and Hamilton Public Health Services to take a deeper look at the program from multiple stakeholders’ perspectives. Over the next year, interviews with different community stakeholders (library members, library workers, and social workers) will help make visible how these different stakeholders understand and use social work activities and services at HPL. </p>
<p>Social workers working in public libraries is a recent but growing partnership practice across North America. <a href="https://www.pbs.org/newshour/show/library-social-worker-helps-homeless-seeking-quiet-refuge">The first social worker in a public library</a> was in San Francisco in 2009. <a href="https://publiclibrariesonline.org/2019/01/providing-social-service-resources-in-a-library-setting/#.XDtQqGtmscY.wordpress">In that case</a>, library members experiencing homelessness were accessing the library to seek refuge and meet their basic needs.</p>
<p>Since this first program, there have been many variations of social services offered in public libraries across North America. Taken together, this is signalling a shift in how we think about and use public libraries — from book repositories to community anchors and social infrastructures. </p>
<h2>Expanding the library’s role</h2>
<p>Social workers in libraries take on multiple roles, including helping people access resources, offering supportive listening and brief counselling and providing training to library staff on how best to deal with crises when they arise.</p>
<p>Social workers also support access to services like housing, harm reduction, employment counselling and food security, and they provide crisis intervention and the de-escalation of disruptive behaviours on-site. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/564562/original/file-20231208-27-wxkgs2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="The glass entrance of a library building." src="https://images.theconversation.com/files/564562/original/file-20231208-27-wxkgs2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564562/original/file-20231208-27-wxkgs2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564562/original/file-20231208-27-wxkgs2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564562/original/file-20231208-27-wxkgs2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564562/original/file-20231208-27-wxkgs2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564562/original/file-20231208-27-wxkgs2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564562/original/file-20231208-27-wxkgs2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">More public libraries are hiring in-house social workers to provide the kinds of help and advice members of the public are searching for.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Library social workers aim to remove systemic barriers to make their services more accessible. They can do this by offering preventative support in their role as community collaborators and advocates, and by helping people access services that offer longer-term solutions to their problems. </p>
<p>Social workers in the library are also crucial; they are trained and able to support trauma, mental-health issues, challenges and complex needs in a way that meets the person where they are at emotionally, physically and/or cognitively.</p>
<p>Ultimately, this project at HPL will help ensure the social work program meets its intended outcomes and will inform decision-making about the program’s future design and sustainability. This work is especially important as HPL is piloting a <a href="https://www.thespec.com/news/hamilton-region/library-expands-use-of-social-workers-to-barton-branch/article_47e845d3-9267-5e45-a0e2-ca09c18333ee.html">second social work program at its Barton branch</a>.</p>
<p><em>Sarah Gauthier, a Manager of Central Information Services with HPL, and Kianosh Keyvani, a Clinical Resource Co-ordinator with the City of Hamilton’s Mental Health and Street Outreach Program, co-authored this article.</em></p><img src="https://counter.theconversation.com/content/218508/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Dalmer receives funding from the Social Sciences and Humanities Research Council of Canada.</span></em></p><p class="fine-print"><em><span>Bridget Marsdin and Leora Sas van der Linden do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The public’s intensifying needs necessitate an expansion of the library’s role in our communities.Nicole Dalmer, Assistant Professor in the Department of Health, Aging and Society, McMaster UniversityBridget Marsdin, PhD student, School of Social Work, McMaster UniversityLeora Sas van der Linden, Program Manager, Community Research Platform, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2148952023-11-30T17:23:43Z2023-11-30T17:23:43ZBuvidal: is it really a ‘game changer’ in the treatment of problematic opioid use?<p>To overcome problematic opioid use, traditional forms of opioid substitution therapy, such as <a href="https://www.nhs.uk/medicines/methadone/">methadone</a> and <a href="https://www.nhs.uk/medicines/buprenorphine-for-pain/">oral buprenorphine</a>, have become valuable tools. <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002209.pub2/full?highlightAbstract=opioid">Research</a> shows that patients receiving substitution therapy are more likely to stay in treatment and stop using heroin than patients receiving treatments that do not involve substitutes – such as counselling or group therapy.</p>
<p>But not all those on substitute medication are able to stop using illicit opioids. Some continue to use them in addition to the substitute. One <a href="https://www.sciencedirect.com/science/article/abs/pii/S0376871621001460">barrier</a> to success is the need to attend a clinic or pharmacy every day, or every few days, to obtain the substitute. </p>
<p>In early 2019, a new form of substitute treatment, long-acting injectable buprenorphine, was approved for use in the UK. Unlike methadone and oral buprenorphine, <a href="https://www.nice.org.uk/advice/es19/evidence/evidence-review-pdf-6666819661#:%7E:text=Buprenorphine%20prolonged%2Drelease%20injection%20is,buprenorphine%20prolonged%2Drelease%20injection%20subcutaneously.">long-acting injectable buprenorphine</a> is administered via an injection either weekly or monthly. The treatment – also known by its brand names Buvidal or Sublocade – has been heralded as a “<a href="https://nation.cymru/news/welsh-university-carries-out-game-changer-drug-treatment-research/">game changer</a>” by both doctors and patients. </p>
<h2>Opioids</h2>
<p>In 2021, nearly 5,000 drug-related deaths were <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2021registrations">registered</a> in England and Wales. About half of those involved an opioid. </p>
<p>Opioids are a class of drugs that include substances derived from the opium poppy. They include <a href="https://www.nhs.uk/medicines/morphine/">morphine</a> and <a href="https://www.emcdda.europa.eu/publications/drug-profiles/heroin_en">heroin</a>, as well as synthetic alternatives that mimic the effects of naturally occurring opioids such as <a href="https://www.nhs.uk/medicines/tramadol/">tramadol</a> and <a href="https://bnf.nice.org.uk/drugs/fentanyl/">fentanyl</a>.</p>
<p>Opioids work in the brain to produce a variety of effects, including pain relief. They also produce feelings of euphoria, joy and pleasure. Opioids have a depressant effect on the body, so if someone overdoses, they can stop breathing and may die. Overdose is a particular risk for those who use illegally obtained opioids of unknown strength, such as heroin.</p>
<p>Often people are unable to stop using opioids despite the risk of death and the serious negative health and social consequences. Such drugs are hard to give up, partly because stopping causes painful physical and psychological withdrawal symptoms.</p>
<h2>Opioid substitution therapy</h2>
<p>An effective form of treatment for problematic opioid use is opioid substitution therapy, where illegally obtained opioids are substituted for prescribed alternatives. </p>
<p>Providing a legal substitute of known purity is useful in many ways. Most notably, it removes the need to buy and use illicit opioids. This reduces the risk of <a href="https://www.bmj.com/content/357/bmj.j1550">overdose</a> and the need to commit crimes like <a href="https://academic.oup.com/bjc/article-abstract/49/4/513/2747197">theft and shoplifting</a> to get money to pay for drugs.</p>
<p>But while daily attendance and supervised consumption may help to minimise the risk of misuse, it also has its drawbacks. For example, it can bring patients into regular contact with their former drug-using networks and can require time-consuming journeys that interfere with employment, education and other responsibilities.</p>
<p>Long-acting injectable buprenorphine does not have these drawbacks. It is not unlike <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8369037/">long-acting</a> forms of contraception, in that the medicine releases slowly over time, thereby avoiding the peaks and troughs associated with oral formulations.</p>
<p>When the pandemic broke and the UK went into lockdown, <a href="https://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs_en">concerns</a> were raised by experts that daily attendance at clinics or pharmacies for opioid substitution medication might increase the risk of COVID transmission. </p>
<p>Keen to stop the spread of the virus while also providing safe and continuous treatment to patients, the Welsh government <a href="https://committees.parliament.uk/writtenevidence/107535/pdf/">agreed</a> to fund the roll-out of long-acting injectable buprenorphine to drug services across Wales. </p>
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<figcaption><span class="caption">Two doctors discuss Buvidal from the perspective of lived experience.</span></figcaption>
</figure>
<p>That decision was supported by <a href="https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-023-01348-5">emerging evidence</a> of the effectiveness of the medication from a drug service in south Wales that had been piloting the medicine before the pandemic. </p>
<h2>Results</h2>
<p>While the primary aim at that time was to stop the spread of COVID, it quickly became clear that the medication was benefiting patients in many other ways. </p>
<p>Patients taking part in a <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">survey</a> about the new medication reported reductions in cravings, lower levels of anxiety, reductions in offending and abstinence from illicit opioids. They described rebuilding their lives, getting jobs, reconnecting with family members and heralded long-acting injectable buprenorphine as a “game changer”, “life changing” and even a “miracle”. </p>
<p>Positive results have also been reported in <a href="https://www.jsatjournal.com/article/S0740-5472(22)00058-7/fulltext">systematic reviews</a> that summarise the findings of the currently small, and not very robust, body of evidence on the effectiveness of the medication.</p>
<p>However, alongside the reports of success, less positive <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">stories</a> have emerged suggesting that the treatment may not be a silver bullet. Some patients have found the transition onto the medication challenging because it required them to be in full withdrawal before their first dose. </p>
<p>Others have been overwhelmed with emotions because the medication made them feel so clear-headed that their past traumas – suppressed by years of illicit opioid use – had begun to resurface. There have also been <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">reports</a> of an increase in crack cocaine use among some patients and concerns about the reduced amount of contact (from daily to monthly) with drug services.</p>
<p>Even though there is a “<a href="https://pubmed.ncbi.nlm.nih.gov/16764215/">ceiling effect</a>” that reduces the risk of overdose, this medication still carries a risk of respiratory depression. This risk is <a href="https://pubmed.ncbi.nlm.nih.gov/15957155/">greater</a> among those using alcohol, benzodiazepines or other opioids such as heroin.</p>
<p>Long-acting injectable buprenophine is still in its infancy worldwide, so the evidence for its effectiveness is slim. To determine if it really is a “game changer”, experts will need to look at its impact across a wider range of outcomes, over longer periods and with larger samples than have been considered to date.</p><img src="https://counter.theconversation.com/content/214895/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katy Holloway receives funding from Welsh Government and is a member of Welsh Government's National Implementation Board for Drug Poisoning Prevention. </span></em></p><p class="fine-print"><em><span>Fabrizio Schifano receives funding from Welsh Government. Currently a World Health Organization (WHO) member of the Expert Committee on Drug Dependence (ECDD; 2023). Previously, Schifano was a member of the ACMD UK and an expert advisor of the European Medicines Agency (EMA) for Psychiatry. </span></em></p>Long-acting injectable buprenorphine is also known by the brand names Buvidal or Sublocade.Katy Holloway, Professor of Criminology, University of South WalesFabrizio Schifano, Chair in Clinical Pharmacology and Therapeutics, University of HertfordshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2044342023-11-16T13:20:24Z2023-11-16T13:20:24ZColleges face gambling addiction among students as sports betting spreads<figure><img src="https://images.theconversation.com/files/549155/original/file-20230919-23-xg2xb1.jpg?ixlib=rb-1.1.0&rect=144%2C202%2C4672%2C3408&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Around 6% of college students have a gambling problem. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.ca/detail/photo/stadium-crowd-cheering-one-man-looking-at-mobile-royalty-free-image/200244684-001?phrase=students+watching+college+football+on+their+phones&adppopup=true">John Rowley/The Image Bank via Getty Images</a></span></figcaption></figure><p>Three out of four college students have <a href="https://www.ncpgambling.org/files/NPGAWcollegefactsheet.pdf">gambled in the past year</a>, whether legally or illegally, according to the <a href="https://www.ncpgambling.org/">National Council on Problem Gambling</a>.</p>
<p>An <a href="https://www.ncpgambling.org/help-treatment/faq/">estimated 2% to 3% of U.S. adults</a> have a gambling problem. The portion of college students with a problem, however, is potentially twice that number – <a href="https://www.beforeyoubet.org/college-students-gambling/">up to 6%</a>.</p>
<p>As an <a href="https://sites.miamioh.edu/jason-w-osborne/">educational psychologist</a> who follows gambling in America, I foresee the potential for gambling on campus to become an even bigger problem. <a href="https://theconversation.com/a-boon-for-sports-fandom-or-a-looming-mental-health-crisis-5-essential-reads-on-the-effects-of-legal-sports-betting-199657">Sports betting continues to expand</a>, including on college campuses, since a <a href="https://www.cnn.com/2018/05/14/politics/sports-betting-ncaa-supreme-court/index.html">2018 Supreme Court ruling allowing states to make it legal</a>.</p>
<p>As a faculty fellow at an <a href="https://miamioh.edu/aspire/muirgls/index.html">institute that promotes responsible gaming</a>, I know that colleges can take steps to curtail problem gambling among students. It is all the more urgent given that adolescents in general, including college students, are often <a href="https://doi.org/10.1016/j.jadohealth.2010.05.003">uniquely susceptible to gambling problems</a>, both because of their exposure to video games – which often have hallmarks of gambling behavior – and the <a href="https://doi.org/10.1016/j.addbeh.2020.106386">stress and anxiety of college life</a>, which can lead to using gambling as a <a href="https://doi.org/10.1111/j.1475-3588.2004.00092.x">coping strategy</a>.</p>
<h2>The spread of legal sports betting</h2>
<p>As of November 2023, <a href="https://www.legalsportsreport.com/sportsbetting-bill-tracker/">sports betting is legal</a> in some form in 38 states and Washington, D.C. Further, 26 states allow sports betting online. Bills have been introduced – and some recently passed – in more states. These states include <a href="https://www.legalsportsreport.com/vermont/">Vermont</a>, <a href="https://www.legalsportsreport.com/missouri/">Missouri</a> and <a href="https://www.legalsportsreport.com/nc/">North Carolina</a>. Thanks to technology, sports betting is now accessible beyond casinos. Anyone can access it online and on their smartphone.</p>
<p>More than <a href="https://www.legalsportsreport.com/sports-betting/revenue/">US$268 billion has been gambled legally</a> on sports betting between June 2018 and November 2023. Revenue in all U.S. gaming sectors has increased significantly, with sports betting growing the fastest, at <a href="https://www.visualcapitalist.com/sp/the-explosive-growth-of-sports-betting/">an estimated 75% annually</a>. It has generated about <a href="https://www.legalsportsreport.com/sports-betting/revenue/">$3.9 billion in tax revenue</a> to date.</p>
<p>Sports betting is also becoming more accessible on college campuses. A New York Times investigation found that sports betting companies and universities have essentially <a href="https://www.nytimes.com/2022/11/20/business/caesars-sports-betting-universities-colleges.html">“Caesarized” college life</a>. That is to say, they’ve made campuses resemble elements of the world famous casinos by introducing online gambling to students.</p>
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<figcaption><span class="caption">College betting scandals shine light on campus wagering.</span></figcaption>
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<p>These profits have driven increased advertising. Some estimate that total advertising through all media channels could <a href="https://www.forbes.com/sites/bradadgate/2022/09/15/sports-betting-is-revving-up-ad-spending-for-fourth-quarter/?sh=64c692c05dff">approach $3 billion annually</a>. This includes social media platforms like TikTok, where young adults are <a href="https://www.theguardian.com/australia-news/2023/feb/14/sportsbet-is-targeting-young-women-on-tiktok-to-diversify-male-client-base-experts-say">more likely to see ads for gambling</a>. A study in the United Kingdom found that <a href="https://link.springer.com/article/10.1007/s40429-022-00457-0">72% of 18- to 24-year-olds</a> have seen gambling ads through social media. </p>
<p>While advertisers reportedly focus on young adults of legal age, research suggests that children under 18 are also being <a href="https://doi.org/10.1016/j.puhe.2022.11.019">exposed to advertising</a> related to gambling. The intensity of advertising activity on social media has raised concerns and brought scrutiny. Earlier this year, for example, prosecutors in the <a href="https://www.masslive.com/politics/2023/03/are-you-and-your-kids-overwhelmed-by-mass-sports-betting-ads-youre-not-alone.html">Massachusetts attorney general’s office</a> expressed concern that sports betting and other gambling might spread quickly through college campuses as a result of advertising. </p>
<h2>Why college students are at greater risk of gambling addiction</h2>
<p>Gambling addiction affects people from all backgrounds and across all ages, but it is an even bigger threat to college students. Adolescents of college age are uniquely likely to engage in impulsive or risky behaviors because of a <a href="https://doi.org/10.1002/dev.20442">variety of developmental factors</a>, leaving them more susceptible to take bigger risks and experience adverse consequences.</p>
<p>It’s no secret that drinking alcohol is prevalent on college campuses, and this can increase the likelihood of other <a href="https://doi.org/10.1016/B978-0-12-813125-1.00054-4">risk-taking behaviors such as gambling</a>. Like other addictive behaviors, gambling can <a href="https://doi.org/10.1111/adb.12378">stimulate the reward centers of the brain</a>, which makes it more difficult to stop even if someone is building up losses. </p>
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<img alt="Group of friends watch a game on a phone." src="https://images.theconversation.com/files/549159/original/file-20230919-27-9yeabv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549159/original/file-20230919-27-9yeabv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549159/original/file-20230919-27-9yeabv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549159/original/file-20230919-27-9yeabv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549159/original/file-20230919-27-9yeabv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549159/original/file-20230919-27-9yeabv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549159/original/file-20230919-27-9yeabv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Sports betting has become more accessible on college campuses with the rise of gambling apps.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.ca/detail/photo/group-of-friends-watching-their-favorite-match-on-a-royalty-free-image/964387178?phrase=students+gambling&adppopup=true">GCShutter/E+ via Getty Images</a></span>
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<h2>What colleges and universities can do to help</h2>
<p>If you’re worried a student in your life might have a gambling problem, the Mayo Clinic describes <a href="https://www.mayoclinic.org/diseases-conditions/compulsive-gambling/symptoms-causes/syc-20355178">signs to look for</a>. These include restlessness or irritability when attempting to stop or reduce gambling, gambling more when feeling distressed, and lying to hide gambling or financial losses from it. Gamblers Anonymous provides a <a href="http://www.gamblersanonymous.org/ga/content/20-questions">20-question, self-diagnostic questionnaire</a> to help people identify problems or compulsive gambling.</p>
<p>For more resources, organizations like the <a href="https://www.gatewayfoundation.org/addiction-blog/how-to-help-someone-that-has-gambling-problem/">Gateway Foundation</a> offer information and support to help someone with a gambling problem. Immediate help is available at the national problem gambling helpline, <a href="https://www.ncpgambling.org/help-treatment/national-helpline-1-800-522-4700/">1-800-GAMBLER</a>. The National Council on Problem Gaming has <a href="https://www.ncpgambling.org/help-treatment/help-by-state/">lists of resources within each state</a> that can provide more local support and assistance. </p>
<p>At the Miami University Institute for Responsible Gaming, Lottery and Sport, my colleagues and I are working to ensure that the recent dramatic expansion of legalized gaming is matched by effective guidance for policymakers and leaders within higher education. Many institutions, like the <a href="https://dos.uoregon.edu/gambling-support">University of Oregon</a>, have begun to acknowledge that widespread legalized sports betting and gambling can affect their students. A comprehensive and coordinated approach is required to protect them from harm. </p>
<p>There are resources available to help institutions, such as the “get set before you bet” initiative adopted by the <a href="https://www.colorado.edu/health/blog/gambling">University of Colorado, Boulder</a> and others. This gives students practical tips to follow if they are going to gamble, such as setting time and money limits before they start.</p>
<p>Colleges and universities could do even more. According to the <a href="https://www.icrg.org/cg-information/task-force-on-college-gambling-policies-and-recommendations">International Center for Responsible Gaming</a>, institutions can address gambling risks to students by:</p>
<ul>
<li><p>Ensuring there are clear policies on gambling and making sure they align with alcohol policies. <a href="https://www.ue.org/risk-management/health-and-well-being/student-gambling-policies/">United Educators</a> provides examples of how institutions can create effective policies and support student wellness, like <a href="https://ogc.asu.edu/gambling-raffles">Arizona State’s policy</a>. Theirs prohibits legal and illegal gambling at any event related to ASU and reinforces that alcohol possession, consumption or inebriation is illegal for all students under 21.</p></li>
<li><p>Promoting awareness of addiction as a mental health disorder and making resources for getting help available to students.</p></li>
<li><p>Ensuring those who work in campus counseling and health services are familiar with gambling addiction and prepared to support students struggling with addiction or problem behavior. Providers should also be aware that multiple addictions can be present, enhancing the challenges to management and recovery.</p></li>
<li><p>Surveying student attitudes toward gambling to track changes in attitudes, behaviors and norms.</p></li>
</ul>
<p>With various sports championships, including in baseball, football and college basketball, taking place throughout the academic year, there’s no shortage of occasions for universities to check in with students about sports betting on campus. Gambling addiction is treatable, but preventing it from the start is the best solution.</p><img src="https://counter.theconversation.com/content/204434/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason W. Osborne works for Miami University</span></em></p>The rise of sports betting has made gambling addiction a bigger issue on college campuses, but there are steps universities can take to address it.Jason W. Osborne, Professor of Statistics, Miami UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2175872023-11-15T12:14:15Z2023-11-15T12:14:15ZStranger in My Own Skin: Pete Doherty documentary reviewed by a mental health and addiction expert<p><a href="https://www.dohertyincinema.com/">Stranger in My Own Skin</a> is a documentary about the life of musician Pete Doherty, who is as well known for his drug use and spells in prison as he is for forming The Libertines and later Babyshambles. From recreational beginnings, through first realising he had a drug problem, Doherty finally ended up consumed by full-blown addiction. As he explains it: “Hard drugs entered my life and slowly, slowly, quickly took control.”</p>
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<figcaption><span class="caption">The trailer for Stranger In My Own Skin.</span></figcaption>
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<p>In the film, Doherty’s life seems to play out many of the characteristics experts know <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3749318/">increases vulnerability for drug use</a>. He had an authoritarian childhood growing up on army bases, surrounded by metaphorical and actual barbed wire. He experienced feelings of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4070144/">not belonging</a>, unless at one with a football crowd. He was a young adult in a subculture where drug use was not only part of the escape, it was also accepted, normalised – <a href="https://www.tandfonline.com/doi/abs/10.1080/16066350500053497">even expected</a>.</p>
<p>However, this film captures something else. Doherty was, and still is, superstar famous – The Libertines were once feted as the coolest band on the planet. Yet he has never hidden his heroin use. </p>
<p>As his relationship with heroin develops from habit to dependence, it’s accompanied by the erratic behaviour and chaotic surroundings that are <a href="https://journals.sagepub.com/doi/abs/10.1177/00914509231189934">often seen in addiction</a>. Doherty embraces the “havoc”. When he’s not careering about or agitated about something, he’s flat out on his back, seemingly only finding stillness in heroin. </p>
<p>Alongside this, the camera reveals his physical disintegration from a beautiful young man into someone with scabs, poor personal hygiene and a stumbling gait.</p>
<p>Doherty’s havoc is coupled with a romantic notion of opium and laudanum use. He smokes heroin expecting revelatory dreams, looking to writers like <a href="https://www.britannica.com/biography/Oscar-Wilde">Oscar Wilde</a>, <a href="https://www.britannica.com/biography/James-Joyce">James Joyce</a> and <a href="https://www.britannica.com/biography/Fyodor-Dostoyevsky">Fyodor Dostoyevsky</a> for inspiration.</p>
<p>He’s obsessed with Paris and uses a fountain pen and a typewriter. He creates a romanticised interpretation of his roots, adopting the Union Jack as a backdrop in his homes as well as on stage. He longs for some mythical Albion, his <a href="https://i.pinimg.com/originals/8d/bf/59/8dbf596f6d8ae9a215e9e388688b6f1f.jpg">trademark red military frock coats</a> perhaps mocking his army upbringing while revealing an inability to break free from it. </p>
<p>Then there’s his relationship with <a href="https://www.theguardian.com/lifeandstyle/2022/mar/26/carl-barat-the-libertines-guiltiest-pleasure-love-island">Carl Barât</a>, co-founder of The Libertines. Barât plays a small supporting role in the film, but the little he says is revealing, describing their relationship as “two one-legged men strapped to each other to learn to walk”. Ricocheting between intense love and deep antagonism, Doherty <a href="https://www.theguardian.com/uk/2003/sep/09/arts.artsnews">burgled Barât’s flat</a>, was arrested for it and ended up in prison.</p>
<h2>Seeking rehab</h2>
<p>Fast forward through the Babyshambles years, and finally Doherty accepts that he has to quit, if only to stay alive. There’s no great epiphany, more a dawning realisation. To <a href="https://www.tandfonline.com/doi/full/10.1080/13603108.2015.1101999">paraphrase writer Samuel Johnson’s</a> words on habits, the chains of addiction are too light to be felt until they are too heavy to be broken. There is plenty of evidence that addiction does indeed develop over a period of time and may sneak up unawares, but some drugs are known to be more habit forming than others, heroin being one of the most addictive. </p>
<p>Doherty is ambivalent. “I want to make it to the other side, I do, I do”, he says, before shooting up. Doherty is in the rare position that he can afford residential treatment, even if he has to sell some of his possessions to fund it. Only <a href="https://www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2021-to-2022/adult-substance-misuse-treatment-statistics-2021-to-2022-report#treatment-interventions">one in 100</a> people dependent on heroin in the UK have this option. </p>
<p>After a couple of false starts, musing about hiding heroin in his dressing gown cord, he heads to Thailand for detox and rehab. This part of the film is more familiar, we’ve seen portrayals of rehab and recovery before.</p>
<p>Memory is a constant theme in the documentary – what happened, what is remembered and what is not. The film amplifies this uncertainty as it flits in and out of archive footage of Doherty’s musings. There is a ghost which doesn’t appear – <a href="https://www.theguardian.com/tv-and-radio/2023/sep/25/pete-doherty-who-killed-my-son-review-a-shocking-look-at-a-terribly-bungled-case">Mark Blanco</a>. His tragic death at a party attended by Doherty and Doherty’s reaction (he was <a href="https://metro.co.uk/2023/09/26/pete-doherty-mark-blanco-murder-body-cctv-19557878/">filmed running past</a> Blanco’s body), have never been satisfactorily explained. Why didn’t that feature?</p>
<p>Perhaps the answer lies with the filmmaker. The documentary makes use of a decade of off-camera interviews by Katia DeVidas. Spoiler alert: reader, she married him. This perhaps explains some of the film’s extraordinary intimacy, but also why some questions aren’t asked and answered in the film. DeVidas did not reply to requests for comment by the time of publication.</p>
<p>A wealth of pre-existing footage, coupled with DeVidas’ access, goes beyond tabloid portrayals and moralising judgments and bears witness to the paradoxes in a life which is both real and performative, visceral and intellectual. </p>
<p>Towards the end, Doherty says he’s interested in working with people in the thick of addiction, but he seems always to have a bottle of Jim Beam in his hand, acknowledging that clean refers to heroin, not alcohol.</p>
<p>He’s making music again, with DeVidas now in the band, and it is his music and the centrality of creativity to his existence which underpin the whole film. “The talent is the man, not the drugs”, he explains. “In spite of being a drug addict or in spite of being clean, I will create”.</p>
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<hr><img src="https://counter.theconversation.com/content/217587/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sally Marlow currently receives funding from the ESRC, the AHRC and NIHR and in the past has received funding from the Society for the Study of Addiction, the British Council and the Nuffield Foundation. </span></em></p>Doherty’s life features many of the characteristics experts know increases vulnerability for drug use.Sally Marlow, Addictions Researcher, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2168792023-11-06T15:51:04Z2023-11-06T15:51:04ZMatthew Perry: the power of celebrities speaking publicly about their addiction<p>As the outpouring of tributes from celebrities and fans shows, the actor Matthew Perry and his Friends character, Chandler Bing, meant a huge amount to many people. </p>
<p>But Perry, who died suddenly at 54, <a href="https://www.youtube.com/watch?v=BOwhvivGits">said himself</a> that he did not want to be remembered solely for his role on the sitcom: “When I die I don’t want ‘Friends’ to be the first thing that’s mentioned, I want that [helping people] to be the first thing that’s mentioned. And I’m going to live the rest of my life proving that.” </p>
<p>Perry was referring to his lifelong battle with addiction and opioids, which he documented candidly <a href="https://www.theguardian.com/books/2022/nov/16/friends-lovers-and-the-big-terrible-thing-by-matthew-perry-review-being-chandler-bing">in his autobiography</a>. Having visible figures like Perry speak publicly about their struggles can challenge the social stigma of addiction and inspire people to seek treatment.</p>
<p>In my <a href="https://openaccess.city.ac.uk/id/eprint/19635/1/Corcoran,%20Paula%20-%20redacted.pdf">research</a> and work with drug users, I have explored public understandings of addiction and substance dependency. It can take years for people to seek help for addiction issues, and they often report feelings of <a href="https://pubmed.ncbi.nlm.nih.gov/24115936/">guilt and shame</a>. Many people still associate addiction with a <a href="https://openaccess.city.ac.uk/id/eprint/19635/">lack of control and personal chaos</a>, which can evoke fear in those who do not have personal experience of addiction themselves. </p>
<p>Perry himself subscribed to the view of addiction as a disease. He wanted people to be open and compassionate to the struggles of addiction, <a href="https://inews.co.uk/news/entertainment/the-best-thing-about-me-matthew-perry-wanted-to-be-remembered-for-his-work-on-addiction-2719377">describing it as</a> an adversary that is just “outside doing one-arm push-ups, waiting to get you alone”.</p>
<p>After his passing, a clip of Perry’s 2013 <a href="https://www.bbc.co.uk/news/av/entertainment-arts-67254146">Newsnight</a> debate with controversial commentator Peter Hitchens went viral. The debate focused on the topic of <a href="https://www.college.police.uk/research/crime-reduction-toolkit/drug-courts">specialist drug courts</a>, an alternative to the normal court system, which Perry supported. Hitchens, who disagrees with the concept of addiction as a disease and describes drug use as a choice, particularly rankled Perry that night.</p>
<p>In his heated interaction with Hitchens, Perry made it clear that he was a person who was not afraid to stand up for others whose struggles with addiction are misunderstood. This, from someone as famous as Perry, was a powerful moment.</p>
<h2>Celebrities and public struggle</h2>
<p>Perry is not the first famous person to share their personal battles and demons. Celebrity influence can be a powerful force, particularly when viewers <a href="https://journals.sagepub.com/doi/pdf/10.1177/108056999205500315">identify</a> with the actor or singer, or the character they play on screen. </p>
<p>In 1993, Diana, Princess of Wales <a href="https://time.com/4918729/princess-diana-mental-health-legacy">spoke publicly</a> about her battles with bulimia. In the years following, the number of women who sought support for bulimia <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/time-trends-in-eating-disorder-incidence/13DCB26A064CB2634CA4EF8CD8367A4D">doubled</a>.</p>
<p>Others, including <a href="https://www.addictioncenter.com/news/2021/03/demi-lovato-addiction-overdose-documentary/">Demi Lovato</a>, <a href="https://www.aspenridgerecoverycenters.com/charlie-sheen-addiction/">Charlie Sheen</a> and <a href="https://www.foxnews.com/entertainment/joaquin-phoenix-rehab">Joaquin Phoenix</a> have all discussed their battles with mental health and addiction.</p>
<p>Research has shown that celebrity stories can inspire behaviour change when it comes to health. A celebrity <a href="https://pubmed.ncbi.nlm.nih.gov/23845155/">cancer diagnosis</a> can inspire people to get screened, or a public <a href="https://www.ukat.co.uk/blog/society/giving-up-alcohol-inspiration-celebrities-long-term-recovery/">struggle with alcohol</a> may motivate someone to seek help themselves.</p>
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<a href="https://theconversation.com/what-long-term-opioid-use-does-to-your-body-and-brain-193494">What long-term opioid use does to your body and brain</a>
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<p>This may be because of the <a href="https://www.everydayhealth.com/emotional-health/what-are-parasocial-relationships-and-are-they-healthy/">one-sided relationship</a> an audience has with a public figure. Fans develop a psychological and emotional attachment and may view the famous person as a friend or someone who can be trusted. Indeed, in Perry’s death, many people felt they had <a href="https://theconversation.com/the-enduring-appeal-of-friends-and-why-so-many-of-us-feel-weve-lost-a-personal-friend-in-matthew-perry-216626">lost a friend</a>.</p>
<p>When Perry’s autobiography was released in 2022, he proudly reported that several people <a href="https://metro.co.uk/2022/11/19/matthew-perry-says-five-people-checked-into-rehab-inspired-by-memoir-17789607/#:%7E:text=helped%20by%20it.-,','">checked into rehab</a> after reading his book. Other fans attributed their sobriety to his inspirational <a href="https://nypost.com/2023/10/31/entertainment/matthew-perrys-memoir-saved-my-life-recovering-addict/">memoir</a> because Perry was a person they could identify with.</p>
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<h2>A lasting legacy</h2>
<p>Publicly sharing experiences with addiction is a gamble, as stars may be judged and rejected by fans. Perry himself faced a <a href="https://www.pedestrian.tv/entertainment/friends-matthew-perry-shamed-media-fans/">negative reaction</a> on social media during the Friends reunion in 2021. </p>
<p>Comments focused on his aged appearance and his “slurred” speech, possibly lasting effects of a years-long battle with addiction. It would have been easy for Perry to retire from the public view and hide his struggles.</p>
<p>But in his final years, Perry made clear that he wanted to use his story to help others. He demonstrated this commitment when in 2013 he converted his Malibu mansion into <a href="https://www.msn.com/en-gb/entertainment/celebrity/inside-matthew-perrys-former-beachfront-sober-living-home-for-addicts/ar-AA1j8i9Z">Perry House</a> – a sober-living house for men in recovery. </p>
<p>The project ran for two years, closing due to the financial cost. Before his death, he was reportedly setting up a new <a href="https://www.dailymail.co.uk/tvshowbiz/article-12690211/Matthew-Perry-early-stages-foundation-substance-abuse-issues.html">foundation</a> to support people living with substance-use issues.</p>
<p>While he may influence some to begin their journey to recovery, perhaps his most lasting legacy will be that he brought a human face to addiction. In a world where people still feel judged and ashamed when struggling with drugs or alcohol, Perry reminded us all that an addict is <a href="https://www.theguardian.com/commentisfree/2023/oct/30/matthew-perry-death-addict-friends">more than their addiction</a>.</p><img src="https://counter.theconversation.com/content/216879/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paula Corcoran does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Famous faces sharing their struggles can inspire fans to seek help.Paula Corcoran, Senior Lecturer in Health Psychology, City, University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2167362023-11-03T02:51:53Z2023-11-03T02:51:53ZWhen Oregon decriminalised drugs, overdoses went up. Will that happen in the ACT?<figure><img src="https://images.theconversation.com/files/557192/original/file-20231101-27-2zu0r.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5806%2C3687&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A <a href="https://www.abc.net.au/news/2023-10-28/canberra-drug-decriminalisation-laws-begin-today/103032128">new bill</a> came into effect in the ACT at the weekend decriminalising personal possession of common illegal drugs. </p>
<p>The bill decriminalises the possession of <a href="https://www.health.act.gov.au/about-our-health-system/population-health/drug-law-reform#:%7E:text=The%20reforms%20aim%20to%20divert,of%20paying%20a%20%24100%20fine.">small amounts of illicit drugs</a>, including cocaine, methamphetamine, MDMA, LSD, psilocybin (magic mushrooms) and heroin for personal use.</p>
<p>Critics of the move say when similar laws were brought into effect in the US state of Oregon, overdose deaths went up. However, there was already an upward trend, and Oregon now has lower rates of death from overdose than most other US states. </p>
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Read more:
<a href="https://theconversation.com/drugs-could-soon-be-decriminalised-in-the-act-heres-why-that-would-be-a-positive-step-157709">Drugs could soon be decriminalised in the ACT. Here's why that would be a positive step</a>
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<h2>Remind me again, what does decriminalisation mean?</h2>
<p>Decriminalisation isn’t legalisation. With decriminalisation, <a href="https://adf.org.au/talking-about-drugs/law/decriminalisation/overview-decriminalisation-legalisation/">drugs are still illegal</a>, but the criminal penalties are removed. Instead, they usually attract a fine, a bit like a speeding fine.</p>
<p>The ACT will be the first Australian jurisdiction to decriminalise common illegal drugs. In this model, people will be diverted from police to <a href="https://www.health.act.gov.au/about-our-health-system/population-health/drug-law-reform#:%7E:text=The%20reforms%20aim%20to%20divert,of%20paying%20a%20%24100%20fine.">attend a one-off health information session</a> where a health worker assesses their wellbeing and the need for support or intervention. They provide education and harm-reduction information and make referrals to other services if needed.</p>
<p>Police will still confiscate illicit drugs they find on people. Drug dealing and trafficking are still criminal offences.</p>
<p>This system means people who are caught with small amounts of some drugs will be diverted away from the criminal justice system. Contact with the criminal justice system is one of the <a href="https://www.smh.com.au/national/nsw/coroner-compares-drug-prohibition-laws-to-racism-20181104-p50dwj.html">biggest harms</a> from illicit drugs. </p>
<p>There’s no evidence enforcement-led solutions to personal drug use reduce use or harms. But having a criminal record can have a long-term impact on getting a job or secure housing, which can then increase the likelihood of further drug use. Current punishments in many states and territories include a possible prison sentence. </p>
<p>Policing of drug laws, and the justice system itself, disproportionately impacts Aboriginal people and other people of colour. Young people have been described as being traumatised and dehumanised by the use of <a href="https://rlc.org.au/news-and-media/rlc-media/abuse-power-needs-stop-why-drug-dogs-and-strip-searches-just-dont-work">drug dogs and strip searches</a> by police.</p>
<p>The change is supported by <a href="https://preventionconversation.org/wp-content/uploads/2018/07/ccsa-decriminalization-controlled-substances-policy-brief-2018-en.pdf">decades of research</a> and backed by major health and human rights organisations, such as the <a href="https://www.theverge.com/2014/7/17/5913057/world-health-organization-drugs-narcotics-legalization">World Health Organization</a>, <a href="https://www.drugpolicy.org.au/un_supports_decriminalisation_of_drugs">the United Nations</a> and the <a href="https://www.unaids.org/en/topic/decriminalization">Joint United Nations Programme on HIV/AIDS</a>.</p>
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Read more:
<a href="https://theconversation.com/our-drugs-policies-have-failed-its-time-to-reinvent-them-based-on-what-actually-works-69984">Our drugs policies have failed. It's time to reinvent them based on what actually works</a>
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<h2>Where else has decriminalised drugs?</h2>
<p>We know from other jurisdictions that decriminalisation reduces harms from drugs and increases seeking help. <a href="https://transformdrugs.org/blog/drug-decriminalisation-in-portugal-setting-the-record-straight">Portugal</a> is the most well-known case. It decriminalised all drugs more than 20 years ago and has seen significant reductions in drug deaths, crime and drug use.</p>
<p>But critics in Australia are concerned about the possible negative outcomes, pointing to problems in Oregon. The federal opposition unsuccessfully introduced a bill to <a href="https://www.abc.net.au/news/2023-10-19/senator-michaelia-cash-fails-to-overthrow-act-drug-laws/102995412#">overturn the ACT legislation</a>.</p>
<p>In November 2020, Oregon passed <a href="https://www.oregon.gov/oha/hsd/amh/pages/measure110.aspx">Measure 110</a>, which decriminalised the possession of small amounts of drugs for personal use. Instead of criminal charges, people are now given a US$100 (A$155) fine for possession, which is waived if they contact a support hotline. </p>
<p>After Portugal decriminalised personal drug use in 2001, there was a <a href="https://transformdrugs.org/blog/drug-decriminalisation-in-portugal-setting-the-record-straight">drop in drug-related deaths</a>.</p>
<p>In the two years after Measure 110 passed, opioid overdose deaths in Oregon <a href="https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/quarterly_opioid_overdose_related_data_report.pdf">more than doubled</a>.</p>
<h2>Why did this happen in Oregon?</h2>
<p>The purpose of decriminalisation is merely to reduce one of the biggest harms from illicit drugs: contact with the criminal justice system. It has certainly <a href="https://www.sciencedirect.com/science/article/pii/S0955395923002025?via%3Dihub">achieved that in Oregon</a>, especially among Black Americans, who are over-represented in the criminal justice system.</p>
<p>In the year before Measure 110 was passed, overdose deaths in Oregon were <a href="https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/quarterly_opioid_overdose_related_data_report.pdf">already on the increase</a>, up 69% on the previous year. Oregon was ranked <a href="https://sos.oregon.gov/audits/Documents/2023-03.pdf">second-highest</a> of all US states for substance use disorders, and ranked <a href="https://sos.oregon.gov/audits/Documents/2023-03.pdf">last</a> of 50 states for access to treatment. </p>
<p>Decriminalisation on its own isn’t intended to directly reduce use or overdoses. Portugal’s success in reducing use and other harms, such as overdoses, is likely more to do with the significant investment in treatment and support. And as Oregon continues the roll-out of treatment program funding, there are indications 2023 overdose death rates have come down, tracking at <a href="https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/quarterly_opioid_overdose_related_data_report.pdf">half the rate</a> of the year before.</p>
<p>Oregon’s overdose death rate is now one of <a href="https://drugabusestatistics.org/drug-overdose-deaths/#oregon">the lowest</a> in the <a href="https://www.beckershospitalreview.com/rankings-and-ratings/states-ranked-by-drug-overdose-death-rate.html">United States</a>.</p>
<p>We know treatment is the most effective and cost-effective way to reduce use and harms. A study in California found for every $1 spent on drug treatment, the <a href="https://pubmed.ncbi.nlm.nih.gov/16430607/">community saved</a> $7 in other costs, primarily by reducing crime and increasing employment earnings.</p>
<p>Decriminalisation needs to be supported by treatment, support and evidence-based harm reduction measures, such as access to naloxone and drug checking.</p>
<p>Naloxone has been available for free with no prescription since July 2022 in Australia, and the <a href="https://www.health.gov.au/our-work/take-home-naloxone-program">Take Home Naloxone program</a> will increase the availability of naloxone Australia-wide.</p>
<p>The Queensland government has given <a href="https://statements.qld.gov.au/statements/97250">drug checking services</a> the green light to start operating, and Canberra’s fixed-site drug checking service has been <a href="https://www.health.act.gov.au/about-our-health-system/population-health/pill-testing">extended</a> until December 2024. The service checked nearly <a href="https://directionshealth.com/wp-content/uploads/2023/10/CanTEST-Summary_Month-12-2-1.pdf">1,200 samples</a> for their contents and provided more than <a href="https://directionshealth.com/cantest-health-drug-checking-service/">1,500 brief interventions</a> in the first 12 months.</p>
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Read more:
<a href="https://theconversation.com/we-cant-eradicate-drugs-but-we-can-stop-people-dying-from-them-54636">We can't eradicate drugs, but we can stop people dying from them</a>
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<h2>Will drug decriminalisation work in the ACT?</h2>
<p>The ACT is Australia’s most progressive jurisdiction when it comes to drug laws. It <a href="https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/Evaluation%20of%20the%20Australian%20Capital%20Territory%20Drug%20Diversion%20Programs.pdf">removed criminal penalties from cannabis</a> possession more than 30 years ago, and in 2019 it introduced a “<a href="https://theconversation.com/home-grown-cannabis-to-be-legal-in-the-act-now-what-124268">home grown</a>” model, removing all penalties for the use and possession of small amounts of homegrown cannabis for personal use. </p>
<p>It has the <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data?&page=1">lowest rate of cannabis use</a> in Australia. There has been no change in rates of cannabis use, drug driving offences or hospital presentations, and there has been a significant reduction in the number of Canberrans being exposed to the police and criminal justice system. </p>
<p>Ultimately, we won’t know the full impact of decriminalisation in the ACT until the bill has been implemented for some time. But evidence from places such as Portugal says it will increase diversion from the criminal justice system, improve access to treatment and harm reduction, and reduce stigma towards people who use drugs. To significantly reduce drug use itself, the ACT also needs to increase investment in drug treatment.</p>
<p><em>If you are worried about your own or someone else’s alcohol or other drug use, you can contact the National Alcohol and other Drug Hotline on 1800 250 015 for free, confidential advice.</em></p>
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Read more:
<a href="https://theconversation.com/as-many-states-weigh-legalising-cannabis-heres-what-they-can-learn-from-the-struggles-of-growers-in-canberra-212009">As many states weigh legalising cannabis, here's what they can learn from the struggles of growers in Canberra</a>
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<img src="https://counter.theconversation.com/content/216736/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee is CEO at Hello Sunday Morning and also works as a consultant in the alcohol and other drug sector and a psychologist in private practice. She has previously been awarded funding by Australian and state governments, NHMRC and other bodies for evaluation and research into alcohol and other drug prevention and treatment.</span></em></p>Overdose deaths did go up in Oregon after drug decriminalisation, but they were already increasing, as they were in nearby states.Nicole Lee, Professor at the National Drug Research Institute (Melbourne), Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2158892023-10-26T12:31:10Z2023-10-26T12:31:10ZTo better understand addiction, students in this course take a close look at liquor in literature<figure><img src="https://images.theconversation.com/files/555246/original/file-20231023-15-kxsfnv.jpg?ixlib=rb-1.1.0&rect=23%2C31%2C5152%2C3383&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Characters in books can teach lessons about addiction.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/open-book-and-glass-of-white-wine-in-sunlight-royalty-free-image/1219727594?phrase=wine+literature&adppopup=true">Nataliia Shcherbyna via iStock/Getty Images Plus</a></span></figcaption></figure><figure class="align-right ">
<img alt="Text saying: Uncommon Courses, from The Conversation" src="https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em><a href="https://theconversation.com/topics/uncommon-courses-130908">Uncommon Courses</a> is an occasional series from The Conversation U.S. highlighting unconventional approaches to teaching.</em> </p>
<h2>Title of course:</h2>
<p>Alcohol in American Literature</p>
<h2>What prompted the idea for the course?</h2>
<p>I got the idea for the course when I was writing a chapter on the temperance movement in American literature for my doctoral dissertation. I ended up reading a lot of fiction and poetry about alcohol and the anti-alcohol movement. I thought it would be fun to teach a class that <a href="https://www.academia.edu/12903259/_Temperance_Novels_and_Moral_Reform_in_Oxford_History_of_the_Novel_in_English_Oxford_UP_2014_">surveyed American literature through a booze-themed lens</a>. </p>
<p>Since alcohol affects and disables people regardless of gender, sexual orientation, race, ethnicity or class, it is easy to find literature about the impact of alcohol from many points of view. </p>
<h2>What does the course explore?</h2>
<p>I pair my course with a medical doctor who teaches a course on the <a href="https://www.verywellmind.com/addiction-4157312">biology of addiction</a>. In the biology course, students learn about the <a href="https://www.verywellmind.com/addiction-overview-4581803">biological and physiological effects</a> of diseases of addiction, <a href="https://www.verywellmind.com/substance-use-vs-substance-use-disorder-whats-the-difference-6385961">substance use and abuse</a>, dependency and recovery.</p>
<p>The core curriculum at John Carroll University requires students to take paired courses from different departments that are linked together. A colleague who teaches biology courses approached me about linking my alcohol class to her addiction class. Students must take both of our courses during the same semester. The combined courses give students both a scientific and literary view of addiction. </p>
<p>Students read fiction, poetry and drama about many aspects of alcohol and other addictive substances: celebrating them, struggling with them, even prohibiting and regulating them. Students compare the literary representations of substance and alcohol abuse with medical descriptions and impacts. For example, when my class reads Kristen Roupenian’s viral short story “<a href="https://www.newyorker.com/magazine/2017/12/11/cat-person">Cat Person,</a>” we talk about the role of alcohol in reducing inhibition when casually dating.</p>
<h2>What’s a critical lesson from the course?</h2>
<p>My goal is for students to come to a better understanding of how alcohol influences literature. They learn how some writers portray the way alcoholism further marginalizes minorities. For example, characters in <a href="https://fallsapart.com/">Sherman Alexie</a>’s “<a href="https://bookshop.org/p/books/the-lone-ranger-and-tonto-fistfight-in-heaven-20th-anniversary-edition-sherman-alexie/12459512?ean=9780802121998">The Lone Ranger and Tonto Fistfight in Heaven</a>” are enrolled members of the Spokane Tribe of Indians. They live on the reservation and have great difficulty finding or keeping a job. Many characters suffer from intergenerational trauma, poverty and a pervasive addiction to alcohol. </p>
<p>For their final project, students must pitch a movie that offers a compelling plot with relatable characters. The storyline must be backed up by a deep understanding of the science of disease and addiction. </p>
<h2>What materials does the course feature?</h2>
<p>• “<a href="https://tinhouse.com/book/night-of-the-living-rez/">Night of the Living Rez</a>,” by Morgan Talty, explores addiction and poverty among the Penobscot Nation.</p>
<p>• “<a href="https://www.hemingwayhome.com/store/p/the-sun-also-rises-softcover">The Sun Also Rises</a>,” by Ernest Hemingway, is a classic novel set in 1920s Paris about a set of heavy-drinking American ex-pats dealing with the trauma of World War I.</p>
<p>• We visit <a href="https://karamuhouse.org/">Karamu House</a>, the U.S.’s oldest continuing African American theater, to watch a performance of “<a href="https://www.dramatists.com/cgi-bin/db/single.asp?key=6301">Clyde’s</a>,” a popular play by Lynn Nottage that is set in a truck stop sandwich shop that employs the recently incarcerated.</p>
<h2>What will the course prepare students to do?</h2>
<p>Students can be better advocates for their own personal health, and the health of others, if they understand how addictive substances affect their minds and bodies. Pre-health students in particular get a general introduction to medical issues related to addiction and how American authors have long portrayed booze. </p>
<p>For example, Frances Watkins Harper’s “<a href="https://www.literaryladiesguide.com/full-texts-of-classic-works/the-two-offers-by-frances-watkins-harper/">The Two Offers</a>,” written in the 1850s, is believed to be the first short story ever published by an African American woman. It is a temperance story that encourages young women not to marry a drunkard, highlighting the antebellum Black community’s concerns about sobriety and domestic well-being, in addition to freedom.</p>
<p>The course hones students’ critical reading and writing skills while challenging them to think about the role of alcohol, substance abuse, sobriety and recovery in their lives and in American culture.</p><img src="https://counter.theconversation.com/content/215889/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Debra J. Rosenthal does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This course beckons students to examine how alcoholic beverages are portrayed in books by American authors.Debra J. Rosenthal, Professor of English, John Carroll UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2151392023-10-25T11:16:03Z2023-10-25T11:16:03ZCrack vaccine research we did on rats could help babies of mothers who use cocaine – and reduce addiction<p>The most recent <a href="https://inpad.org.br/wp-content/uploads/2014/03/Lenad-II-Relat%C3%B3rio.pdf">statistics</a> put the number of <a href="https://www.unodc.org/res/WDR-2023/annex/1.1_Prevalence_of_drug_use_in_the_general_population_regional_and_global_estimates.xlsx">regular cocaine or crack cocaine users</a> in the world at 20 million. Of these, one in four will become addicted or develop use disorders.</p>
<p>Among the addicts, many are women who, when they become pregnant, can bring risks to themselves and their children. <a href="https://academic.oup.com/epirev/article-abstract/16/2/315/415440?redirectedFrom=fulltext">Cocaine use during pregnancy</a> is associated with serious conditions for pregnant women (such as severe pre-eclampsia or miscarriage) and babies (premature birth with complications, low birth weight, malformations and withdrawal syndrome in the newborn).</p>
<p>A study carried out by a research team I am part of at Universidade Federal de Minas Gerais (UFMG), in Brazil, has achieved a breakthrough: <a href="https://pubs.acs.org/doi/10.1021/acs.jmedchem.3c00366">a vaccine</a> that uses the immune system to prevent the perinatal consequences of drug use, and which could protect the children of drug-using mothers. If clinical studies prove the vaccine’s efficacy, it could be an important tool to complement the biopsychosocial treatments already used to treat people with cocaine and crack addictions.</p>
<p>Pre-clinical tests with the new vaccine on animals have already been carried out successfully. At the moment, the research project is trying to get this experimental drug registered with the Brazilian Health Regulatory Agency <a href="https://www.gov.br/anvisa/pt-br/english">Anvisa</a> so that clinical trials can begin and is looking for funds to carry them out.</p>
<h2>More than a decade in the making</h2>
<p>During <a href="https://www.sciencedirect.com/science/article/pii/S0306453012000522">my doctorate</a>, I studied how our bodies produce antibodies that contribute to the perception of certain symptoms of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0278584610003726">depression</a>. These antibodies, induced by intestinal bacteria, are capable of changing the action of certain hormones and neurotransmitters and changing our perception, creating symptoms and modifying our perception. In 2011, when I applied to UFMG, I started working on the idea of using this knowledge to produce a vaccine against cocaine.</p>
<p>A few years earlier, <a href="https://linkinghub.elsevier.com/retrieve/pii/S0264410X0100425X">an American group had published articles</a> showing that cocaine produced antibodies in some addicts who used very large quantities of the drug. They then began studies with the aim of using this mechanism, which we can call a self-defensive mechanism of the organism, to help people with addictions to cocaine and its derivatives, such as crack.</p>
<p>I was already working on the vaccine when scientific research ran into reality: a tragic situation we experienced in Minas Gerais state became another trigger for the vaccine’s development. In 2013, the Public Prosecutor’s Office issued a rule to the Family Courts, obliging doctors to notify cases of births to drug-dependent women, which would take the newborn children into the adoption system. Immediately, hundreds of women arrived at the drug addiction clinic at UFMG’s Hospital das Clínicas, asking for help so they wouldn’t lose custody of their children.</p>
<p>It was a very sad situation. Motherhood is a time of conflict for these women, who want to protect the baby, but often can’t avoid the compulsion to use the drug. Only <a href="https://link.springer.com/article/10.1007/s11469-018-0005-7">25 per cent</a> of them manage to stop using during pregnancy.</p>
<p>But science is also made up of encounters. When I raised the issue with Professor <a href="http://lattes.cnpq.br/5930812704632756">Ângelo de Fátima</a>, one of Brazil’s leading experts in medicinal chemistry, he offered to replicate the molecule that the Americans had produced so that we could try an experiment on pregnant rats. A while later we talked about a new type of molecule, which had produced an immunogenic response to cancer, and from there came an innovation, a <a href="https://www.sciencedirect.com/science/article/pii/S2090123221001715">totally synthetic molecule</a>, which we now call UFMG-V4N2.</p>
<p>After discussing the possible immunogenicity - the ability to induce an immune response - of molecular structures called calixarenes, we agreed that he would synthesise a new molecule, called UFMG-V4N2, which is the basis of the Calixcoca vaccine. UFMG-V4N2 is actually a vaccine platform that can virtually be used to produce other vaccines, against methamphetamine, opioid and nicotine addiction, for example, for which we already have molecule designs under study.</p>
<h2>Protected pregnancy</h2>
<p>In the <a href="https://pubmed.ncbi.nlm.nih.gov/36822966/">study with the rats</a>, we observed that the vaccination induced the production of antibodies in the pregnant animals, which is a major challenge: pregnancy is a state in which the body’s immune response is lower, so that the baby is not considered a foreign body. The production of antibodies in pregnant women is therefore usually more complicated and, in the case of cocaine users, the drug itself already has an immunosuppressive effect.</p>
<p>Given the presence of the two immunosuppressive effects, we thought it would be very difficult for the mechanism to work. But paradoxically, the antibody production response was almost <a href="https://pubmed.ncbi.nlm.nih.gov/34381172/">a thousand times greater</a> than in the male mice. It’s a paradox for which we don’t yet have an immunological explanation, but it’s a finding that opens up a very interesting window of opportunity if this mechanism is reproduced in humans.</p>
<p>The vaccinated rats did not experience the lack of appetite or hyperactivity induced by cocaine, and had 30 per cent more offspring than the unvaccinated rats, which indicates a reduction in miscarriages, placental abruption and other perinatal complications. The antibodies produced were able to block the passage of the drug through the placenta, protecting the mice. Furthermore, we identified that the antibodies also pass through the milk, so when breastfeeding, the women, even when using the drug, may not cause harm to the babies.</p>
<h2>Addiction</h2>
<p>In addition to the benefits of the vaccine for pregnant women and their children, we believe that Calixcoca could also become an important tool to add to the addiction treatment package, which should also involve psychiatric, psychological and social care support and help from the family.</p>
<p>There are medicines that help with other addictions, such as alcohol or tobacco, but not so far for crack and cocaine, which are the drugs that most stimulate the brain’s reward circuit and, consequently, have a very high addictive power. Only 20 per cent of patients who undergo treatments manage to be drug-free within five years, which is a pretty poor result.</p>
<p>UFMG-V4N2 proved effective in producing antibodies and making them <a href="https://www.sciencedirect.com/science/article/pii/S2666934X23000053">block the passage of cocaine into the brain</a>, which means that the vaccinated animals have a reduced perception of the drug’s effect: a very important advantage in a treatment.</p>
<p>This blockage occurs in the following way: we have a “protective shield” called <a href="https://pubmed.ncbi.nlm.nih.gov/25561720/">the blood-brain barrier</a>, which prevents toxic elements, viruses or bacteria from entering the brain, but because the cocaine molecule is very small, it manages to pass through this barrier. The vaccine stimulates the production of antibodies, which bind to the drug molecules, increasing their weight and size and thus preventing them from getting past the protective shield. The cocaine is retained in the blood, but as it is bound to the antibody, it doesn’t act on the heart or arteries either, which means the risk of overdoses is reduced.</p>
<p>Cocaine and crack cocaine addiction is an extremely important medical, psychological and social problem that still has no definitive solution. Even before human trials begin, around 3,500 people have already contacted us spontaneously, interested in taking part as volunteers in clinical studies. That’s why the results achieved so far are so relevant: there is no treatment approved by regulatory agencies worldwide for this purpose, and Calixcoca could represent hope for thousands of users who want to quit the drug but can’t avoid relapsing. We still have a long way to go to complete the development of this treatment, which could contribute to improving the psychosocial treatments currently used to care for people suffering from cocaine and crack addiction.</p><img src="https://counter.theconversation.com/content/215139/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The research into the development of Calixcoca received funding from the Ministry of Justice - National Drug Policy Secretariat; the Minas Gerais State Research Support Foundation (Fapemig); the Chamber of Deputies; the National Council for Scientific and Technological Development (CNPq); and the Minas Gerais State Health Secretariat.</span></em></p>Calixcoca, which is in the final stages of study, could be a tool in the addiction treatment package.Frederico Garcia, Professor do Departamento de Psiquiatria da Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2159872023-10-19T05:11:15Z2023-10-19T05:11:15ZAdele called herself a ‘borderline alcoholic’. But is that a real thing?<p>British singer-songwriter Adele says she has quit drinking, <a href="https://www.theguardian.com/music/2023/oct/18/adele-says-she-has-quit-drinking-after-being-a-borderline-alcoholic">describing herself</a> as a “borderline alcoholic” when she was in her 20s.</p>
<p>She joins a <a href="https://theconversation.com/why-are-young-people-drinking-less-than-their-parents-generation-did-172225">growing number of people</a> who are trying to quit or reduce their drinking.</p>
<p>But what does “borderline alcoholic” mean and is it a real thing?</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-are-young-people-drinking-less-than-their-parents-generation-did-172225">Why are young people drinking less than their parents’ generation did?</a>
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</em>
</p>
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<h2>It’s not all-or-nothing any more</h2>
<p>In the <a href="https://theconversation.com/does-alcoholics-anonymous-actually-work-179665">early days</a> of alcohol treatment, people used to think of problems with alcohol as all-or-nothing. They used to believe there was something different about people who had problems with alcohol and those who didn’t. That’s how the idea of the “<a href="https://theconversation.com/is-there-really-such-a-thing-as-an-addictive-personality-184137">addictive personality</a>” came about.</p>
<p>But now we think of drinking on a continuum. It goes from not drinking at all to dependent drinking. And people can move up and down that continuum at different points in their lives. The old saying “once an alcoholic, always an alcoholic” doesn’t apply any more.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-there-really-such-a-thing-as-an-addictive-personality-184137">Is there really such a thing as an 'addictive personality'?</a>
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</em>
</p>
<hr>
<h2>How much is it OK to drink?</h2>
<p>The Australian national alcohol <a href="https://www.nhmrc.gov.au/health-advice/alcohol">guidelines</a> say healthy men and women should drink no more than ten <a href="https://alcoholthinkagain.com.au/resources-and-tools/standard-drink-tool">standard drinks</a> a week and no more than four a day. So that’s about two to three drinks three to four times a week. <a href="https://www.abs.gov.au/statistics/health/health-conditions-and-risks/alcohol-consumption/latest-release">Most Australians</a> drink within these guidelines.</p>
<p>If you drink over those guidelines you are more likely to experience a number of long- and short-term <a href="https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-reduce-health-risks-drinking-alcohol">problems</a> including alcohol dependence, cancers, diabetes and heart disease. The risk of problems increases the more you drink and the more frequently you drink.</p>
<p>About 25% of Australians drink at <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data">risky levels</a> and around 6% drink at such high levels that they would probably be dependent. Daily drinking is associated with dependence.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/554657/original/file-20231019-29-3mp7dg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Someone with hand over glass of red wine, saying 'no' to a top up" src="https://images.theconversation.com/files/554657/original/file-20231019-29-3mp7dg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554657/original/file-20231019-29-3mp7dg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554657/original/file-20231019-29-3mp7dg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554657/original/file-20231019-29-3mp7dg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554657/original/file-20231019-29-3mp7dg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554657/original/file-20231019-29-3mp7dg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554657/original/file-20231019-29-3mp7dg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">How much do you drink a week, or on any one day?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/womans-hand-rejecting-more-alcohol-wine-1840663135">Shutterstock</a></span>
</figcaption>
</figure>
<h2>So when is someone an alcoholic or a borderline alcoholic?</h2>
<p>The term “alcoholic” is rarely used by health professionals any more. It can make people believe there is nothing they can do about the problems they might be experiencing. Historically, that’s what the early treatment providers believed in the 1930s and that <a href="https://theconversation.com/alcohol-problems-arent-for-life-and-aa-isnt-the-only-option-8-things-film-and-tv-get-wrong-about-drug-and-alcohol-treatment-180946">myth has continued</a>. But some people find identifying as an “alcoholic” helpful to maintain their goal of quitting drinking.</p>
<p>Health professionals have never used the term “borderline alcoholic”. But in describing herself that way Adele is really saying alcohol is having too much of a negative impact on her life, and like many others has decided to do something positive about it by taking a break.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/many-define-adeles-voice-by-its-power-but-the-true-artistry-comes-from-her-fragile-authentic-self-172299">Many define Adele's voice by its power. But the true artistry comes from her fragile, authentic self</a>
</strong>
</em>
</p>
<hr>
<h2>Which terms do we use now?</h2>
<p>Now, we tend to talk about “dependence” on a continuum from mild to moderate to severe. We also talk about the range of problems other than dependence that people can experience, which also lie on a continuum.</p>
<p>The threshold for whether someone is a problem or dependent drinker is not just how much they drink (although that is important), but also how severe the alcohol-related problems are. </p>
<p>Problems with alcohol don’t always correlate with consumption. Some people can drink a moderate amount and have a lot of problems and others can drink a lot and appear not to have many negative consequences.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-different-drinks-make-you-different-drunk-88247">Do different drinks make you different drunk?</a>
</strong>
</em>
</p>
<hr>
<h2>I’m worried about my drinking. What next?</h2>
<p>If you are wondering if you are drinking too much you can <a href="https://hellosundaymorning.org/nib_alcohol_self-assessment/">check online</a> with a free and anonymous assessment.</p>
<p>Signs you may have a <a href="https://alcoholtreatmentguidelines.com.au/resources/appendix-3-diagnostic-criteria-for-alcohol-dependence">problem with alcohol</a> include:</p>
<ul>
<li><p>having trouble stopping once you start drinking</p></li>
<li><p>wanting or trying to cut back but slipping up frequently</p></li>
<li><p>spending a lot of time drinking or recovering from drinking</p></li>
<li><p>having cravings to drink alcohol, such as if you come home from work and reach straight for a drink</p></li>
<li><p>dropping the ball at work, study or home because you’ve been drinking, such as not being able to do your work because you’re hungover</p></li>
<li><p>continuing to drink alcohol even though you know it’s causing problems with your health, friends, work or relationships</p></li>
<li><p>giving up or reducing social and work activities to drink instead</p></li>
<li><p>drinking when it’s not safe, such as before driving or swimming.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/did-you-look-forward-to-last-nights-bottle-of-wine-a-bit-too-much-ladies-youre-not-alone-109078">Did you look forward to last night's bottle of wine a bit too much? Ladies, you're not alone</a>
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<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/554656/original/file-20231019-23-d4d6te.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Friends drinking alcohol, clinking glasses, outside" src="https://images.theconversation.com/files/554656/original/file-20231019-23-d4d6te.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554656/original/file-20231019-23-d4d6te.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554656/original/file-20231019-23-d4d6te.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554656/original/file-20231019-23-d4d6te.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554656/original/file-20231019-23-d4d6te.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554656/original/file-20231019-23-d4d6te.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554656/original/file-20231019-23-d4d6te.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">If you cannot quit alcohol like Adele, you can cut down.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cheerful-young-friends-toasting-summer-cocktails-1868806051">Shutterstock</a></span>
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</figure>
<p>If you find you aren’t getting the same effects from alcohol as you used to or you need more and more alcohol to get the same effect, you have probably developed a dependence. </p>
<p>Sometimes people who are very dependent can experience withdrawal symptoms when they stop – strong cravings, nausea, sweating, agitation and anxiety. </p>
<p>The more of these signs you have, the more likely you are to be dependent on alcohol. </p>
<p>If you have any of these signs, taking a break from alcohol for a few months or longer can help. If you find that’s too hard, you can try sticking within the Australian alcohol guidelines by reducing the number of drinks per occasion and increasing your drink-free days.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/trying-to-cut-back-on-alcohol-heres-what-works-179664">Trying to cut back on alcohol? Here's what works</a>
</strong>
</em>
</p>
<hr>
<h2>There’s help</h2>
<p>Sometimes when people experience some of these problems they need a bit of help to keep them on track. You can talk to your GP who can refer you to a psychologist or treatment service. Or you can try self-help options such as the Hello Sunday Morning’s <a href="https://hellosundaymorning.org/daybreak/">Daybreak app</a> (a community of people supporting each other to change their relationship with alcohol). If your problems are more severe, you can try something like <a href="https://smartrecoveryaustralia.com.au">SMART Recovery</a> (evidence-based group support for alcohol and other drug problems).</p>
<hr>
<p><em>If you are worried about your own or someone else’s alcohol or other drug use, you can contact the National Alcohol and other Drug Hotline on 1800 250 015 for free, confidential advice.</em></p><img src="https://counter.theconversation.com/content/215987/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee is CEO at Hello Sunday Morning and also works as a consultant in the alcohol and other drug sector and a psychologist in private practice. She has previously been awarded funding by Australian and state governments, NHMRC and other bodies for evaluation and research into alcohol and other drug prevention and treatment.</span></em></p>Adele is really saying alcohol is have too much of a negative impact on her life, and like many others has decided to do something positive about it by taking a break.Nicole Lee, Professor at the National Drug Research Institute (Melbourne), Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2137162023-10-16T21:49:31Z2023-10-16T21:49:31ZThe roots of the North American opioid crisis, and 3 key strategies for stopping it<figure><img src="https://images.theconversation.com/files/554088/original/file-20231016-21-1blzbh.jpg?ixlib=rb-1.1.0&rect=31%2C7%2C4866%2C3210&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Approaching the opioid crisis from a public health perspective includes massively increasing access to care and treatment for patients experiencing substance use disorder.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-roots-of-the-north-american-opioid-crisis-and-3-key-strategies-for-stopping-it" width="100%" height="400"></iframe>
<p>The Netflix series <em><a href="https://www.netflix.com/ca/title/81095069">Painkiller</a></em> recently depicted how the over-prescribing of the medicine OxyContin wreaked havoc on American society. </p>
<p>Today the grim reality is that opioid-related deaths in North America reached a record level in 2022, with more than <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">109,000 fatalities in the United States</a>. The same year in Canada, <a href="https://www.statista.com/statistics/812260/number-of-deaths-from-opioid-overdose-canada-province/">deaths exceeded 7,400</a>, a number equivalent to 20 opioid-related deaths every day, and this is <a href="https://www.thelancet.com/infographics-do/opioid-crisis-north-america">likely to continue to increase over the coming years</a>.</p>
<p>The opioid overdose crisis has been ongoing for over two decades in Canada and the U.S. The current mortality rate is greater than the <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5021a2.htm">worst years</a> of the <a href="https://www.jstor.org/stable/41994093">HIV/AIDs epidemic</a> in these <a href="https://doi.org/10.14745%2Fccdr.v43i12a01">countries</a>. </p>
<p><a href="https://www.canada.ca/en/health-canada/services/opioids.html">Opioids</a> are drugs primarily used to treat severe pain, such as after surgery. When prescribed responsibly they are an effective medication, but if over-prescribed or used recreationally they can lead to an addiction (known as <a href="https://www.canada.ca/en/health-canada/services/opioids/opioids-use-disorder-treatment.html">opioid use disorder</a>) that can result in overdose death and wider community problems.</p>
<h2>The roots of the crisis</h2>
<p>After introduction of the opioid painkiller OxyContin in 1996, <a href="https://doi.org/10.2105%2FAJPH.2007.131714">Purdue Pharma marketed the drug aggressively</a>, underplaying its potential for addiction. Prescriptions increased and many patients became addicted. Purdue Pharma eventually <a href="https://www.justice.gov/opa/pr/justice-department-announces-global-resolution-criminal-and-civil-investigations-opioid">pleaded guilty to criminal charges in 2020</a>.</p>
<p>To address addiction, <a href="https://store.samhsa.gov/sites/default/files/d7/priv/sma16-4997.pdf">prescription monitoring programs</a> aimed to limit supply but many patients then sought illicit opioids, leading to large heroin markets in the 2010s. </p>
<p>From 2015 onwards, illegally made <a href="https://www.canada.ca/en/health-canada/services/substance-use/controlled-illegal-drugs/fentanyl.html">fentanyl</a> — a very strong opioid that is easy to manufacture — became widely available, and rapidly replaced the heroin market. Fentanyl is extremely toxic — up to 100 times stronger than heroin — and is largely responsible for the increase in overdose deaths. </p>
<p>Now North Americans face an urgency on how to end the suffering. There is no single solution given the complexity of the problem, but we explain three potential strategies for treating patients and managing this epidemic.</p>
<h2>1. Treat substance use disorders as a public health problem</h2>
<p>The traditional “<a href="https://www.lse.ac.uk/ideas/publications/reports/ending-drugs">war on drugs</a>” approach that focuses only on criminalization has been unsuccessful. In reality the data shows that illegal drug prices have fallen whilst purity and deaths have increased. <a href="https://www.themarshallproject.org/2021/07/15/inside-the-nation-s-overdose-crisis-in-prisons-and-jails">Overdose deaths have also increased in prisons</a> showing that places with even the highest level of security are vulnerable to drug smuggling.</p>
<p>Focusing on the opioid crisis through a public-health approach includes massively increasing access to care and treatment for patients experiencing substance use disorder. It requires more evidence-based services such as addiction clinics, psychotherapy harm reduction strategies and education for both patients and families about treatments that are available to them. </p>
<p>Beyond initial treatment there should be continued professional social support and a wider national effort to address the <a href="https://doi.org/10.2105%2FAJPH.2017.304187">socioeconomic causes</a> in disadvantaged communities. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/HHiN7JftdcY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Scott McFadden, an addictions counsellor in recovery from opioid use, shares his own journey and the impact of stigma and shame.</span></figcaption>
</figure>
<p>Just as there is <a href="https://www.youtube.com/watch?v=HHiN7JftdcY">stigma associated with addiction</a> that stops people from seeking help, there also appears to be stigma at the political and community level, as there is reluctance to fully acknowledge community drug problems. This <a href="https://doi.org/10.1371/journal.pmed.1002969">stigma needs to be reduced</a> so patients can get help.</p>
<h2>2. Find better treatments through research</h2>
<p>There are currently three main medicines approved for <a href="https://www.canada.ca/en/health-canada/services/opioids/opioids-use-disorder-treatment.html">treating patients with opioid use disorder</a> in Canada and the U.S.: methadone, buprenorphine/naloxone and extended-release naltrexone.</p>
<p>Although these are effective when used, there are barriers to access and long-term engagement with these treatments. <a href="https://thetyee.ca/News/2023/10/06/Catastrophe-No-Sense-Crisis/">Less than 10 per cent of overdose survivors have access to meaningful care.</a> The limited number of medications available does not work for everyone. We need more innovation to rapidly increase access to care and to find better therapies that suit the needs of different patients.</p>
<p>For example, our <a href="https://www.bccsu.ca/about/">research centre in Vancouver</a>, is evaluating a slow-release formulation of morphine compared to methadone, which has been the dominant treatment for the past 40 years. This study will generate real-world evidence on the effectiveness of novel treatments in contexts of increasing fentanyl use.</p>
<p>Other research is exploring <a href="https://classic.clinicaltrials.gov/ct2/show/NCT05985850">cannabis-based therapy</a> and the <a href="https://www.bccsu.ca/road-to-recovery-study/">best pathways patients can access for recovery</a>. These research initiatives aim to increase the number of evidence-based treatments that can be used to enhance patient recovery and quality of life.</p>
<h2>3. Stop the international spread of the epidemic</h2>
<p>Currently the epidemic is contained within North America but there is the real <a href="https://doi.org/10.1007/s40429-018-0231-x">concern of the crisis spreading</a> to other countries. There is a steady <a href="https://theconversation.com/over-the-counter-opioids-does-britain-have-a-codeine-problem-205331">increase in prescription</a> and illicit opioid use in the United Kingdom and other European countries, which should be an early warning sign that they do not follow the same trajectory. Clinicians must remain actively vigilant on how they prescribe these drugs. </p>
<p>There should be <a href="https://doi.org/10.1016/S0140-6736(21)02252-2">greater international regulation</a> in the marketing and operational strategies of pharmaceuticals, and oversight of the “<a href="https://www.science.org/content/article/fda-s-revolving-door-companies-often-hire-agency-staffers-who-managed-their-successful">revolving door</a>” between industry and regulator employment. There is a potential conflict of interest when pharma companies hire the government employees who oversee their applications. As shown in <em>Painkiller</em>, the FDA regulator who initially had issues with the drug’s approval, and then later approved it, subsequently went on to work for Purdue.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">‘Benzo-dope’ may be replacing fentanyl: Dangerous substance turning up in unregulated opioids</a>
</strong>
</em>
</p>
<hr>
<p>Another concern is that the current increase in overdose deaths is coinciding with increased deaths where other illicit recreational drugs, such as cocaine and benzodiazepines, are <a href="https://www.bccsu.ca/blog/news/fentanyl-laced-cocaine-appears-in-b-c-amid-calls-for-safe-supply/">contaminated with fentanyl</a> unknown to the users. More effort should be made towards the public awareness of the dangers of an increasingly toxic drug market.</p>
<p>Speaking at a health-care summit in June, Rahul Gupta, the <a href="https://www.politico.com/news/2023/06/07/gupta-opioid-crisis-deaths-00100756">director of the U.S. Office of National Drug Control Policy</a>, said, “There is almost no other area today (that) affects our public health, national security and economic prosperity.”</p>
<p>Valuable knowledge has been gained in confronting this crisis. Governments and communities should support evidence-based recommendations to help patients. There are still many challenges, but they are not beyond solving.</p><img src="https://counter.theconversation.com/content/213716/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Smith Foundation for Health Research/ St. Paul’s Foundation Scholar Award.
Peer-review grants from the Canadian Institutes of Health Research and Vancouver Foundation.
Partial funding from Indivior for an investigator initiated study.
</span></em></p><p class="fine-print"><em><span>Rohan Anand does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There were more than 100,000 opioid-related deaths in North America in 2022. How the crisis grew to such proportions, and three potential paths to ending it.Rohan Anand, Post Doctoral Fellow, British Columbia Centre on Substance Use, University of British ColumbiaM. Eugenia Socias, Assistant Professor, Dept of Medicine, University of British Columbia and Research Scientist with the BC Centre on Substance Use, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2071442023-09-27T20:05:08Z2023-09-27T20:05:08ZGabor Maté claims trauma contributes to everything: from cancer to ADHD. But what does the evidence say?<p>Our health consumes a growing share of our economy and our attention, but we are not in great shape. Even as a ruinous pandemic subsides, epidemics of chronic disease, obesity, addiction and mental illness continue. Systems of care strain to cope and many of us engage in an anxious and often thankless quest for wellbeing.</p>
<p>In his latest book, <a href="https://www.penguin.com.au/books/the-myth-of-normal-9781785042713">The Myth of Normal</a>, Gabor Maté offers a diagnosis for our health crisis. The problem, he suggests, is the burden of <a href="https://theconversation.com/more-than-half-of-australians-will-experience-trauma-most-before-they-turn-17-we-need-to-talk-about-it-159801">trauma</a> people endure and the toxic culture that creates and compounds it. He prescribes profound societal change, holistic healing practices and spiritual growth assisted by <a href="https://theconversation.com/psychedelic-medicine-is-on-its-way-but-its-not-doing-shrooms-with-your-shrink-heres-what-you-need-to-know-208568">psychedelics</a>.</p>
<p>Both diagnosis and prescription have proven to be controversial. Skeptics worry that Maté’s explanations for ill health oversimplify a complex and incompletely understood web of causes and that his solutions dart ahead of the scientific evidence, sometimes veering towards quackery.</p>
<p><a href="https://en.wikipedia.org/wiki/Gabor_Mat%C3%A9">Maté</a> is a Canadian physician who has become a global celebrity in wellness circles. He recently participated in a very public <a href="https://www.thestar.com/life/i-talked-to-prince-harry-about-trauma-and-therapy-here-s-what-he-got-right/article_56d7fe40-5927-52cf-986b-682b62b09e36.html">therapeutic dialogue with Prince Harry</a>, in which he conversationally “diagnosed” the prince with ADHD.</p>
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<figcaption><span class="caption">Gabor Maté conversationally diagnosed Prince Harry with ADHD, based on reading his book.</span></figcaption>
</figure>
<p>The Budapest-born son of Holocaust survivors, Maté has profound personal experience of trauma and suffering. As an infant, his mother left him in the care of strangers for several weeks to save his life, and he believes the themes of abandonment, loss and rage have continued to play out in his adult life. </p>
<p>In previous books, Maté has explored addiction and <a href="https://theconversation.com/is-it-anxiety-or-adhd-or-both-how-to-tell-the-difference-and-why-it-matters-205304">attention deficit hyperactivity disorder (ADHD)</a>, both of which he has identified in himself, as well as the nature and cause of chronic disease. </p>
<p>Reverberating throughout his work are a few fundamental ideas: the centrality of trauma, the intimacy of the mind-body connection, and the culpability of capitalism and the materialistic and individualistic culture it breeds.</p>
<h2>The trauma explanation</h2>
<p>Maté’s 2018 book <a href="https://www.penguin.com.au/books/in-the-realm-of-hungry-ghosts-9781785042201">In the Realm of Hungry Ghosts</a> prosecutes the case that <a href="https://theconversation.com/a-mental-disorder-not-a-personal-failure-why-now-is-the-time-for-australia-to-rethink-addiction-151686">addictions</a> spring from the pain of unresolved trauma, rather than from brain disease or self-destructive choices. Maté combines a compassionate lack of judgement for addicts with fierce condemnation of a society that foments and criminalises substance use. </p>
<p>His subsequent work, <a href="https://www.penguin.com.au/books/scattered-minds-9781785042218">Scattered Minds</a>, argues ADHD is a way of coping with childhood trauma, rather than the <a href="https://www.additudemag.com/is-adhd-hereditary-yes-and-no/">highly heritable brain disorder</a> or <a href="https://theconversation.com/what-causes-adhd-and-can-it-be-cured-170179">form of neurodivergence</a> it is usually taken to be. (Maté has three children diagnosed with ADHD, as he is, but <a href="https://www.healthyplace.com/adhd/transcripts/alternative-thoughts-about-add-adhd">attributes this</a> to “emotional stresses” in their early environment, including his own parenting.) This unorthodox position, which dismisses the genetic contribution to the condition and sees it as linked to sensitivity to stress and anxiety, has been controversial.</p>
<p><a href="https://scribepublications.com.au/books-authors/books/when-the-body-says-no-9781925849646">When the Body Says No</a> argues that life stress plays a part in conditions as varied as cancer, multiple sclerosis and diabetes, whereas <a href="https://www.penguin.com.au/books/hold-on-to-your-kids-9781785042195">Hold on to Your Kids</a> makes an extended plea for more actively engaged and attuned parenting.</p>
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<a href="https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=901&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=901&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=901&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1133&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1133&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1133&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>The Myth of Normal, written with his son Daniel, is a culmination of Maté’s prior work, drawing its threads together into a large and sometimes tangled skein of ideas. Its ambitions are grand. </p>
<p>Illness, he writes, is “a function or feature of how we live” in a time of deteriorating collective health. It is rooted in a society where “much of what passes for normal […] is neither healthy nor natural” and where conformity is “profoundly abnormal in regard to our Nature-given needs”. </p>
<p>To Maté, “normal” is a myth because our culture has skewed our sense of what is acceptable and accustomed us to damaging ways of living.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-psychiatry-shrinking-whats-considered-normal-142477">Is psychiatry shrinking what's considered normal?</a>
</strong>
</em>
</p>
<hr>
<h2>Trauma and ‘illness of all kinds’</h2>
<p>Fittingly, Maté opens the book with a discussion of trauma, his pivotal concept. He sees it as an experience of being emotionally wounded rather than an extreme event, as it is typically seen within mainstream psychiatry. </p>
<p>It encompasses relatively severe “big-T trauma” – responses to extraordinary events – but also “small-t trauma”, which includes more mundane experiences of stress and adversity or even of “good things not happening”. </p>
<p>In promoting this expansive, subjectivised definition, by which “someone without the marks of trauma would be an outlier in our society”, Maté follows current trends favouring a <a href="https://muse.jhu.edu/article/773952">broadened concept of trauma</a>. </p>
<p>This shift has been documented in <a href="https://sciendo.com/article/10.58734/plc-2023-0002">recent</a> <a href="https://psycnet.apa.org/doiLanding?doi=10.1037%2Famp0000847">studies</a>, and although it arguably draws welcome attention to the prevalence of adversity, it also risks diluting the concept, trivialising the experiences of “big-T” trauma survivors and promoting a counterproductive sense of being permanently damaged by one’s past.</p>
<p>To Maté, trauma is a contributor to “illness of all kinds”, as well as causing personal fragmentation, disconnection from other people, shame, a loss of flexibility in how we behave and alienation from the present. How we cope with trauma forges our personality, which is therefore implicated in susceptibility to a wide range of medical conditions, through immune and inflammatory processes. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Maté believes trauma is a contributor to ‘illness of all kinds’.</span>
<span class="attribution"><span class="source">Michelle Leman/Pexels</span></span>
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<p>Often, Maté argues, disease-prone people suppress and repress their emotions, and appear stoical, hyper-responsible and overly conscientious. These and other strong claims about links between personality and illness overstate the scientific evidence – which typically finds them to be small, absent or inconsistent with the hypothesis of excessive responsibility.</p>
<p>For example, very large studies have found no links between personality traits and suffering or dying from <a href="https://www.nature.com/articles/bjc201458">cancer</a>, and revealed a small association between <a href="https://psycnet.apa.org/record/2013-29655-001">diabetes</a> and low, rather than high, conscientiousness. The research literature on this topic is littered with <a href="https://www.sciencedirect.com/science/article/abs/pii/B9780128053003000116?via%3Dihub">debunked theories</a>, such as the supposed association between <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2012.300816">Type A personality</a> and heart disease.</p>
<p>Personality aside, Maté proposes that trauma and abuse histories underpin many autoimmune disorders – a case of <a href="https://www.healthdirect.gov.au/scleroderma">scleroderma</a> is ascribed to “inflamed emotions” – in a way that demonstrates the hyphen-dissolving unity of the “bodymind”. Disease, Maté believes, is a systemic imbalance of the whole person rather than something external that afflicts them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-body-keeps-the-score-how-a-bestselling-book-helps-us-understand-trauma-but-inflates-the-definition-of-it-184735">The Body Keeps the Score: how a bestselling book helps us understand trauma – but inflates the definition of it</a>
</strong>
</em>
</p>
<hr>
<h2>Nature and nurture</h2>
<p>Maté traces a great deal of the trauma that ails us to our childhood. He amplifies the many obstacles to healthy child development: the effects of parental stress on the growing child <em>in utero</em>, medicalised birth, weakened communal ties, excessive screen time and corporate marketing to children. </p>
<p>In one instance of intra-Canadian sniping directed at <a href="https://theconversation.com/is-jordan-peterson-the-philosopher-of-the-fake-news-era-91308">Jordan Peterson</a>, his political mirror image, Maté disparages parenting advice that aims to socialise and shape desired behaviour. Instead, parents are counselled to express an innate parenting “instinct” whose call, he argues, is better heeded by First Nations people.</p>
<p>Maté’s commitment to the “nurture” side of <a href="https://theconversation.com/nature-v-nurture-score-one-all-3697">the nature-nurture binary</a> is accompanied by a dismissal of “the prevalent myth that genetic traits account for human behavior.” What a “genetic trait” might be, as distinct from a genetically influenced one – essentially <a href="https://www.nature.com/articles/ng.3285">all of them</a>, according to behavioural genetic research – is not clarified. </p>
<p>To Maté, any genetic influences that exist are typically conditional on environmental conditions (<a href="https://theconversation.com/explainer-what-is-epigenetics-13877">epigenetics</a>) and have been exaggerated by problematic science. </p>
<h2>‘Addiction is a kind of refugee story’</h2>
<p>Developmental processes underpin psychological problems. Addiction – understood expansively as any behaviour that brings relief or pleasure, causes lasting suffering to the self or others, and is difficult to stop – is ascribed to trauma. </p>
<blockquote>
<p>All addiction is a kind of refugee story: from intolerable feelings incurred through adversity and never processed, and into a state of temporary freedom, however illusory. </p>
</blockquote>
<p>Addiction – whether to heroin or <a href="https://theconversation.com/can-gaming-addiction-lead-to-depression-or-aggression-in-young-people-heres-what-the-evidence-says-168847">video games</a> – is a way of coping with pain and a lack of love, writes Maté. The addict attempts to reproduce feelings of warmth that should arise naturally if development had not blocked them. </p>
<p>Genes play no meaningful role in addiction, Maté advises. “No single addiction gene has ever been found – nor will ever be,” is a flatly false statement. Unless “addiction gene” is straw-manned as a gene that singlehandedly and invariably causes addiction, a requirement that would also be failed by every life experience, personality trait, brain chemical, or subjective feeling. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Addiction, whether to heroin or video games, is a way of coping with pain and a lack of love.</span>
<span class="attribution"><span class="source">Jaroslav Nymbursky/Pexels</span></span>
</figcaption>
</figure>
<p>Maté acknowledges genes may contribute to our susceptibility to addiction, but imagines that contribution to be causally irrelevant.</p>
<p>The same dogmatic and disingenuous rejection of genetic influence is repeated in the book’s exploration of mental illness, which it conceptualises as trauma-caused psychological injury. </p>
<p>Despite the identification of <a href="https://www.nature.com/articles/s41588-021-00857-4">64 genomic loci</a> associated with <a href="https://theconversation.com/explainer-what-is-bipolar-disorder-7502">bipolar disorder</a>, Maté finds the scientific evidence for a genetic contribution to it to be “nearly nonexistent” and he rejects twin studies, a staple of genetic research in psychiatry and far beyond, as fatally flawed.</p>
<p>Here, as elsewhere, Maté’s extreme position against genetic and brain disease explanations contains germs of truth. Biologically reductionist explanations deserve to be challenged, even if they are caricatures of how most mental health professionals understand or treat mental illness in practice. The role of trauma in mental ill health has indeed often been neglected in psychiatry. </p>
<p>But to neglect the role of genetic factors in mental illness is just as ideologically distorted and over-simplifying as neglecting the role of adversity. The truth here is frustratingly complex. Decades of research show that myriad life experiences and genetic variants combine in intricate ways to make some people more vulnerable to illness than others. </p>
<p>Genetic influences may be expressed only in specific environmental conditions, and apparent environmental influences – such as traumas – may themselves be <a href="https://journals.sagepub.com/doi/full/10.1177/1077559519888587">genetically influenced</a>, rather than being uncaused causes. <a href="https://acamh.onlinelibrary.wiley.com/doi/abs/10.1111/jcpp.12621">Recollections of childhood adversity</a> are themselves influenced and distorted by adult personality and emotional distress.</p>
<p>A more evenhanded evaluation of the scientific evidence would recognise this complexity, rather than wish it away out of a desire to highlight the undoubted importance of adverse life experiences.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/treatment-for-drug-and-alcohol-misuse-should-involve-families-and-communities-197536">Treatment for drug and alcohol misuse should involve families and communities</a>
</strong>
</em>
</p>
<hr>
<h2>A toxic culture</h2>
<p>Maté’s analysis of the forces responsible for the excess of trauma in the world condemns several societal and cultural pathologies. A series of chapters in The Myth of Normal variously identify corporate malfeasance, poverty and inequality, racism and the patriarchy. </p>
<p>Women’s anger suppression and self-silencing, and the burdens of care they shoulder, are identified as sources of their high rates of anxiety, depression and a range of autoimmune diseases.</p>
<p>National leaders are dissected under a harsh surgical light. Stephen Harper, Justin Trudeau, Donald Trump and Hillary Clinton receive quick, trauma-centred psychobiographies. The take-home message is bracing, though it comes close to pantomime villainy. </p>
<blockquote>
<p>Those with the sorts of early coping mechanisms that prime them to deny reality, block out empathy, fear vulnerability, mute their own sense of right and wrong, and abjure looking at themselves too closely – will be elevated to power.</p>
</blockquote>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/mb5W9cMi6C8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The Myth of Normal identifies various problems with our culture, from corporate malfeasance to racism.</span></figcaption>
</figure>
<p>What is to be done about this mess? Maté advocates an ongoing process of healing that has political and spiritual – as well as psychological – dimensions. We need to become more authentic, agency-seizing, (healthily) angry and accepting, and practice compassion. We must learn to say no, try not to be overly selfless, avoid self-blame and undo self-limiting beliefs. </p>
<p>Beyond this rather standard guidance on how to iron out our psychic wrinkles, Maté has some more radical advice. He promotes the use of psychedelics to get to the unconscious roots of our problems and to activate against “the global corporate capitalist system” to create a trauma-conscious society. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-doppelganger-naomi-klein-says-the-world-is-broken-conspiracy-theorists-get-the-facts-wrong-but-often-get-the-feelings-right-209990">In Doppelganger, Naomi Klein says the world is broken: conspiracy theorists 'get the facts wrong but often get the feelings right'</a>
</strong>
</em>
</p>
<hr>
<h2>Holistic health</h2>
<p>Maté’s vision is a rousing and almost prophetic one that has won him many dedicated followers. His work speaks to a widely held dissatisfaction with the state of contemporary society, health and politics, and offers some powerful correctives. </p>
<p>It’s true that the rise of biological psychiatry has led to a neglect of the role of the social environment and life adversity in mental illness. It’s also true that stigmatising views of substance users and the mentally ill are often grounded in moralistic beliefs about bad choices and fatalistic beliefs about brain disease. Maté’s trauma-focused approach rejects both.</p>
<p>There is a deep appetite for more holistic health care that recognises the emotional suffering in (primarily) physical illness and the embodiment of mental illness. Equally, many people hope for a kind of health and wellbeing that transforms them, rather than merely reduces their symptoms and helps them better tolerate intolerable life circumstances.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many people hope for a kind of health and wellbeing that transforms them, rather than merely reduces symptoms.</span>
<span class="attribution"><span class="source">RDNE Stock Project/Pexels</span></span>
</figcaption>
</figure>
<h2>Timely corrective or a step too far?</h2>
<p>Even so, The Myth of Normal has its own contradictions. It sometimes swings the corrective pendulum to snapping point. </p>
<p>There is something puzzling about a worldview that criticises <a href="https://theconversation.com/atlas-shrugged-ayn-rands-hero-burns-the-world-down-when-he-doesnt-get-his-way-her-fans-run-the-world-should-we-worry-192510">individualism</a> as a source of human misery but presents personal authenticity as the goal of healing, refers to each person’s “own unique and genuine essence”, and urges us to resist conforming to a sick society. This is just another, therapy-culture form of individualism.</p>
<p>Maté’s focus on trauma as the singular primary cause of ill health is also unbalanced. It’s every bit as reductive and oversimplifying as a single-barrelled genetic or neurobiological explanation. At times, it applies an evidential double standard. To be legitimate explanations, <a href="https://theconversation.com/blame-it-on-biology-how-explanations-of-mental-illness-influence-treatment-48578">biogenetic factors</a> must fully determine illness. But for trauma to count as the primary source of a problem, some measure of adversity must simply be associated with it.</p>
<p>There is now very solid evidence, for example, that the number of adverse experiences people encounter in childhood is associated with their risk of developing <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30118-4/fulltext">a wide range of illnesses and life problems</a>. This is a genuinely vital insight. </p>
<p>However, many of these associations are relatively modest (like obesity, diabetes, cancer, heart disease) and even the strongest (like problematic drug use, perpetration of violence) are far from perfect. Most people who live through the greatest levels of adversity do not become ill or impaired. And many whose early lives were entirely unruffled do. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=322&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=322&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=322&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=404&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=404&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=404&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">There’s solid evidence childhood adversity is associated with risk of illnesses and life problems – but it’s complex.</span>
<span class="attribution"><span class="source">Aa Dil/Pexels</span></span>
</figcaption>
</figure>
<p>The influences of adversity and trauma on mental illness are real and crucially important, but they are not consistently stronger than other influences. Understandings of illness need to recognise this <a href="https://www.nature.com/articles/mp2011182">dappled complexity</a> rather than simplify it with overconfident claims.</p>
<p>Too often, Maté writes that some X “invariably” leads to some Y, or that in his clinical experience he has “yet to find an exception” to a pattern he has detected. In the slippery, probabilistic world of human psychology, claims to certainty are simply not credible. They should raise red flags.</p>
<p>Even if they find some questionable assertions in the book, many readers will also find inspiration. It is full of hope and laced with compelling stories of personal transformation and recovery, many drawn from interviews with public figures. Several chapters offer practical advice and exercises.</p>
<p>Readers will also find comfort and solace. The book teaches that we are not alone in our suffering, nor responsible for it. At root, our troubles are caused by what others have done to us and they implicate our selfless, overly obliging personalities. In Maté’s broad world view, individual distress is connected to a larger social justice narrative.</p>
<p>More skeptical readers, who find Maté’s good-individual-broken-by-bad-society framework too stark, will also benefit from reading The Myth of Normal. His voice is an influential example of the increasingly prominent nexus between progressive politics and mental health discourse. Its popularity is all the more reason to take it seriously.</p><img src="https://counter.theconversation.com/content/207144/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Haslam receives funding from the Australian Research Council. </span></em></p>Our health consumes a growing share of our economy and our attention, but we are not in great shape. Even as a ruinous pandemic subsides, epidemics of chronic disease, obesity, addiction and mental illness…Nick Haslam, Professor of Psychology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2124352023-08-30T21:16:09Z2023-08-30T21:16:09ZDecriminalization: How police drug seizure, even without arrest, can create harms<iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/decriminalization-how-police-drug-seizure-even-without-arrest-can-create-harms" width="100%" height="400"></iframe>
<p><a href="https://www.overdoseday.com/">International Overdose Awareness Day</a>, an annual campaign to end overdose and drug poisonings while also remembering those who have died, is Aug. 31. Events are being held in <a href="https://www.momsstoptheharm.com/ioad23">communities across Canada</a>, a sign of a worsening crisis that has taken more than <a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/">36,000 lives since 2016</a>.</p>
<p>The day also represents an opportunity to discuss much-needed policy changes. The <a href="https://drugpolicy.org/issue/decriminalize-drugs-invest-in-health-services/">decriminalization of people who use drugs</a> has long been one of the proposed solutions, an approach that is currently being piloted in British Columbia.</p>
<p>On Jan. 31, 2023, B.C. began a first-in-Canada <a href="https://www.canada.ca/en/health-canada/services/health-concerns/controlled-substances-precursor-chemicals/policy-regulations/policy-documents/exemption-personal-possession-small-amounts-certain-illegal-drugs-british-columbia.html">pilot “decriminalization” policy</a>, in which criminal sanctions for the possession of small amounts of certain illegal drugs for personal use were removed for adults aged 18 or above.</p>
<p>Seven months into this experiment, the impact of this policy remains unclear. Because <a href="https://vancouverisland.ctvnews.ca/data-on-b-c-s-drug-decriminalization-plan-to-be-publicly-available-on-dashboard-1.6252744">a dashboard</a> of policy impact indicator data has not yet been published at the time of writing, it is difficult to weigh <a href="https://vancouversun.com/news/local-news/six-months-into-b-c-s-decriminalization-experiment-whats-working-and-whats-not">the initial effects of the policy</a>.</p>
<p>However, in the city of Vancouver, a policy of <a href="https://doi.org/10.1177/1477370819887514">depenalization</a> (also referred to as de facto decriminalization) has been in place since 2006, providing an opportunity to understand how the provincial pilot may be working — or even improved.</p>
<h2>Depenalization in Vancouver</h2>
<p>Seventeen years ago, the Vancouver Police Department (VPD) launched <a href="https://vpd.ca/wp-content/uploads/2021/06/vpd-policy-drug.pdf">its drug policy</a> to promote <a href="https://doi.org/10.1177/1477370819887514">the depenalization</a> of simple possession offences. Under this policy, VPD officers were encouraged to not arrest or charge people for simple drug possession for personal use except for certain circumstances.</p>
<p>The VPD’s policy differed from B.C.’s pilot decriminalization in several important ways. For example, the VPD’s policy did not specify the class or threshold quantity of drugs to define simple possession. VPD officers were given broad enforcement discretion with respect to drug possession.</p>
<p>Although publicly available VPD data are limited, <a href="https://vpd.ca/wp-content/uploads/2021/06/cleared-drug-charges-january-2014-to-present.pdf">available data</a> indeed indicated low and declining numbers of simple possession charges recommended by the VPD to Crown counsel from 2016 to 2019. These numbers have often <a href="https://vancouversun.com/news/drug-possession-charges-vary-widely-by-police">been cited</a> as the indicator of success of the VPD’s depenalization policy: fewer people are sent to the criminal justice system for the sake of personal drug use.</p>
<p>However, <a href="https://www.straight.com/news/1213101/vancouver-police-stats-suggest-softer-touch-drugs-users-say-its-different-story-streets">anecdotal reports</a> and <a href="https://doi.org/10.1016/j.drugpo.2021.103471">previous qualitative research</a> suggested that police officers might not arrest people for simple possession, but they would still seize drugs. Local communities of people who use drugs and public health advocates in Vancouver expressed concern about the harm created by this policing behaviour.</p>
<p>We undertook <a href="https://doi.org/10.1186/s12954-023-00833-7">surveys involving more than 1,800 people</a> who used drugs on a daily basis in Vancouver to investigate this often undocumented discretionary policing practice.</p>
<h2>Police drug seizures without arrest</h2>
<p>During a 16-month study period in 2019-2021, we found that six per cent of 995 people who used drugs daily in Vancouver (60 per cent residing in the Downtown Eastside neighbourhood that is known for high rates of marginalization and drug use) had had their drugs seized by police without arrest at least once in the past six months. Of those, more than one in four experienced it more than once during the same six-month period.</p>
<p>Of particular concern, 68 per cent of our study participants who had their drugs taken by police without arrest reported having obtained new drugs immediately after the seizure. This portion of the data was collected from the same study population between 2009 and 2012.</p>
<p><a href="https://www.pivotlegal.org/project_inclusion_full">Previous qualitative research</a> documented that acquiring drugs this way could put health and safety at risk in multiple ways. For example, it can put people at a higher risk of drug market violence by creating drug debts.</p>
<p>Some users may also be compelled to acquire new drugs in a rush from an unknown supplier, especially when experiencing painful withdrawal. <a href="https://app.powerbi.com/view?r=eyJrIjoiOGFhMTkwOTktYWQ1My00MzQ4LThlNzItMzVhOWY3NGFmOWQ4IiwidCI6IjZmZGI1MjAwLTNkMGQtNGE4YS1iMDM2LWQzNjg1ZTM1OWFkYyJ9">Amid the ongoing drug toxicity crisis</a>, increasing the frequency of buying drugs in the unregulated drug market, especially through an unknown source, increases risk of drug poisoning.</p>
<p>This is contrary to <a href="https://doi.org/10.1016/j.drugpo.2021.103471%22%22">a belief held among some police officers</a> that seizing drugs would prevent harms, including drug poisoning.</p>
<h2>The role of police in the toxic drug crisis</h2>
<p>A broader question is: Are there any circumstances where police drug seizures are beneficial in preventing drug poisoning? <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2023.307291">A recent study from the United States</a> highlighted that police efforts to reduce the unregulated drug supply may worsen the drug toxicity crisis by showing a consistent pattern. As police seizures of drugs increased, drug poisoning cases also increased.</p>
<p>Several scholars noted that <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2023.307328">police drug seizures would not address the toxic drug supply</a>, that <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2023.307329">the narrow mission of police may exacerbate drug-related harms</a> and that <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2023.307320">more harm reduction interventions to address the toxic drug supply are needed</a>.</p>
<p><a href="https://doi.org/10.1186/s12954-023-00833-7">Findings from our study</a> indicate that the VPD’s depenalization policy essentially “<a href="https://d3n8a8pro7vhmx.cloudfront.net/pivotlegal/pages/3494/attachments/original/1639066365/Decriminalization_Report_Final_Revised.pdf">mimics the health and safety harms associated with criminalization</a>” and likely undermines overdose prevention efforts.</p>
<p>Under B.C.’s pilot decriminalization policy, police officers can no longer seize drugs from an adult who possesses up to 2.5 grams of certain illegal drugs. However, the threshold quantity of drugs that defined simple possession has been shown to be <a href="https://doi.org/10.1016/j.drugpo.2023.104126">too low</a> to fulfil the policy objectives. Some people who use drugs, particularly those more marginalized and engaging in high-intensity drug use, may carry more than 2.5 grams of drugs. They may get arrested or experience police drug seizures without arrest.</p>
<p>The annual International Overdose Awareness Day compels us to reckon with ongoing toxic drug deaths and what we can do to reverse this worsening crisis. If decriminalization is going to contribute to positive change, police need to stop seizing drugs from people who use them.</p><img src="https://counter.theconversation.com/content/212435/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kanna Hayashi holds the St. Paul's Hospital Chair in Substance Use Research and is supported in part by a U.S. National Institute on Drug Abuse (NIDA) grant (U01DA038886) and the St. Paul’s Foundation. For the research work presented here, she received funding through a NIDA grant (U01DA038886), a Michael Smith Health Research BC Scholar Award and the William and Ada Isabelle Steel Fund through Simon Fraser University. She also receives funding from the Canadian Institutes of Health Research and the Social Sciences and Humanities Research Council to support her ongoing research in this area. She is also affiliated with the Vancouver Coastal Health Authority as research staff and the Division of Social Medicine, Department of Medicine, University of British Columbia as an affiliate assistant professor. </span></em></p>A police policy of not making arrests for simple possession is a way to essentially decriminalize personal drug use. However, confiscating drugs — even without arrests — can be harmful in many ways.Kanna Hayashi, Research Scientist at the British Columbia Centre on Substance Use & St. Paul's Hospital Chair in Substance Use Research and Associate Professor, Faculty of Health Sciences, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2065802023-08-24T20:20:46Z2023-08-24T20:20:46ZFriday essay: ‘black bile’, malaria therapy and insulin comas – a brief history of mental illness<p>Possibly the earliest account of a disturbed mind is recorded in a 3,500-year-old <a href="https://en.wikipedia.org/wiki/Vedas">Hindu text</a> that describes a man who is “gluttonous, filthy, walks naked, has lost his memory and moves about in an uneasy manner”.</p>
<p>In the Bible’s Old Testament, in the first <a href="https://www.britannica.com/topic/Books-of-Samuel">Book of Samuel</a>, we read that King David simulated madness to gain safety: </p>
<blockquote>
<p>And he changed his behaviour … and feigned himself mad in their hands, and scrabbled on the doors of the gate, and let his spittle fall down upon his beard.</p>
</blockquote>
<p>In the <a href="https://www.britannica.com/topic/The-Book-of-Daniel-Old-Testament">Book of Daniel</a>, we find a vivid description of King Nebuchadnezzar’s mental state: </p>
<blockquote>
<p>And he was driven from men, and did eat grass as oxen, and his body was wet with the dew of heaven, till his hairs were grown like eagles’ feathers, and his nails like birds’ claws.</p>
</blockquote>
<p>The ancient Greeks made early attempts to explain madness. In the 5th century BC, <a href="https://fherehab.com/learning/humors-ancient-mental-health">Hippocrates</a> viewed it as seated in the brain and influenced by four bodily fluids: blood, phlegm, black bile and yellow bile. </p>
<p>The Greek physician Galen, who practised in Rome 600 years later, argued that depression was caused by an excess of black bile (hence the term “melancholia”, from <em>melan</em>, black, and <em>khole</em>, bile). </p>
<p>His contemporary, <a href="https://www.britannica.com/biography/Aretaeus-of-Cappadocia">Aretaeus of Cappadocia</a>, colourfully described how, if black bile moves upwards in the body, “it forms melancholy; for it produces flatulence and eructations [or, belches] of a fetid and fishy nature, and it sends rumbling wind downwards, and disturbs the understanding”. </p>
<h2>A troubled mind, possessed</h2>
<p>During the Middle Ages, monasteries preserved the view of madness as an illness, and of those afflicted as sick rather than sinful. At the same time, the more sinister belief that the <a href="https://pubmed.ncbi.nlm.nih.gov/25208453/">principal cause</a> of the troubled mind was possession by spirits or the devil prevailed.</p>
<p>Sufferers were taken to sanctioned healers for <a href="https://theconversation.com/exorcisms-have-been-part-of-christianity-for-centuries-107932">exorcisms</a>, a practice still carried out today in some cultures. People who failed to respond to such treatment might then seek out a celebrated expert. </p>
<p>Consider Hwaetred, a young man living in what is now England in the 7th century, who became tormented by an “evil spirit”. So terrible was his madness that he attacked others with his teeth and killed three men with an axe when they tried to restrain him. Taken to several sacred shrines, he obtained no relief. His despairing parents then heard of Guthlac, a monk who lived a hermit life north of Cambridge. After three days of prayer and fasting, Hwaetred was purportedly cured.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">St Francis Borgia Helping a Dying Impenitent – Goya (1788)</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Over time, the role of religious authorities in mental illness dwindled, and the medical profession claimed the exclusive practice of the healing arts. Insanity once more came to be seen more as a physical malady than a spiritual taint. Even so, life for the mentally ill could be appalling. </p>
<p>During the 17th century, religiously inspired persecution of the mentally ill was justified by the clerical hierarchy, and treatment was often some combination of neglect and bestial restraint. </p>
<p>Psychiatrists Martin Roth and Jerome Kroll <a href="https://books.google.com.au/books/about/The_Reality_of_Mental_Illness.html?id=pCQ4AAAAIAAJ&redir_esc=y">describe</a> the insane in this period as “miserable individuals, wandering around in village and in forest, taken from shrine to shrine, sometimes tied up when they became too violent”.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-invention-of-satanic-witchcraft-by-medieval-authorities-was-initially-met-with-skepticism-140809">The invention of satanic witchcraft by medieval authorities was initially met with skepticism</a>
</strong>
</em>
</p>
<hr>
<h2>A watershed: asylums</h2>
<p>The late 18th century was a watershed in the history of psychiatry. The insanity of England’s <a href="https://www.bbc.com/news/magazine-22122407">King George III</a> revealed society’s ambivalence to the mentally ill (vividly captured in the 1994 film <a href="https://www.imdb.com/title/tt0110428/">The Madness of King George</a>). </p>
<p>In France, <a href="https://www.britannica.com/biography/Philippe-Pinel">Philippe Pinel</a> released the chains that had fettered the “lunatic” for centuries, ushering in an unprecedented phase of benevolent institutional care. </p>
<p><a href="https://dictionary.apa.org/moral-therapy">Moral therapy</a>, a form of individualised care in small hospital settings, was promoted by English Quakers at the <a href="https://en.wikipedia.org/wiki/The_Retreat">York Retreat</a> and gradually supplanted inhumane physical treatments such as purging, bleeding and dunking in cold water.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/BHNSAK8d3qc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">English society’s ambivalence to the mentally ill in the 18th century is depicted in the 1994 film, The Madness of King George.</span></figcaption>
</figure>
<p>As populations grew and urbanised, the sheer numbers of mentally ill people in burgeoning city slums demanded action. An institutional solution emerged. </p>
<p>Asylums (from the Greek word meaning “refuge”) were built in rural settings with the best of intentions, planned to be havens in which patients would receive humane care. In the serenity of the countryside, and through carrying out undemanding tasks, they could be distracted from their internal torment and find dignity far from the bustling crowd. </p>
<p><a href="https://www.britannica.com/biography/Daniel-Defoe">Daniel Defoe</a>, the English writer, remained unconvinced: “This is the height of barbarity and injustice in a Christian country; it is a clandestine Inquisition, nay worse.”</p>
<p>Although conceived in a spirit of optimism, asylums tended to deteriorate into centres of hopelessness and demoralisation. They soon became overcrowded dumps. Institutions built for a few hundred people were soon holding thousands. Very few residents were discharged; many stayed for decades. Brutal oppression replaced anything that might have resembled treatment; malnutrition and infectious disease became rife.</p>
<p>In the grim environment, people were shut away and forgotten. With them out of sight and out of mind, a loss of public interest and political neglect became the norm.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=483&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=483&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=483&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=607&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=607&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=607&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Asylums were conceived optimistically, but more often housed oppression than treatment. Picture: The Hospital of Bethlehem.</span>
<span class="attribution"><span class="source">Wellcome Collection</span></span>
</figcaption>
</figure>
<p>The brooding building on the hill came to symbolise the stigma and fear attached to mental illness. By the mid-19th century, critics were voicing concerns that asylums had become human warehouses that entrenched mental illness rather than curing it. </p>
<p>The combination of powerless patients, hospitals run more for the convenience of staff than for the benefit of the sick, inadequate inspection by state bodies, and lack of resources led at times to quite disgraceful conditions. Unwittingly, the spread of asylums also triggered the movement of psychiatry away from the mainstream of medicine.</p>
<p>The conditions of the asylums are evocatively described in Henry Handel Richardson’s Australian novel <a href="https://www.textpublishing.com.au/books/the-fortunes-of-richard-mahony">The Fortunes of Richard Mahony</a>. We read of Richard’s decline, probably from syphilis affecting the brain, which at that time afflicted a large proportion of mental patients.</p>
<p>Towards the end of the novel, his wife comes to visit him in the asylum:</p>
<blockquote>
<p>She hung her head … while the warder told the tale of Richard’s misdeeds. 97B was, he declared, not only disobedient and disorderly, he was extremely abusive, dirty in his habits … he refused to wash himself, or to eat his food … she had to keep a grip on her mind to hinder it from following the picture up: Richard, forced by this burly brute to grope on the floor for his spilt food, to scrape it together, and either eat it or have it thrust down his throat … There was not only feeding by force, the straitjacket, the padded cell. There were drugs and injections, given to keep a patient quiet and ensure his warders their freedom.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-case-for-the-fortunes-of-richard-mahony-by-henry-handel-richardson-24474">The case for The Fortunes of Richard Mahony by Henry Handel Richardson</a>
</strong>
</em>
</p>
<hr>
<h2>Great and desperate cures</h2>
<p>In the asylum, psychiatry turned into a modern medical discipline. The
accumulation of thousands of patients provided the first opportunity
to study mental illness systematically and to develop theories about its
causes. </p>
<p>The idea that these conditions were due to brain alterations, and especially degenerative processes, became dominant, encouraged by the discovery of the cerebral pathology associated with <a href="https://www.healthline.com/health/neurosyphilis">neurosyphilis</a> and <a href="https://theconversation.com/what-causes-alzheimers-disease-what-we-know-dont-know-and-suspect-75847">Alzheimer’s disease</a>. A similar degenerative process was proposed by the great German psychiatrist <a href="https://www.britannica.com/biography/Emil-Kraepelin">Emil Kraepelin</a> to cause <a href="https://www.sciencedirect.com/topics/computer-science/dementia-praecox">dementia praecox</a> – later renamed “schizophrenia” – leading to pessimism about the possibility of recovery.</p>
<p>But the priority for asylums was to relieve the suffering of overwhelming numbers of disturbed patients. Psychiatrists grasped for “great and desperate cures”. <a href="https://en.wikipedia.org/wiki/Henry_R._Rollin">Henry Rollin</a>, an English psychiatrist and medical historian, captures the intense zeal:</p>
<blockquote>
<p>The physical treatment of the frankly psychotic during these centuries makes spine-chilling reading. Evacuation by vomiting, purgatives, sweating, blisters, and bleeding were considered essential […] There was indeed no insult to the human body, no trauma, no indignity which was not at one time or other piously prescribed for the unfortunate victim.</p>
</blockquote>
<p>Treatments were sometimes based on rational grounds. Malaria therapy, for instance, was launched as a treatment for neurosyphilis by the Viennese psychiatrist <a href="https://www.britannica.com/biography/Julius-Wagner-Jauregg">Julius Wagner-Jauregg</a> in 1917, earning him a Nobel Prize ten years later. </p>
<p>The high fever caused by the malarial parasite disabled the <a href="https://www.britannica.com/science/spirochete">spirochete</a> that caused neurosyphilis, but the hope that it would be equally effective for other forms of psychosis was soon dashed. The wished-for panacea was not to be.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Malaria therapy, a treatment for neurosyphilis, earned its inventor a Nobel Prize.</span>
<span class="attribution"><span class="source">Jimmy Chan/Pexels</span></span>
</figcaption>
</figure>
<p><a href="https://www.britannica.com/science/insulin-shock-therapy">Insulin-coma therapy</a> was introduced by Manfred Sakel in the 1930s in Vienna and was soon being used in many countries to treat schizophrenia. An insulin injection was administered six days a week for several weeks, producing a state of light coma lasting about an hour, because of reduced glucose reaching the brain. </p>
<p>Many years later, an investigation carried out in the Institute of Psychiatry in London, a leading research centre at the time, showed conclusively that the coma itself was of no therapeutic value. Any positive change was probably due to the staff’s painstaking care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/girl-interrupted-interrogates-how-women-are-mad-when-they-refuse-to-conform-30-years-on-this-memoir-is-still-important-199211">Girl, Interrupted interrogates how women are 'mad' when they refuse to conform – 30 years on, this memoir is still important</a>
</strong>
</em>
</p>
<hr>
<h2>ECT and lithium</h2>
<p>The first widely available and effective biological treatments for mental illness were developed in the asylum. The discovery in 1938 of <a href="https://theconversation.com/electroconvulsive-therapy-a-history-of-controversy-but-also-of-help-70938">electroconvulsive therapy</a> (ECT) by <a href="https://www.psychiatrictimes.com/view/ugo-cerletti">Ugo Cerletti</a> and Lucio Bini, two Italian psychiatrists, led to a dramatically effective treatment for people with severe depression. </p>
<p>ECT was eagerly adopted in practice, but its history illustrates a typical pattern of treatment in psychiatry: unbridled early enthusiasm is later tempered by a protracted process of scientific evaluation. </p>
<p>The same can be said of the use of brain surgery to modify psychiatric symptoms. This was pioneered in 1936 by Portuguese neurologist <a href="https://www.britannica.com/biography/Antonio-Egas-Moniz">António Egas Moniz</a> (another Nobel Prize winner in the field of psychiatry) and surgeon Almeida Lima, and remains controversial in psychiatry to this day.</p>
<p>A momentous breakthrough was the discovery in 1949 by <a href="https://www.nature.com/articles/d41586-019-02480-0">John Cade</a>, an Australian psychiatrist, of lithium as a treatment for manic excitement. The lithium story reveals how the incorporation of a new medication into psychiatric practice is not always smooth. </p>
<p>Several US and Danish psychiatrists had experimented with lithium in the 1870s and 1890s, only to have their work ignored until Cade’s rediscovery. It was another 18 years before lithium was shown to prevent the recurrence of severe changes of mood, its primary clinical use now.</p>
<p>Major tranquillisers were added to the growing range of psychiatric medications after being discovered fortuitously in 1953. An antihistamine used to calm patients undergoing surgery was shown to reduce the torment of psychotic patients, but without making them sleepy. </p>
<p>Shortly after this, the US psychiatrist <a href="https://www.nytimes.com/1983/02/14/obituaries/nathan-kline-developer-of-antidepressants-dies.html">Nathan Kline</a> discovered that a drug being tested for its effect in patients with tuberculosis had antidepressant properties — the forerunner of medications for depression. All these drugs radically transformed the practice of psychiatry. </p>
<h2>Freud, ‘talking cures’ and shell shock</h2>
<p>A very different aspect of mental health care arose in the 1890s, outside
the asylum. Concerned with neurotic conditions, the new treatment grew chiefly out of neurology but was also influenced by a scientific interest in hypnosis and the unconscious. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=816&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=816&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=816&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1025&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1025&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1025&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sigmund Freud.</span>
<span class="attribution"><span class="source">Max Halberstadt/Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Sigmund Freud conceived a dynamic model of the mind in which, through the mechanism of repression, painful or threatening emotions, memories and impulses are prevented from escaping into conscious awareness. </p>
<p><a href="https://theconversation.com/a-dangerous-method-in-defence-of-freuds-psychoanalysis-5989">Psychoanalysis</a> grew to become an integrated set of concepts about normal and abnormal mental functioning and personality development, and spawned a new method of psychologically based treatment. Psychoanalysis emerged as a major theoretical underpinning of contemporary “talking cures” (psychotherapies), and its influence spread far beyond treating mental ill-health.</p>
<p>Both world wars profoundly influenced the field. The high incidence of “<a href="https://theconversation.com/shell-shock-treatments-reveal-the-conflict-in-psychiatrys-heart-29822">shell shock</a>” in World War I drove home the lesson that mental illness could affect not only those genetically predisposed, but even the supposedly robust. It soon emerged that anyone exposed to traumatic experiences was vulnerable. </p>
<p>A positive outcome from World War II was the development of techniques for screening large numbers of recruits, which revealed the substantial prevalence of emotional problems among young adults. </p>
<p>The need to treat numerous psychiatric casualties led to the development of group therapies. These paved the way for the so-called <a href="https://en.wikipedia.org/wiki/Therapeutic_community">therapeutic community</a>, based on the idea that an entire ward of patients could be an integral part of treatment.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ehPcYibzUKc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Group therapy, as depicted in One Flew Over the Cuckoo’s Nest.</span></figcaption>
</figure>
<p>The idea of deinstitutionalisation began to gather pace in the 1960s, driven by a burgeoning civil-rights movement. <a href="https://www.penguin.com.au/books/asylums-9780241548004">Asylums</a>, an influential book at the time by sociologist Erving Goffman, containing his minute observations of the sense of oppression experienced by patients in these “total institutions”, was one catalyst for their closure. </p>
<p>Hundreds of thousands of long-stay patients began to be transferred to alternative accommodation and specialist care in the community, a process that is still in progress.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-body-keeps-the-score-how-a-bestselling-book-helps-us-understand-trauma-but-inflates-the-definition-of-it-184735">The Body Keeps the Score: how a bestselling book helps us understand trauma – but inflates the definition of it</a>
</strong>
</em>
</p>
<hr>
<h2>What is mental illness?</h2>
<p>It is challenging to define what makes a pattern of behaviour and experience a mental disorder. Generally, such a pattern – or “syndrome” – is considered to be a disorder if it is associated with psychological distress, such as intense and prolonged anxiety or sadness, or significant dysfunction, such as a serious impairment in functioning in one or more key areas of daily life. </p>
<p>If the pattern is short-lived, relatively mild, or entirely understandable in light of the trials and tribulations of the person’s life, it should be seen as a problem in living rather than a mental disorder. Such problems may still benefit from consultation with a mental health professional despite not being diagnosable disorders.</p>
<p>This definition of what counts as a mental disorder also clarifies what is not a mental disorder. Merely being unusual or violating social norms does not mean a person has a disorder. </p>
<p>It is difficult sometimes to decide whether a new kind of behaviour is a mental disorder. For instance, should <a href="https://theconversation.com/no-youre-probably-not-addicted-to-your-smartphone-but-you-might-use-it-too-much-89853">excessive smartphone use</a> or <a href="https://theconversation.com/gambling-on-pokies-is-like-tobacco-no-amount-of-it-is-safe-51037">compulsive gambling</a> be counted as diagnosable addictions?</p>
<h2>Troubling cases</h2>
<p>These decisions about what to include under the umbrella of mental illness are fraught, and there have been some troubling historical cases when disturbing decisions were made or proposed. </p>
<p>In the 1850s, for example, Samuel Cartwright, a physician from Alabama, proposed a new diagnosis called “<a href="https://www.nytimes.com/2000/01/15/arts/bigotry-as-mental-illness-or-just-another-norm.html">drapetomania</a>” to explain why African-American slaves would wish to escape their servitude. </p>
<p>He recommended slaves should be treated kindly and humanely to prevent the disorder, but whipped if this treatment failed. A more patent abuse of the concept of mental illness would be hard to imagine, and it should be noted that other physicians ridiculed Cartwright’s proposal at the time.</p>
<p>Two other controversial cases date to the last century. In the early 1970s, one of us (Sidney) stumbled across disturbing media reports that many political and religious dissenters and human-rights activists in the Soviet Union were being labelled as mentally ill and detained in mental hospitals indefinitely or until they renounced their “disturbed ideas”. </p>
<p>For instance, <a href="https://en.wikipedia.org/wiki/Petro_Grigorenko">General Pyotr Grigorenko</a> criticised the privileges of the Soviet elite and publicly espoused the rights of the <a href="https://en.wikipedia.org/wiki/Crimean_Tatars">Crimean Tatar</a> ethnic minority group. He was diagnosed with paranoid tendencies, one symptom being his “reformist ideas”, and forcibly committed to a psychiatric facility. </p>
<p>In effect, Soviet psychiatry’s definition of mental illness, and psychosis in particular, was so broad that political beliefs about the desirability of social change were recast as delusions.</p>
<p>The second case comes from the US. <a href="https://daily.jstor.org/how-lgbtq-activists-got-homosexuality-out-of-the-dsm/">Until 1973</a>, homosexuality was defined as a sexual deviation and included in the set of recognised mental disorders. Under pressure from civil, women’s and gay rights activists, it was removed from the diagnostic manual.</p>
<p>Noting such cases, whenever the boundary of a mental illness is expanded to include new diagnoses or loosen old ones, some critics will worry we are treating normal behaviour as a pathology and that we will harm people by labelling them. And whenever the boundary contracts, others will worry that people with psychological troubles are being excluded from clinical care. </p>
<p>Deciding what is and isn’t a mental illness is difficult, but has marked consequences.</p>
<hr>
<p><em>This is an edited extract from <a href="https://scribepublications.com.au/books-authors/books/troubled-mindSees-9781922585875">Troubled Minds: Understanding and treating mental illness</a> by Sidney Bloch and Nick Haslam (Scribe Publications), published 29 August 2023.</em></p><img src="https://counter.theconversation.com/content/206580/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Haslam receives funding from the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Sidney Bloch does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Humans have attempted to understand and treat mental illness for centuries – from ancient Greek medicine, Middle Ages exorcisms and the rise of asylums, to modern medical breakthroughs.Sidney Bloch, Emeritus Professor in Psychiatry, The University of MelbourneNick Haslam, Professor of Psychology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2076822023-07-13T12:37:25Z2023-07-13T12:37:25ZMyths about will power and moral weakness keep people with opioid use disorder from receiving effective medications like methadone, buprenorphine and naltrexone<figure><img src="https://images.theconversation.com/files/534714/original/file-20230628-17-b8qav.jpg?ixlib=rb-1.1.0&rect=8%2C4%2C2986%2C1989&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse dispenses liquid Methadose, an FDA-approved medication that helps people addicted to opioids.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/vanessa-leavitt-dispenses-a-dosage-of-the-liquid-form-of-news-photo/462014722">Whitney Hayward/Portland Press Herald via Getty Images</a></span></figcaption></figure><p>The <a href="https://store.samhsa.gov/sites/default/files/pep21-02-01-002.pdf">most effective science-based treatment</a> for opioid use disorder is medication. Methadone and buprenorphine prevent intense cravings and other symptoms of withdrawal, while naltrexone works by blocking <a href="https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work">the effects of opioids</a>. </p>
<p>Despite <a href="https://doi.org/10.1001/jamanetworkopen.2020.29676">abundant research</a> <a href="https://doi.org/10.1016/j.jsat.2021.108447">showing these medications reduce the risk</a> <a href="https://doi.org/10.1001/jamanetworkopen.2023.14925">of relapse and overdose</a>, many people, no matter their relationship with opioids or with people who use them, are still <a href="https://doi.org/10.1177/19367244231159096">hesitant to support the use of these medications</a>. And the majority of people who would benefit from such treatments <a href="https://doi.org/10.1016/j.drugpo.2022.103786">do not have access to them</a>.</p>
<p><a href="https://scholar.google.com/citations?user=NKKkSF8AAAAJ&hl=en">We</a> <a href="https://scholar.google.com/citations?user=fZr3zoUAAAAJ&hl=en">study</a> opioid use disorder and the attitudes that surround it. To better understand hesitancy around the use of medication to treat opioid use disorder, we <a href="https://scholar.google.com/citations?hl=en&user=D4mtQ3IAAAAJ">and</a> <a href="https://scholar.google.com/citations?hl=en&user=_VuWPDAAAAAJ">our</a> <a href="https://www.lifespringhealthsystems.org/">colleagues</a> <a href="https://www.ecommunity.com/locations/community-fairbanks-recovery-center">conducted</a> focus groups with three populations intimately involved in the opioid crisis – those in recovery, their friends and family and their health care providers – as well as with community members with no direct connection to opioid use disorder. We spoke with 101 people in all across rural and urban locations in Indiana. </p>
<p>We asked what they thought about using medication to treat opioid use disorder. We found all four groups had negative opinions about using medication. No matter who they were, <a href="https://doi.org/10.1177/19367244231159096">participants voiced</a> an underlying belief that opioid use disorder results from moral weakness that can be overcome with willpower and commitment to behavior change, despite research-based evidence that overwhelmingly shows that opioid use disorder is a <a href="https://www.ncbi.nlm.nih.gov/books/NBK541390/">chronic brain disease best managed with medication</a>. </p>
<p>Across all four groups, we heard three myths about using medication for opioid use disorder. Research reveals these stigmatizing beliefs are counter to reality.</p>
<h2>Medication isn’t trading one drug for another</h2>
<p>Many of our participants expressed the belief that using medication is the same as using opioids to get high. This misperception is likely rooted in the outdated idea that recovery is defined by <a href="https://nida.nih.gov/research-topics/recovery">total abstinence from all substances</a>, except perhaps caffeine and nicotine. As one service provider working with people in recovery declared, “If you’re on Suboxone or you’re on methadone and you’re not being tapered down, you’re using.” </p>
<p>The truth is, taking medication is not the same as using prescription or street opioids to get high. These medications <a href="https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work">do not produce the same experience of euphoria or high</a> as heroin, morphine or other opioids. <a href="https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2020/12/medications-for-opioid-use-disorder-improve-patient-outcomes">In different ways</a>, methadone, buprenorphine and naltrexone all reduce cravings and <a href="https://www.recoveryanswers.org/research-post/better-down-the-road-the-long-term-outcomes-of-opioid-use-disorder-patients-treated-with-medication/">allow people to remain sober</a> and to work, raise their children and engage in activities of healthy productive living – all challenges for people to do well when using opioids to get high. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up photo of a woman's hands holding two small packages labeled Suboxone." src="https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Suboxone is a medicine containing buprenorphine and naltrexone. It is most often taken under the tongue.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/susan-stevens-shows-off-a-prescription-for-suboxone-her-news-photo/1134203790">Eamon Queeney/The Washington Post via Getty Images</a></span>
</figcaption>
</figure>
<h2>Medication is an important part of long-term recovery</h2>
<p>We found that people’s overall discomfort with the idea of using medication to treat opioid use disorder led to a belief that such treatment should be used only as a steppingstone on the way to sobriety. A community member we spoke with said, “It’s a way of weaning them off everything. I think that’s just one of the steps they have to take to get clean.” </p>
<p>The belief that medication should be used for only a short time runs counter to <a href="https://doi.org/10.1001/jama.1977.03270390032021">research showing</a> <a href="https://doi.org/10.1016/0002-9343(78)90691-5">higher rates of relapse</a> <a href="https://doi.org/10.1080/10550490701860971">after tapering</a>. <a href="https://www.cms.gov/about-cms/story-page/cdcs-tapering-guidance.pdf">Guidelines from the U.S. Department of Health and Human Services</a> discourage rapid tapers and affirm that long-term use is the best way to prevent relapse, overdose and death.</p>
<h2>Long-term treatment counts as success</h2>
<p>Many of our study participants voiced the belief that long-term use of medication means the treatment did not work. As one family member put it, “If you’re on it for 10 or 15 years, then that’s not really helping you.” </p>
<p>The myth that long-term use of medication means the medicine is ineffective – or has failed – runs counter to both the <a href="https://doi.org/10.1001/jama.283.10.1303">life outcomes of those on maintenance treatment</a> and the <a href="https://doi.org/10.1080/10550490701860971">physiological reality</a> that such drugs may remain <a href="https://doi.org/10.1016/j.jsat.2009.05.003">necessary to normalize brain function</a> for the person in recovery. </p>
<p>Just as those with high blood pressure or diabetes may need to remain on medications for the long term, so might some people with opioid use disorder. Keeping people in treatment and alive through use of medications is treatment success, not failure.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man walks in a peaceful demonstration carrying a sign saying 'Treatment is Effective #recoverymatters.'" src="https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Marchers celebrate National Recovery Month in Grand Rapids, Mich.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/sacredheartrehab/15173561710/in/photolist-p7QtfW-27rXxBC-pnimPN-pp41Va-S3zEL3-CbHjig-2h4m9TE-D96W66-27rXxAL-CFYWwb-2h4oKL5-R9cAic-2h4oL3h-pninfh-2h4nZHE-2h4oKRR-2h4m9ED-R9cESH-pnimDh-2h4m9mN-QXFtr2-pp3ZGt-2h4oL1D-2h4nZTz-2oAQSr8-QyZHBY-LZNzgj-R9cD2i-2cqYiND-PUxY8p-f7izxQ-HRdXWU-R9cFd2-QXB1ix-2ojTUQi-2h4kKJb-2hQGWS3-CbHkg8-2ojUFCF-qsmpB6-D1PbJg-2ojPTAR-uRqk2e-vNhxTz-nCKoZG-2hQLtBT-D6Mppq-pqeL95-9TckNM-QXFtEZ">Sacred Heart/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>An <a href="https://www.ncbi.nlm.nih.gov/books/NBK448203/">estimated 3 million Americans</a> have had or currently struggle with opioid use disorder. The latest data from the U.S. Centers for Disease Control and Prevention <a href="https://blogs.cdc.gov/nchs/2023/05/18/7365/">estimates nearly 83,000 deaths in 2022</a> involved opioids.</p>
<p>Methadone, buprenorphine and naltrexone are lifesaving medications. Myths associated with their use cause avoidable relapse, overdose and death by keeping people from using the most effective tool for entering into and maintaining recovery.</p><img src="https://counter.theconversation.com/content/207682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melissa S. Fry receives funding from Indiana University Addictions Grand Challenge Program, and provides evaluation services to Substance Abuse and Mental Health Services Administration funded programs. </span></em></p><p class="fine-print"><em><span>Melissa Cyders receives funding from Indiana University Addictions Grand Challenge Program and the National Institutes of Alcohol Abuse and Alcoholism.</span></em></p>Prescription medications can help people with opioid use disorder avoid the risks of relapse and overdose. But stigma based on misperceptions about addiction limits their use.Melissa S. Fry, Director, Applied Research and Education Center & Associate Professor of Sociology, Indiana UniversityMelissa Cyders, Professor of Psychology, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2047832023-07-04T21:51:22Z2023-07-04T21:51:22ZScaling up community drug-checking services in B.C. could help respond to the overdose crisis<figure><img src="https://images.theconversation.com/files/535609/original/file-20230704-27-lyamti.jpg?ixlib=rb-1.1.0&rect=30%2C105%2C4986%2C3083&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drug checking is a harm reduction practice that provides chemical analysis of substances. Fentanyl test strips help drug users ensure that substances are free of dangerous fentanyl. </span> <span class="attribution"><span class="source">(AP Photo/Carlos Giusti)</span></span></figcaption></figure><p>British Columbia is in the midst of an enduring drug overdose crisis that continues to claim hundreds of people every year with no end in sight. With a <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf">significant rise in deaths over the last seven years</a>, innovative responses are urgently needed.</p>
<p>Among these responses is community drug checking, which continues to gain traction in both public health practice and research. Drug checking is a harm reduction practice that provides chemical analysis of substances. This is not only to inform harm reduction for people who use, buy and sell drugs (<a href="https://doi.org/10.1186/s12954-021-00545-w">and those who support them</a>), but also to monitor the supply for emerging trends that inform both the community and policymakers about the state of the unregulated supply, <a href="https://doi.org/10.1016/j.drugalcdep.2022.109427">which remains volatile, unpredictable and dangerous</a>. </p>
<p>As researchers providing drug checking on Vancouver Island, we see value in exploring new ways to deliver this service to reach more people who use drugs, at a scale required to address the current crisis.</p>
<h2>Drug checking in global perspective</h2>
<p><a href="https://doi.org/10.1111/add.15734">While drug checking has been around since the 1990s</a>, it remains an underused intervention that is often limited in both scope and scale. However, innovations in <a href="https://doi.org/10.3390/ijerph191911960">how and where the service is provided</a>, as well as <a href="https://doi.org/10.1016/j.drugpo.2022.103611">technological advancements within analytical chemistry and instrumentation</a>, are helping to overcome these limitations.</p>
<p>Internationally, groups like the <a href="https://www.drugs-test.nl/en/about-dims/">Drug Information Monitoring System</a> in the Netherlands have been pioneering drug checking and continuing to inform drug-checking research and practice internationally. </p>
<p>While services in some countries remain beholden by archaic <a href="https://doi.org/10.1016/j.drugalcdep.2022.109425">prohibitory legislative environments that challenge the legality of drug checking</a>, others are finding success in embedding drug checking within novel legal frameworks, <a href="https://doi.org/10.1108/DHS-03-2022-0016">like the legalization of drug checking in New Zealand</a>.</p>
<h2>Drug checking in Canada</h2>
<figure class="align-right ">
<img alt="A person's hand seen using a fentanyl test strip to test a dose of heroin in a small container" src="https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=624&fit=crop&dpr=1 600w, https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=624&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=624&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=784&fit=crop&dpr=1 754w, https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=784&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=784&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A drug user places a fentanyl test strip into a mixing container to check for contamination, using a fentanyl test strip.</span>
<span class="attribution"><span class="source">(AP Photo/Bebeto Matthews)</span></span>
</figcaption>
</figure>
<p>In Canada, drug checking has its origins in the festival and rave scene as a grassroots bottom-up response to the harms of an unregulated market. <a href="http://michelow.ca/doc/drug-checking-guide-online-v1.pdf">The oldest drug-checking project has provided critical services at Shambhala Music Festival in Salmo, B.C.</a> for the last two decades. </p>
<p>The success of drug checking in festival settings for <a href="https://doi.org/10.17269/s41997-018-0126-6">lowering potential harms and highlighting broader trends</a> is now <a href="https://doi.org/10.1186/s12889-021-11243-4">increasingly being evaluated as a response to the overdose crisis</a> in B.C. and <a href="https://drugchecking.cdpe.org/">other parts of the country</a>. </p>
<p>Drug checking alone is not enough to curb the dramatic increase in drug toxicity deaths in the province and nationally. However, some of its strengths include <a href="https://doi.org/10.1108/DHS-01-2022-0005">generating evidence of trends</a> within the drug supply, as well as evidence for its effectiveness as a harm-reduction measure. It can also be <a href="https://doi.org/10.1080/09687637.2022.2087487">incorporated into other harm reduction programs and methods</a>, including safe supply.</p>
<h2>Substance: The Vancouver Island drug-checking project</h2>
<p>Our <a href="https://substance.uvic.ca/">research-based service in Victoria, B.C.</a> has spent the last five years developing and evaluating drug-checking service models while conducting robust multi-disciplinary research in the fields of social work, chemistry, computer science and public health. This research provides evidence to support services that <a href="https://doi.org/10.1186/s12954-020-00373-4">respond to the unique needs of people accessing drug-checking services</a>.</p>
<p>On the chemistry side, our research <a href="https://doi.org/10.1002/jrs.6133">evaluates and improves analytical technologies and methods, and boosts their effectiveness in detecting fentanyl and other adulterants</a>. Public health research highlights <a href="https://doi.org/10.1186/s12889-021-11243-4">how drug checking goes beyond individualistic responses to act within community, market and policy arenas</a>. This research supports services that <a href="https://doi.org/10.1186/s12954-020-00373-4">respond to the unique needs of people accessing drug-checking services</a>.</p>
<h2>Vancouver Island’s unique model of drug checking</h2>
<p>In responding to the challenges of scaling up drug-checking services, <a href="https://doi.org/10.1108/DHS-01-2022-0005">we developed a unique distributed drug-checking model</a> to increase the reach of these services. </p>
<p>This model aims to fill in gaps in service delivery for diverse communities that are vulnerable to the unregulated drug supply. It also highlights the importance of multidisciplinary research and service design that draws critical insight from multidisciplinary fields to better inform drug-checking services. </p>
<figure class="align-center ">
<img alt="A window with a logo in a circle reading Substance, est. 2018, surrounded by paper hearts with handwritten messages." src="https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Substance’s distributed model provides a hybrid, easy-to-use drug-checking program that blends immediate portable drug-checking technologies for timely harm reduction with more comprehensive lab-based technologies that provide greater accuracy of drug composition.</span>
<span class="attribution"><span class="source">(Substance)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Drawing on a network that enables the collection of samples in various locations and communities, our distributed model provides a hybrid, easy-to-use drug-checking program. The program blends immediate portable drug-checking technologies for timely harm reduction with more comprehensive lab-based technologies that provide greater accuracy of drug composition. </p>
<p>Through the use of <a href="https://doi.org/10.1186/s12954-023-00764-3">specialized spectrometers and test</a> strips distributed at various sites and connected to a central server and database, drug analysis can be done remotely within our central hub. These results get looped back to service users distributed across Vancouver Island who also have the opportunity to receive further analysis at a later time using a lab-based method called <a href="https://doi.org/10.1111/dar.13370">paper spray mass spectrometry</a>.</p>
<p>This model responds to the unique challenges of providing critical harm reduction across geographical locations and within different communities. Through the distributed model, we continue to evaluate what works best for whom in <a href="https://theconversation.com/why-the-drug-poisoning-crisis-in-b-c-wont-be-addressed-by-the-new-decriminalization-policy-199239">the context of an ever-changing drug supply and policy landscape</a>. </p>
<p>Most consumables in Canada have quality controls that help inform purchasing and consumption decisions. People who use drugs and those who support them deserve the same. It is long past time that we respond to the enduring crisis to the magnitude it deserves. </p>
<p><a href="https://doi.org/10.1186/s12954-022-00727-0">Drug checking everywhere for everyone</a>: is it possible? It is certainly a worthwhile goal with life-saving potential, and we will continue working to achieve it.</p><img src="https://counter.theconversation.com/content/204783/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bruce Wallace received funding from Health Canada, the Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council, Vancouver Foundation, and the Island Health Authority. </span></em></p><p class="fine-print"><em><span>Dennis Hore received funding from Health Canada, the Natural Sciences and Engineering Research Council of Canada, and the Canadian Institutes of Health Research.</span></em></p><p class="fine-print"><em><span>Piotr Burek does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most consumables in Canada have quality controls that inform purchasing and consumption decisions. People who use illicit drugs deserve the same. Drug checking provides that harm-reduction service.Piotr Burek, Master of Arts student, Social Dimensions of Health Program, University of VictoriaBruce Wallace, Professor, School of Social Work, University of VictoriaDennis Hore, Professor, Chemistry, University of VictoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2076792023-06-27T21:21:32Z2023-06-27T21:21:32ZLet evidence, not opinion, guide harm reduction policy and practice in Canada’s drug poisoning crisis<p>The poisoning of the unregulated drug supply, especially in Canada, is a public health crisis that deserves a high priority for the integration of evidence into policy and practice. </p>
<p>The <a href="https://www.cbc.ca/news/health/drug-poisoning-deaths-language-1.6457834">drug poisoning crisis</a> is often referred to as the opioid crisis, but it is all illicit substances, including stimulants, that are tainted with fentanyl, benzodiazepines and other dangerous ingredients, <a href="https://doi.org/10.1111/add.15844">increasing the risk of harm, especially overdose</a>. </p>
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Read more:
<a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">‘Benzo-dope’ may be replacing fentanyl: Dangerous substance turning up in unregulated opioids</a>
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<p>It is still an ongoing battle for those in positions of power to submit to the rigorous evidence supporting harm reduction, despite strategies like <a href="https://doi.org/10.1186/s12954-017-0154-1">supervised consumption sites</a> and the distribution of drug equipment <a href="https://www.phs.ca/insite-an-anniversary-of-hope/">being more than two decades old</a>. </p>
<p>For example, North America’s first formal supervised consumption site, <a href="https://www.phs.ca/program/insite/">Insite</a>, has been in operation for 20 years showcasing what its founding organization, PHS Community Services, calls a “<a href="https://www.phs.ca/insite-an-anniversary-of-hope/">pragmatic and humane approach to the risks of drug use</a>.” </p>
<p>Thorough evaluation of harm reduction strategies has shown they can <a href="https://doi.org/10.1186/s12954-017-0154-1">save money, save lives and promote health</a> at an individual and population level. Furthermore, denial of access to supervised consumption is a <a href="https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/7960/index.do">violation of Section 7 of the Canadian Charter of Rights and Freedoms</a>, which protects an individual’s right to life, liberty and security of the person.</p>
<h2>Stigma and ideology</h2>
<p>Recently, Canada’s leader of the Opposition Pierre Poilievre had his motion to defund safer supply voted down in Parliament. His reference to a “<a href="https://www.ourcommons.ca/DocumentViewer/en/44-1/house/sitting-200/hansard">tax-funded drug supply</a>” as fuelling addiction rather than recovery is not supported by evidence and follows the <a href="https://www.cbc.ca/news/politics/conservative-motion-safe-supply-fails-1.6858551">failed prejudicial ideology of the war on drugs era</a>. </p>
<p>Poilievre’s actions mirror the sentiments of former federal health minister Rona Ambrose, whose opinion also superseded evidence while in a position of influence. In 2013 she attempted to deny access to heroin assisted treatment (HAT) — an <a href="https://doi.org/10.1136/bmj.327.7410.310">opioid substitution treatment using diamorphine/diacetylmorphine (medical grade heroin</a>) — for persons with substance use disorder in Vancouver. </p>
<p><a href="https://www.providencehealthcare.org/sites/default/files/Supreme%20Court%20of%20British%20Columbia%20Decision.pdf">Ambrose publicly stated that</a> “Our policy is to take heroin out of the hands of addicts, not to put it into their arms.”</p>
<p>Ambrose made this public declaration <a href="https://doi.org/10.1016/j.jsat.2006.04.007">despite evidence</a> from both <a href="https://doi.org/10.1056/NEJMoa0810635">Canada</a> and <a href="https://doi.org/10.1136/bmj.317.7150.13">Europe</a> that <a href="https://doi.org/10.1192/bjp.bp.106.026112">showcased the efficacy</a> of HAT in six <a href="https://doi.org/10.1016/S0140-6736(10)60349-2">randomized controlled trials</a> with over 1,500 patients.</p>
<h2>What is evidence?</h2>
<p>What is considered evidence, especially regarding public health? From an epistemological (justified belief, as opposed to opinion) perspective, we may think evidence equals truth. However <a href="https://global.oup.com/academic/product/population-health-science-9780190459376?cc=ca&lang=en&">causation cannot be observed, only inferred</a>. While evidence may be viewed as more of a confirmation, truly <a href="https://doi.org/10.1046/j.1365-2753.2000.00244.x">definitive scientific evidence is rare due to its ever-changing and evolving nature</a>. </p>
<p>Evidence comes in many forms, and although it may not constitute absolute “proof,” it is reliable.</p>
<p>In harm reduction, best practices are grounded in evidence that comes from several facets including peer-reviewed literature, unpublished reports or grey literature, and the experiential knowledge of persons who use drugs themselves. </p>
<p>The way <a href="https://doi.org/10.1016/j.drugpo.2020.103015">harm reduction has progressed in Canada</a> tells us that <a href="https://doi.org/10.1186/s13011-021-00406-6">people who use drugs are key informants at the table</a> as they articulate their own experience of what it is like to use substances from an unregulated supply and to navigate the health and social services system. <a href="https://doi.org/10.1111/add.158441196COMMENTARIES">Their voice in the conversation</a> helps to reduce stigma, support client-centred essential services and policies, and prioritize the needs of people who use substances.</p>
<h2>Barriers to progress</h2>
<p>The question still remains as to why government policies across Canada, public stigma, and ignorance towards the use of substances and the people who use them, are still able to create barriers to the promotion of strategies that fight the current drug poisoning crisis. </p>
<p>During the COVID-19 pandemic, <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline">public health strategies were implemented at a rapid pace</a>, but this same urgency is not translating to our community of people who use unregulated drugs. One would think that <a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants">the loss of nearly 40,000 Canadians to opioid overdoses since 2016</a> would be impetus for not just change, but bold action.</p>
<p>Has government not learned its lessons about taking all aspects of evidence into consideration while also considering the urgency of action required in crisis situations? After public health failures during the 2001 SARS crisis, <a href="https://doi.org/10.1098/rsfs.2021.0079">Justice Archie Campbell recommended in his report</a>: </p>
<blockquote>
<p>“Where there is reasonable evidence of an impending threat to public harm, it is inappropriate to require proof of causation beyond a reasonable doubt before taking steps to avert the threat…that reasonable efforts to reduce risk need not await scientific proof.” </p>
</blockquote>
<p>The ultimate question that needs to be asked to those who have the power to move harm reduction forward is: If they want to be a part of ending the drug toxicity crisis, then why and for whom? Is their primary objective more votes? Or is it to value all members of our community, and not just keep people who use drugs alive, but to help them thrive? </p>
<p>If the goal is wanting to be a part of ending this crisis for the betterment of the persons experiencing it, then the approach must include weighing evidence from a variety of sources and triumphing over public and political ideology and stigma. </p>
<p><a href="https://plato.stanford.edu/entries/egalitarianism/#Pri">Prioritarianism</a>, as a principle of justice, puts the focus on the population most in need, whether it be in terms of health, resources, opportunities or access. The moral and ethical values of this approach intend to maximize overall well-being for those who need it the most. </p>
<p>Movement forward requires collaboration that builds on existing strengths and capacities, with the guiding principle being to <a href="https://healthydebate.ca/2021/09/topic/encampments-pandemic-covid/">put the needs of the persons living this experience first</a>. Bioethicist Anita Ho describes epistemic humility — the ability to challenge one’s preconceived and biased assumptions — as “<a href="https://doi.org/10.2979/intjfemappbio.4.2.102">characterized by a commitment to mutual collaboration and trust with those they serve</a>.” </p>
<p>A healthy public includes us all.</p><img src="https://counter.theconversation.com/content/207679/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ross Upshur receives funding from Health Canada, CIHR, Atlas Institute for Veterans and Families</span></em></p><p class="fine-print"><em><span>Karla Ghartey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Harm reduction is grounded in evidence. But policies, stigma and ignorance about substance use still create barriers in battling Canada’s drug poisoning crisis.Karla Ghartey, Doctor of Public Health (DrPH) student, University of TorontoRoss Upshur, Professor, Dalla Lana School of Public Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2010412023-06-21T15:03:15Z2023-06-21T15:03:15ZWhy you’re more likely to drink when you’re happy than when you’re sad<figure><img src="https://images.theconversation.com/files/532693/original/file-20230619-23-wl2vw4.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5991%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Contrary to popular belief, we may actually be more likely to drink in excess when we're happy.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-friends-having-fun-drinking-beer-2164874427">Lomb/ Shutterstock</a></span></figcaption></figure><p>There’s a long-held belief that people drink alcohol in excess to drown their sorrows. But <a href="https://psycnet.apa.org/fulltext/2023-79626-001.html">recent research</a> into mood and drinking has found the opposite is also true.</p>
<p>Using data from 69 studies (12,394 people in total) in the US, Canada, France and Australia, all of which employed surveys to assess mood and drinking levels, the researchers found no evidence that people drank more on days when they felt down. Rather surprisingly, however, people tended to drink – and drink heavily – on days when they were in a good mood. </p>
<p>The authors found that participants were between 6% and 28% more likely to drink on days they were in a good mood, and 17%-23% more likely to binge drink (having more than four or five drinks within a few hours) on these days.</p>
<p>These findings suggest that, contrary to popular belief, we may actually be more likely to drink in excess when we’re happy than when we’re feeling down. So, what explains this phenomenon? In <a href="https://www.sciencedirect.com/science/article/pii/S0306460314002688">our research</a>, we have identified several possible factors.</p>
<h2>‘Desire thinking’</h2>
<p>Drinking is associated with a thought process called “<a href="https://www.sciencedirect.com/science/article/pii/S0306460319303776">desire thinking</a>”. This is a way of thinking that’s geared towards anticipating positive outcomes from certain experiences, based on the associations we have with that experience.</p>
<p>Before we drink, we tend to have an expectation of it based on past experiences – such as how the alcohol will taste, the feeling of being intoxicated, or the idea that alcohol will make us more interesting. We may also have positive memories from other times we drank. If so, the next time we think about having a drink, we may immediately default to thinking of it in a positive light.</p>
<p>This can then lead to “<a href="https://www.sciencedirect.com/science/article/abs/pii/S0306460319303776">prolonged self-talk</a>”, where we remind ourselves of the reasons for drinking – such as because you did well at work, or because the weather’s nice. Both this and desire thinking can combine to maintain positive mood and expectations – intensifying the cravings for alcohol. </p>
<figure class="align-center ">
<img alt="A group of men cheers their pints of beer." src="https://images.theconversation.com/files/532695/original/file-20230619-27-6a5ys6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532695/original/file-20230619-27-6a5ys6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532695/original/file-20230619-27-6a5ys6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532695/original/file-20230619-27-6a5ys6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532695/original/file-20230619-27-6a5ys6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532695/original/file-20230619-27-6a5ys6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532695/original/file-20230619-27-6a5ys6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Remembering positive experiences can intensify cravings.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/people-men-leisure-friendship-celebration-concept-464199170">Ground Picture/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Adding another layer of positivity to the mix, our research has also found that people tend to hold what we call positive “<a href="https://www.sciencedirect.com/science/article/pii/S0306460318303721">meta-cognitive beliefs</a>” regarding the usefulness of desire thinking.</p>
<p>In other words, when desire thinking makes us crave alcohol by reminding us of all the good things that come with drinking, we’re likely to trust that positive thought and see it as a good thing. Thinking positively about the positive experiences we’re about to have may increase our motivation to drink more.</p>
<p>The downside to this potent cocktail of positive thoughts and feelings is that it appears to be incredibly hard to control and resist. For example, there’s evidence that positive beliefs can make us feel like we’re <a href="https://www.cambridge.org/core/journals/european-psychiatry/article/abs/dysfunctional-metacognition-across-psychopathologies-a-metaanalytic-review/3EB4D6C4B21547750252ED1C85FD88A2">less in control of our thinking and behaviour</a>.</p>
<h2>Taking control</h2>
<p>In our clinical research with <a href="https://www.frontiersin.org/articles/10.3389/fpsyg.2018.02619/full">addiction</a> and various <a href="https://www.frontiersin.org/articles/10.3389/fpsyg.2018.02211/full">other mental health conditions</a>, we have found that being able to control the way we think about things – whether that thinking is positive or negative – is key to behavioural change and a balanced state of mind.</p>
<p>However, to take control of the way you think about something, you first need to become aware of your extended thought patterns. The better you become at “thinking about your thinking”, the easier it is to control both your positive and negative thoughts.</p>
<p>Let’s say this thought pops into your mind: “I am feeling good – I deserve to drink this weekend.” Instead of thinking more about this, choose to leave the thought alone – a technique called “<a href="https://link.springer.com/article/10.1007/s10942-005-0018-6">detached mindfulness</a>”. It’s also worth reminding yourself that it’s difficult to <a href="https://www.sciencedirect.com/science/article/abs/pii/S0306460314002329">stop craving something</a> if you think about it a lot.</p>
<p>Try to think of the positive and negative thoughts you have as similar to receiving a text message. We don’t always have control over whether the message we receive is good or bad, but we do have complete control over whether we choose to respond to it or not. This will help to show you that you have control over your desire thinking – and therefore your drinking choices.</p>
<p>Positive mood has also been implicated in other addictive behaviours, such as <a href="https://www.sciencedirect.com/science/article/pii/S0306460317302150">nicotine use</a>, <a href="https://www.sciencedirect.com/science/article/abs/pii/S0306460320307309">gambling</a>, and <a href="https://www.sciencedirect.com/science/article/pii/S0306460317300655">internet pornography addiction</a>. This tells us that positive mood may not be the pathway to a healthy body and mind, as we might believe. </p>
<p>Instead, what may be important is the ability to be flexible in the way we think and behave around positive and negative moods – and in particular, knowing that we can always make choices in how we behave, regardless of our patterns of thinking.</p><img src="https://counter.theconversation.com/content/201041/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The study found that people were more likely to binge drink on the days they were in a good mood.Robin Bailey, Reader in Psychology, Psychotherapy and Counselling, University of BoltonAdrian Wells, Professor of Clinical and Experimental Psychopathology, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2045222023-05-30T12:24:11Z2023-05-30T12:24:11ZYour body naturally produces opioids without causing addiction or overdose – studying how this process works could help reduce the side effects of opioid drugs<figure><img src="https://images.theconversation.com/files/528436/original/file-20230525-27-cw53qp.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2309%2C1299&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Opioid neurotransmitters are located in many areas of the body, including the brain, spine and gut.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/neurotransmitter-release-mechanisms-royalty-free-image/1396888608">ALIOUI Mohammed Elamine/iStock via Getty Images Plus</a></span></figcaption></figure><p>Opioid drugs such as morphine and fentanyl are like the two-faced Roman god Janus: The kindly face delivers pain relief to millions of sufferers, while the grim face drives an opioid abuse and overdose crisis that <a href="https://www.cdc.gov/drugoverdose/deaths/index.html">claimed nearly 70,000 lives</a> in the U.S. in 2020 alone. </p>
<p><a href="https://scholar.google.com/citations?user=LXVL7f0AAAAJ&hl=en">Scientists like me who study pain and opioids</a> have been seeking a way to separate these two seemingly inseparable faces of opioids. Researchers are trying to design drugs that deliver effective pain relief without the risk of side effects, including addiction and overdose.</p>
<p>One possible path to achieving that goal lies in understanding the molecular pathways opioids use to carry out their effects in your body.</p>
<h2>How do opioids work?</h2>
<p>The <a href="https://pubmed.ncbi.nlm.nih.gov/16082232/">opioid system in your body</a> is a set of neurotransmitters your brain naturally produces that enable communication between neurons and activate protein receptors. These neurotransmitters include small proteinlike molecules like <a href="https://doi.org/10.1124/mol.120.119388">enkephalins and endorphins</a>. These molecules regulate a tremendous number of functions in your body, including pain, pleasure, memory, the movements of your digestive system and more.</p>
<p>Opioid neurotransmitters activate receptors that are <a href="https://www.ncbi.nlm.nih.gov/books/NBK546642/">located in a lot of places</a> in your body, including pain centers in your spinal cord and brain, reward and pleasure centers in your brain, and throughout the neurons in your gut. Normally, opioid neurotransmitters are released in only small quantities in these exact locations, so your body can use this system in a balanced way to regulate itself.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/NDVV_M__CSI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The opioids your body produces and opioid drugs bind to the same receptors.</span></figcaption>
</figure>
<p>The problem comes when you take an opioid drug like morphine or fentanyl, especially at high doses for a long time. These drugs <a href="https://theconversation.com/how-do-drugs-know-where-to-go-in-the-body-a-pharmaceutical-scientist-explains-why-some-medications-are-swallowed-while-others-are-injected-182488">travel through the bloodstream</a> and can activate every opioid receptor in your body. You’ll get pain relief through the pain centers in your spinal cord and brain. But you’ll also get a euphoric high when those drugs hit your brain’s reward and pleasure centers, and that could <a href="https://doi.org/10.1016%2FS2215-0366(16)00104-8">lead to addiction</a> with repeated use. When the drug hits your gut, you may develop constipation, along with other common <a href="https://www.asahq.org/madeforthismoment/pain-management/opioid-treatment/what-are-opioids/">opioid side effects</a>.</p>
<h2>Targeting opioid signal transduction</h2>
<p>How can scientists design opioid drugs that won’t cause side effects?</p>
<p>One approach my research team and I take is to understand how cells respond when they receive the message from an opioid neurotransmitter. Neuroscientists call this process <a href="https://doi.org/10.1097%2FALN.0b013e318238bba6">opioid receptor signal transduction</a>. Just as neurotransmitters are a communication network within your brain, each neuron also has a communication network that connects receptors to proteins within the neuron. When these connections are made, they trigger specific effects like pain relief. So, after a natural opioid neurotransmitter or a synthetic opioid drug activates an opioid receptor, it activates proteins within the cell that carry out the effects of the neurotransmitter or the drug.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/FQFBygnIONU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Cells communicate with one another in multiple ways.</span></figcaption>
</figure>
<p>Opioid signal transduction is complex, and scientists are just starting to figure out how it works. However, one thing is clear: Not every protein involved in this process does the same thing. Some are more important for pain relief, while some are more important for side effects like <a href="https://theconversation.com/pain-and-anxiety-are-linked-to-breathing-in-mouse-brains-suggesting-a-potential-target-to-prevent-opioid-overdose-deaths-174187">respiratory depression</a>, or the decrease in breathing rate that makes overdoses fatal.</p>
<p>So what if we target the “good” signals like pain relief, and avoid the “bad” signals that lead to addiction and death? Researchers are tackling this idea in different ways. In fact, in 2020 the U.S. Food and Drug Administration <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-opioid-intravenous-use-hospitals-other-controlled-clinical-settings">approved the first opioid drug based on this idea</a>, oliceridine, as a painkiller with fewer respiratory side effects.</p>
<p>However, relying on just one drug has downsides. That drug might not work well for all people or for all types of pain. It could also have other side effects that show up only later on. Plenty of options are needed to treat all patients in need.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="drawing depicting a tangle of red, blue and yellow curly and straight lines" src="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1006&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1006&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1006&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This figure shows the structure of Hsp90.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/heat-shock-protein-90-chaperone-complex-royalty-free-illustration/185759601">Laguna Design/Science Photo Library via Getty Images</a></span>
</figcaption>
</figure>
<p>My research team is targeting a protein called <a href="https://doi.org/10.1007/128_2012_356">Heat shock protein 90, or Hsp90</a>, which has many functions inside each cell. Hsp90 has been a hot target in the <a href="https://doi.org/10.3390/ijms221910317">cancer field</a> for years, with researchers developing Hsp90 inhibitors as a treatment for many cancer types. </p>
<p>We’ve found that Hsp90 is also really important in regulating opioid signal transduction. <a href="https://doi.org/10.1074/jbc.m116.769489">Blocking Hsp90 in the brain</a> blocked opioid pain relief. However, <a href="https://doi.org/10.1126/scisignal.aaz1854">blocking Hsp90 in the spinal cord</a> increased opioid pain relief. Our recently published work uncovered more details on exactly how <a href="https://doi.org/10.1126/scisignal.ade2438">inhibiting Hsp90 leads to increased pain relief</a> in the spinal cord.</p>
<p>Our work shows that manipulating opioid signaling through Hsp90 offers a path forward to improve opioid drugs. Taking an Hsp90 inhibitor that targets the spinal cord along with an opioid drug could improve the pain relief the opioid provides while decreasing its side effects. With improved pain relief, you can take less opioid and reduce your risk of addiction. We are <a href="https://reporter.nih.gov/search/zF-FuD_ZC0CFwl6deU7tQw/project-details/10294366">currently developing</a> a new generation of Hsp90 inhibitors that could help realize this goal. </p>
<p>There may be many paths to developing an improved opioid drug without the burdensome side effects of current drugs like morphine and fentanyl. Separating the kindly and grim faces of the opioid Janus could help provide pain relief we need without addiction and overdose.</p><img src="https://counter.theconversation.com/content/204522/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Streicher receives funding from the National Institutes of Health, the Arizona Biomedical Research Commission, the Flinn Foundation, and the University of Arizona. He is an equity holder in Teleport Pharmaceuticals, LLC, and Botanical Results, LLC, however, no company products or interests were discussed in this article. </span></em></p>Unlike opioid drugs like morphine and fentanyl that travel throughout the body, the opioids your body produces are released in small quantities to specific locations.John Michael Streicher, Associate Professor of Pharmacology, University of Arizona Health SciencesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2004192023-05-28T11:32:23Z2023-05-28T11:32:23ZDeaths of despair: How income inequality puts Canadian youth at risk<figure><img src="https://images.theconversation.com/files/528639/original/file-20230526-19-j4xo.jpg?ixlib=rb-1.1.0&rect=253%2C176%2C4709%2C3096&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Income inequality is the gap between the highest and lowest earners in a given area. It can contribute to people's risk of poor health, and specifically mental health.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Income inequality has been linked to poor physical and mental health in past research, but more recent evidence suggests the issue of income inequality may be much more severe than previously expected. </p>
<p>While completing my PhD in epidemiology at the University of Alberta, I <a href="http://dx.doi.org/10.1136/jech-2022-219630">published a study</a> highlighting an association between experiencing income inequality in youth and deaths of despair among young Canadians.</p>
<p>Deaths of despair are deaths attributable to suicide, drug overdose and alcohol-related liver disease. These deaths are on the rise in Canada, and finding points of intervention is key to reducing the burden of this crisis.</p>
<p>In collaboration with my doctoral supervisor, <a href="https://www.emergeresearchlab.com">Roman Pabayo</a>, I led a study on a representative sample of Canadian youth and followed them up over a 13-year period to calculate average hazard for deaths of despair. The study sample included 1.5 million Canadians between the ages of 0 and 19 from 2006 to 2018. </p>
<h2>Income inequality and health</h2>
<figure class="align-center ">
<img alt="Tiny human figures standing on coins: a few people on a tall stack, and a lot of people on much smaller stacks" src="https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&rect=75%2C0%2C5513%2C3728&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Areas where income inequality is higher are less likely to have the type of social programs that are key to improving the health of communities.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Income inequality is the gap between the highest and lowest earners in a given area. It can contribute to people’s risk of poor health, and specifically mental health, in a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1088996/">few key ways</a>. </p>
<p>First, in areas with higher income inequality, people are less likely to relate to their neighbours, regardless of whether they earn more or less income than they do. This can lead to social comparisons, which are detrimental for mental health and self esteem. </p>
<p>Secondly, this lack of connection with those around you — also called “social cohesion” — can cause mistrust and ill feelings about others. This in turn can lead people to become withdrawn or isolate themselves. Lack of social cohesion and isolation are both risk factors for poor mental health and substance use. </p>
<p>Finally, areas where income inequality is higher are less likely to have the type of social programs that are key to improving the health of communities. For example, divesting in mental health services and supports can lead to worsened mental health, and removal or lack of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685449/">harm reduction services</a> and <a href="https://doi.org/10.1177%2F070674371405901005">mental health services</a> can put people at a higher risk of deaths of despair. </p>
<h2>Income inequality and deaths of despair</h2>
<p>Deaths of despair are on the rise in Canada. Specifically, drug overdose death events have increased so rapidly that the <a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants">drug poisoning crisis</a> has been referred to as an epidemic. This is a major concern, as these deaths have strong <a href="https://doi.org/10.24095%2Fhpcdp.38.6.02">impacts on the well-being of communities, families and friends</a>; but also because this crisis doesn’t appear to be ending anytime soon. </p>
<p>The impact the crisis is having on young Canadians is especially important, considering that unfamiliarity with substances, lower tolerance and risk-taking behaviours may leave them at an increased <a href="https://doi.org/10.1089%2Fcap.2019.0013">risk for drug overdose</a>. Further, suicide is a <a href="https://vizhub.healthdata.org/gbd-compare/">leading cause of death</a> among young people in Canada, indicating a critical need to intervene.</p>
<p>The results of this <a href="http://dx.doi.org/10.1136/jech-2022-219630">new study</a> also showed that higher levels of income inequality in youth are associated with an increased hazard of death from any cause, deaths of despair and drug overdose in young Canadians. </p>
<h2>Urgent need for services</h2>
<p>My colleagues and I are continuing this work by investigating income inequality and deaths of despair in other populations by using other indicators of social equity. We are also investigating more harms we suspect are associated with income inequality, such as hospitalizations owing to despair. </p>
<p>This line of work shows the urgent need for increased access to health services such as counselling and harm reduction, particularly in areas of higher income inequality, to reduce the risk of deaths of despair in these spaces. </p>
<p>The study results should be communicated to policymakers, who inform discussions on reducing income inequality and harms due to drug overdose, suicide and alcohol-related liver disease. Programs to mitigate this problem may include cash transfer programs, increases to minimum wage, or <a href="https://theconversation.com/a-guaranteed-basic-income-could-end-poverty-so-why-isnt-it-happening-182638">universal basic income programs</a> to reduce the gap between the highest and lowest earners.</p><img src="https://counter.theconversation.com/content/200419/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Benny receives funding from the Women and Children's Health Research Institute (WCHRI).</span></em></p>Higher levels of income inequality in youth are associated with increased ‘deaths of despair’ in young Canadians.Claire Benny, PhD Candidate, Epidemiology, University of AlbertaLicensed as Creative Commons – attribution, no derivatives.