Cost of addiction in Europe

Reduction of Aversive Learning Rates in Pavlovian Conditioning by Angiotensin II Antagonist Losartan: A Randomized Controlled Trial

BACKGROUND

Angiotensin receptor blockade has been linked to aspects of aversive learning and memory formation and to the prevention of posttraumatic stress disorder symptom development.

METHODS

We investigated the influence of the angiotensin receptor blocker losartan on aversive Pavlovian conditioning using a probabilistic learning paradigm. In a double-blind, randomized, placebo-controlled design, we tested 45 (18 female) healthy volunteers during a baseline session, after application of losartan or placebo (drug session), and during a follow-up session. During each session, participants engaged in a task in which they had to predict the probability of an electrical stimulation on every trial while the true shock contingencies switched repeatedly between phases of high and low shock threat. Computational reinforcement learning models were used to investigate learning dynamics.

RESULTS

Acute administration of losartan significantly reduced participants' adjustment during both low-to-high and high-to-low threat changes. This was driven by reduced aversive learning rates in the losartan group during the drug session compared with baseline. The 50-mg drug dose did not induce reduction of blood pressure or change in reaction times, ruling out a general reduction in attention and engagement. Decreased adjustment of aversive expectations was maintained at a follow-up session 24 hours later.

CONCLUSIONS

This study shows that losartan acutely reduces Pavlovian learning in aversive environments, thereby highlighting a potential role of the renin-angiotensin system in anxiety development.

Translation and Validation of ID-Migraine Questionnaire to North-Indian Vernacular Languages

Background

ID-Migraine is an established screening tool for migraine. Translation and validation in more languages can increase its reach and scope.

Aim

To translate and validate ID-Migraine for screening migraine patients in two North-Indian vernacular languages, that is, Hindi and Punjabi.

Methods

ID Migraine was translated into Hindi and Punjabi. Subjects with headaches in outpatient clinics were administered the questionnaire according to their preferred language of choice and referenced clinical evaluations, performed by an experienced neurologist, based on current the ICHD-3 diagnostic criteria.

Results

One hundred subjects with complaints of headaches and 60 healthy controls were recruited after informed consent. Of the 100 subjects with headaches, 73 (73%) screened positive with a translated version of ID-Migraine, and 60 (60%) were eventually diagnosed with migraine without aura. The sensitivity of the Hindi version of ID-Migraine was 94% (95% confidence intervals, 79% to 99%); specificity, 56% (95% CI, 31% to 78%); positive predictive value, 79% (95% CI, 69% to 86%) and negative predictive value, 83% (95% CI, 55% to 95%). The Punjabi version demonstrated a sensitivity of 86% (95% CI, 68% to 96%); specificity, 43% (95% CI, 23% to 66%); PPV, 68% (95% CI, 58% to 76%); and NPV, 69% (95% CI, 44% to 86%).

Conclusion

The translated versions of ID-Migraine demonstrated high sensitivity and fair specificity for screening migraine in Indian subjects who speak and understand Hindi and Punjabi.

The effect of high-intensity interval training on cognitive function in patients with substance use disorder: Study protocol for a two-armed randomized controlled trial

Introduction

Substance use disorder (SUD) is characterized by cognitive impairment, especially executive dysfunction. Executive function is recognized as an important determinant of treatment outcome as it is associated with dropout rate, attendance to therapy and potential relapse after treatment termination. Physical activity can have beneficial effects on cognitive function, but there is still a lack of knowledge regarding potential benefits of aerobic exercise for executive function in SUD treatment. The aim of this study is to examine the effect of aerobic high-intensity interval training (HIIT) on cognitive function and the subsequent effect on treatment outcome in patients with SUD.

Methods and analysis

This study is a randomized controlled trial, including men and women ≥18 years with diagnosed SUD by ICD-10. The patients will be recruited from the department for inpatient treatment at Blue Cross - Lade Addiction Treatment Center, Trondheim, Norway. Participants will be randomized 1:1 into either HIIT (3x/week) + treatment as usual (TAU), or TAU alone. Study outcomes will be assessed at baseline, after eight weeks of intervention, and at 3- and 12-months follow-up. The primary outcome is to compare the change in executive function (via altered BRIEF-A score, Behavior Rating Inventory of Executive Function-Adult) measured between the two study groups after eight weeks. Secondary outcomes include mapping of cognitive function in different subgroups (e.g. type of substance, age, fitness level), collecting self-reported information about quality of life, craving, sleep quality, etc., as well as assessing compliance to TAU and long-term treatment outcome.

Ethics and dissemination

The project was approved by the Regional Ethical Committee and will be performed in accordance with this protocol and the Declaration of Helsinki. Written informed consent will be obtained from all participants prior to inclusion. This project will explore a novel approach to how exercise can be applied in SUD treatment, beyond the well-known effects on physical health. We expect to achieve new knowledge in regard to what extent HIIT can improve cognitive abilities and subsequent treatment outcome in SUD.

Trial registration number

https://www.clinicaltrials.gov/NCT05324085.

Recovery homes provide inexpensive and accessible community-based support

Substance abuse disorders (SUDs) create significant and pervasive health and economic burdens in the U.S. and the world. After primary treatment has ended, supportive social environments are critically important to prevent relapse and to sustain long-term sobriety. Although approaches to SUDs and treatment vary internationally, studies in the United States indicate that a major risk factor for SUD relapse are lack of social environments to support sustained remission from substance use after primary treatment has ended. Evidence suggests that abstinence is enhanced when individuals are embedded in drug-free settings that support abstinence. Longabaugh, Beattie, Noel, and Stout proposed a theory of social support that engages two processes: general social support, which affectspsychological functioning, and abstinence-specific social support, which supports ongoing abstinence from substance use.

Decision-making and inhibitory control after smoking-related priming in nicotine dependent smokers and never-smokers

Impaired decision-making and inhibitory control are important characteristics of nicotine dependence (ND). We aimed to test 1) the effects of smoking-related priming cues on subsequent decision-making and inhibitory control in ND and 2) how these priming effects are related to valence ratings, nicotine deprivation and craving. A sample of 27 smokers with ND according to DSM-IV and a control group of 33 never-smokers performed an intertemporal choice task and a go/no-go task. Before each trial of the tasks, a priming cue appeared that was either smoking-related or neutral. Valence ratings, nicotine deprivation and craving were assessed with self-reports. After smoking-related compared to neutral primes, the ND group exhibited increased delay discounting (β = 0.07, 95% confidence-interval (CI): 0.01-0.14) and shorter go reaction times (β = -0.13, CI: -0.32 to -0.01) compared to the never-smoker group. The speed-up in go trials after smoking-related compared to neutral cues was significantly related to more pleasant valence ratings (β = 0.07, CI:0.01-0.13), a longer time since last cigarette (β = -0.17, CI:-0.30 to -0.03), and increased craving (β = -0.19, CI: -0.33 to -0.06) within the ND group. We found evidence for small group effects indicating that individuals with ND compared to never-smokers decide more dysfunctional and react faster after smoking-related compared to neutral cues. Faster reactions after smoking-related cues within the ND group, especially in states of increased nicotine deprivation and craving, without more errors could be explained by an increased attentional focus. Cue-induced alterations in decision-making and inhibitory control in ND highly depend on the temporal sequence of cue presentation.

Schema Modes and Personality Disorder Symptoms in Alcohol-Dependent and Cocaine-Dependent Patients

Substance use disorders (SUD) and personality disorders co-occur frequently. This relationship might be understood by studying schema modes (a key concept in Schema therapy), which explain the dysfunctions characterizing personality disorder patients. In the present study, we compared the schema modes and personality disorder symptoms between alcohol-dependent patients, cocaine-dependent patients and healthy controls. We found indications that specific schema modes are specific for SUD patients. However, no differences between specific subtypes of SUD patients (alcohol- vs. cocaine-dependent patients) could be found regarding schema modes. Further, it is suggested that borderline personality disorder symptoms are highly relevant for SUD patients. A first step is made in understanding the relationship between schema modes and SUD, which may contribute to the understanding of the problematic behaviour seen in patients with personality disorders and SUD (and may possibly contribute to the improvement of the treatment of this group of patients).

Substance abuse/dependence treatment: a European perspective

During the past decade, substantial progress has been made in the field of addiction medicine in Europe, particularly regarding the development of new treatment interventions, resulting in a wide range of therapeutic options for patients with substance use disorders. However, not all interventions are evidence based. Patients with cannabis and cocaine/amphetamine use disorders and special patient populations especially lack evidence-based treatment recommendations. Many patients undergo treatment that has not been scientifically evaluated for quality and efficacy. Moreover, there are large disparities regarding availability and treatment access across Europe, with the new member states of the European Union (EU) reporting long waiting lists and low treatment coverage. Even in Austria, which ranks among the countries with relatively high treatment coverage and good diversification of treatment in opioid maintenance therapy due to the availability of methadone, buprenorphine, and slow-release oral morphine (SROM), a considerable population of untreated or inadequately treated patients exists. Treatment for substance use disorders in Europe still has scope for improvement in terms of treatment availability and access, which is ideally provided by further development and implementation of evidence-based interventions.

Future pharmacological treatments for substance use disorders

Substance use disorders represent a serious public health and social issue worldwide. Recent advances in our understanding of the neurobiological basis of the addictive processes have led to the development of a growing number of pharmacological agents to treat addictions. Despite this progress, there are no approved pharmacological treatments for cocaine, methamphetamine and cannabis addiction. Moving treatment development to the next stage will require novel ways of approaching substance use disorders. One such novel approach is to target individual vulnerabilities, such as cognitive function, sex differences and psychiatric comorbidities. This review provides a summary of promising pharmacotherapies for alcohol, opiate, stimulant and nicotine addictions. Many medications that target positive and negative reinforcement of drugs, as well as individual vulnerabilities to addiction, are in different phases of development. Clinical trials testing the efficacy of these medications for substance use disorder are warranted.

Public spending for illegal drug and alcohol treatment in hospitals: an EU cross-country comparison

Background

In view of the current economic crisis and the resulting austerity measures being implemented by governments across Europe, public expenditure for substance abuse treatment has increasingly become a subject of discussion. An EU cross-country comparison would allow an estimation of the total amount of public resources spent on substance abuse treatment, compare various substance abuse treatment funding options, and evaluate the division of expenditures between alcohol and illegal drugs. The purpose of this study is to estimate the public spending of EU countries for alcohol and illegal drug abuse treatment in hospitals.

Methods

Our study uses a uniform methodology in order to enable valid cross-national comparisons. Our data are drawn from the Eurostat database, which provides anno 2010 data on government spending for the treatment of illegal drug and alcohol abuse in 21 EU member states. The cross-country comparison is restricted to hospitals, since data were unavailable for other types of treatment providers. The systematic registration of in- and outpatient data is essential to monitoring public expenditures on substance abuse treatment using international databases.

Results

Total public spending for hospital-based treatment of illegal drug and alcohol abuse in the 21 EU member states studied is estimated to be 7.6 billion euros. Per capita expenditures for treatment of illegal drug abuse vary, ranging from 0.1 euros in Romania to 13 euros in Sweden. For alcohol abuse, that figure varied from 0.9 euros in Bulgaria to 24 euros in Austria. These results confirm other studies indicating that public expenditures for alcohol treatment exceed that for illegal drug treatment.

Conclusions

Multiple factors may influence the number of hospital days for alcohol or illegal substance abuse treatment, and expenditures fluctuate accordingly. In this respect, we found a strong correlation between gross domestic product (GDP) per capita and public expenditures per hospital day. The prevalence of problematic (illegal or legal) drug use in a country did not correlate significantly with the number of hospital days. Other factors must be included in the analysis of public expenditures for the treatment of substance abuse, such as the drug policy in a given country and the social norms regarding alcohol consumption.

Die medizinischen Kosten schädlichen Alkohol- und Tabakkonsums in Deutschland – eine Analyse mittels GKV-Routinedaten

Fragestellung: Der gesundheitsschädliche Konsum von Alkohol und Tabak ist mit hohen Kosten für das Gesundheitswesen verbunden. Aus Sicht politischer Entscheidungsträger und Gesundheitsbehörden ist es interessant, die durch Alkohol- und Tabakkonsum verursachten Kosten im Gesundheitsbereich sowie deren Entstehungszusammenhang genau zu kennen, um eine notwendige Priorisierung der Versorgung und Prävention zu erreichen. Bisher wurden Kostenquantifizierungen jedoch mit in der Tendenz eher unterschätzenden Methoden durchgeführt. Methodik: Mithilfe eines Paneldatensatzes aus Routinedaten der gesetzlichen Krankenversicherung wird das Ausmaß der durch Tabak- und Alkoholkonsum zusätzlich entstehenden Kosten im deutschen Gesundheitssektor mit statistischen Methoden geschätzt. Ergebnisse: Gemäß dem Prävalenzansatz belaufen sich die Kosten des schädlichen Tabakkonsums auf 400 – 500 € pro Quartal und des schädlichen Alkoholkonsums auf 660 – 800 € pro Quartal und gesetzlich Versichertem in Deutschland. Diese Ergebnisse sind robust gegenüber alternativen Modellspezifikationen und -annahmen. Schlussfolgerungen: Aufgrund der häufig gewählten Methoden der Krankheitskostenrechnung sind die Kosten durch Alkohol- und Tabakkonsum im deutschen Gesundheitswesen unterschätzt worden.

Efficacy of D-penicillamine, a sequestering acetaldehyde agent, in the prevention of alcohol relapse-like drinking in rats

RATIONALE

Nowadays, very few approved anti-relapse treatments for alcoholism exist, and their overall efficacy can be considered moderate. An exciting rationale drug development opportunity for the treatment of chronic alcoholism is the use of acetaldehyde sequestering agents. Although these compounds are able to attenuate or prevent most of the behavioral and neurochemical effects of ethanol, the efficacy of acetaldehyde sequestration, by using agents such as D-penicillamine (DP), in relapse prevention has not been studied yet.

OBJECTIVES

The aim of this study was to analyze the effects of DP treatment on the alcohol deprivation effect (ADE) in long-term ethanol-experienced rats as a model of relapse behavior and measure drug plasma and brain levels during treatment.

METHODS

Rats were subcutaneously implanted with mini-osmotic pumps delivering 0, 0.25, or 1 mg/h of DP during 1 week. The efficacy to prevent ADE was determined. DP plasma and brain levels achieved during its subcutaneous administration were measured. In a second experiment, animals received bilateral infusions of 0 or 1.5 μg/h of DP directly into pVTA, and the appearance of ADE was evaluated.

RESULTS

One milligram per hour, but not 0.25 mg/h, DP infusion prevented ADE and reduced the total ethanol preference in animals. DP plasma concentrations associated with ADE suppression were around 3-4 μg/ml, and brain DP levels in these conditions were about 2-3 % of those found in plasma. Intra-pVTA DP administration also suppressed ADE.

CONCLUSION

DP is able to prevent alcohol-relapse-like drinking in rats suggesting that this drug may be a useful new tool in the management of relapse in alcohol-dependent patients.

The burden and cost of disorders of the brain in Europe with the inclusion of harmful alcohol use and nicotine addiction

Recent publications calculated an annual prevalence of 38% of the population within the European Union having a "disorder of the brain" including substance use disorders (SUD) (Wittchen et al., 2011). The overall economic burden was estimated at 789 billion € (Gustavsson et al., 2011). While these calculations included alcohol dependence, harmful use of alcohol, a common ICD-10 diagnosis, was not considered appropriately. Tobacco related figures were completely left out. We hence estimated burden and costs of these diagnoses for the European Union by extrapolating basic figures from Germany, which have average proportions of alcohol and tobacco related consumption and prevalence rates. Several German Data sets were used to estimate prevalence, disability adjusted life years (DALYs) and Cost-of-Illness for alcohol and tobacco use disorders in Germany. Results were obtained by focussing on the burden of SUD including well-known comorbidities. Results were then extrapolated to the European level. Compared with the earlier estimations DALYs increased from 2.8 million to over 6.6 million for SUDs. Costs augmented from 65.68 billion € PPP to about 350 billion € PPP. We discuss the robustness and validity of our findings under different assumptions and with regard to methodology. We further took into account that in the new DSM 5 alcohol abuse and alcohol dependence - and similar tobacco - will be collapsed into one category of "alcohol related disorder". If added to the burden and cost calculations the substance use disorders rank on top of all disorders of the brain in Europe. Regardless of the calculation procedure our figures represent lower estimates and have to be regarded as conservative approaches.

The psychosocial difficulties in brain disorders that explain short term changes in health outcomes

BACKGROUND

This study identifies a set of psychosocial difficulties that are associated with short term changes in health outcomes across a heterogeneous set of brain disorders, neurological and psychiatric.

METHODS

Longitudinal observational study over approximately 12 weeks with three time points of assessment and 741 patients with bipolar disorders, depression, migraine, multiple sclerosis, parkinson's disease, stroke and traumatic brain injury. The data on disability was collected with the checklist of the International Classification of Functioning, Disability and Health. The selected health outcomes were the Short Form 36 and the World Health Organization Disability Assessment Schedule. Multilevel models for change were applied controlling for age, gender and disease severity.

RESULTS

The psychosocial difficulties that explain the variability and change over time of the selected health outcomes were energy and drive, sleep, and emotional functions, and a broad range of activities and participation domains, such as solving problems, conversation, areas of mobility and self-care, relationships, community life and recreation and leisure.

CONCLUSIONS

Our findings are of interest to researchers and clinicians for interventions and health systems planning as they show that in addition to difficulties that are diagnostic criteria of these disorders, there are other difficulties that explain small changes in health outcomes over short periods of time.

Attitudes towards nicotine, alcohol and drug dependence among physicians in Israel

Prevalence of substance use and substance use disorders in Israel is similar to those in other developed countries. The aim of this study was to examine attitudes of physicians in Israel towards nicotine, alcohol and drug use and dependence. A national sample of physicians from different fields of medical specialty (n = 208, response rate 26%) responded to a 50-item questionnaire. Questions included general questions regarding substance use and addictions, as well as specific questions focusing on nicotine, alcohol, cannabis and heroin use. The poor response rate in this survey dictates caution in interpretation the results. However, they suggest that among medical specialties, psychiatrists had higher levels of self-reported competency in treating addictions and lower rates of moralism towards addictions. Across substances, the highest rates of moralism and lowest ratings of treatment efficacy were directed towards individuals with alcohol dependence. Physicians generally reported experiencing lower levels of satisfaction and higher levels of aggression when treating individuals with alcohol or drug dependence compared with other patients. Physicians' attitudes towards addictions have a significant role in the care that clients with addictions receive. Medical education programs in Israel should devote provisions towards educating physicians about addictions.

Cost of disorders of the brain in Europe 2010

BACKGROUND

The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people.

AIMS

To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country.

METHODS

The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010.

RESULTS

The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US.

DISCUSSION

This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges.

RECOMMENDATIONS

Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Advances in animal models of drug addiction

Drug addiction is a syndrome of impaired response inhibition and salience attribution, which involves a complex neurocircuitry underlying drug reinforcement, drug craving, and compulsive drug-seeking and drug-taking behaviors despite adverse consequences. The concept of disease stages with transitions from acute rewarding effects to early- and end-stage addiction has had an important impact on the design of nonclinical animal models. This chapter reviews the main advances in nonclinical paradigms that aim to at model (1) positive and negative reinforcing effects of addictive drugs; (2) relapse to drug-seeking behavior; (3) reconsolidation of drug cue memories, and (4) compulsive/impulsive drug intake. In addition, recent small animal neuroimaging studies and invertebrate models will be briefly discussed (see also Bifone and Gozzi, Animal models of ADHD, 2011). Continuous improvement in modeling drug intake, craving, withdrawal symptoms, relapse, and comorbid psychiatric associations is a necessary step to better understand the etiology of the disease and to ultimately foster the discovery, validation and optimization of new efficacious pharmacotherapeutic approaches. The modeling of specific subprocesses or constructs that address clinically defined criteria will ultimately increase our understanding of the disease as a whole. Future research will have to address the questions of whether some of these constructs can be reliably used as outcome measures to assess the effects of a treatment in clinical settings, whether changes in those measures can be a target of therapeutic efforts, and whether they relate to biological markers of traits such as impulsivity, which contribute to increased drug-seeking and may predict binge-like patterns of drug intake.

Detection of cocaine induced rat brain activation by photoacoustic tomography

Photoacoustic tomography (PAT) was used to detect the progressive changes on the cerebral cortex of Sprague-Dawley rats after the administration of cocaine hydrochloride. Different concentrations (0, 2.5, and 5.0 mg per kg body) of cocaine hydrochloride in saline solution were injected into Sprague-Dawley rats through tail veins. Cerebral cortex images of the animals were continuously acquired by PAT. For continuous observation, PAT system used multi-transducers to reduce the scanning time and maintain a good signal-to-noise ratio (SNR). The obtained photoacoustic images were compared with each other and confirmed that changes in blood volume were induced by cocaine hydrochloride injection. The results demonstrate that PAT may be used to detect the effects of drug abuse-induced brain activation.

A cost-effectiveness analysis of modafinil therapy for psychostimulant dependence

INTRODUCTION AND AIMS

To examine the cost-effectiveness of modafinil (200 mg daily) plus counselling compared with placebo for the treatment of psychostimulant dependence.

DESIGN AND METHODS

Cost and outcome data were collected alongside two randomised controlled trials of modafinil 200 mg daily over 10 weeks for methamphetamine (n = 74) and cocaine dependence (n = 8), respectively. Incremental cost-effectiveness ratios representing the additional costs to achieve a given outcome were calculated for both the change in the number of stimulant-free days and quality-adjusted life years 12 weeks post-treatment.

RESULTS

The incremental cost-effectiveness ratio indicated that it would cost an additional $AUD79 to achieve an extra stimulant-free day with modafinil compared with placebo. This result was not statistically significant, but appeared to be a robust estimate after sensitivity analysis. Counselling, whether received within program or from other services, improved the cost-effectiveness of modafinil relative to placebo.

DISCUSSION AND CONCLUSIONS

Strategies to improve the uptake of counselling are recommended as cost-effective.

Global burden of disease from alcohol, illicit drugs and tobacco

The use of alcohol, tobacco and illicit drugs entails considerable burden of disease: in 2000, about 4% of the global burden as measured in disability adjusted life years was attributable to each alcohol and tobacco, and 0.8% to illicit drugs. The burden of alcohol in the above statistic was calculated as net burden, i.e. incorporating the protective health effects. Tobacco use was found to be the most important of 25 risk factors for developed countries in the comparative risk assessment underlying the data. It had the highest mortality risk of all the substance use categories, especially for the elderly. Alcohol use was also important in developed countries, but constituted the most important of all risk factors in emerging economies. Alcohol use affected younger people than tobacco, both in terms of disability and mortality. The burden of disease attributable to the use of legal substances clearly outweighed the use of illegal drugs. A large part of the substance-attributable burden would be avoidable if known effective interventions were implemented.

Why should addiction medicine be an attractive field for young physicians?

AIMS

The clinical practice and science of addiction are increasingly active fields, which are attracting professionals from diverse disciplines such as psychology and neurobiology. Our scientific knowledge of the pathophysiology of addiction is rapidly growing, along with the variety of effective treatments available to clinicians. Yet, we believe that the medical specialties of addiction medicine/psychiatry are not attracting the interest and enthusiasm of young physicians. What can be done?

METHODS

We offer the opinions of two experience addiction psychiatrists.

RESULTS

In the US, there has been a decline in the number of psychiatrists seeking training or board certification in addiction psychiatry; about one-third of graduates with such training are not practicing in an addiction psychiatry setting. There is widespread neglect of addiction medicine/psychiatry among the medical profession, academia and national health authorities. This neglect is unfortunate, given the enormous societal costs of addiction (3-5% of the gross domestic product in some developed countries), the substantial unmet need for addiction treatment, and the highly favourable benefit to cost yield (at least 7:1) from treatment.

CONCLUSIONS

We believe that addiction medicine/psychiatry can be made more attractive for young physicians. Helpful steps include widening acceptance as a medical specialty or subspecialty, reducing the social stigma against people with substance use disorders, expanding insurance coverage and increasing the low rates of reimbursement for physicians. These steps would be easier to take with broader societal (and political) recognition of substance use disorders as a major cause of premature death, morbidity and economic burden.

Modelling human drug abuse and addiction with dedicated small animal positron emission tomography

Drug addiction is a chronically relapsing brain disorder, which causes substantial harm to the addicted individual and society as a whole. Despite considerable research we still do not understand why some people appear particularly disposed to drug abuse and addiction, nor do we understand how frequently co-morbid brain disorders such as depression and attention-deficit hyperactivity disorder (ADHD) contribute causally to the emergence of addiction-like behaviour. In recent years positron emission tomography (PET) has come of age as a translational neuroimaging technique in the study of drug addiction, ADHD and other psychopathological states in humans. PET provides unparalleled quantitative assessment of the spatial distribution of radiolabelled molecules in the brain and because it is non-invasive permits longitudinal assessment of physiological parameters such as binding potential in the same subject over extended periods of time. However, whilst there are a burgeoning number of human PET experiments in ADHD and drug addiction there is presently a paucity of PET imaging studies in animals despite enormous advances in our understanding of the neurobiology of these disorders based on sophisticated animal models. This article highlights recent examples of successful cross-species convergence of findings from PET studies in the context of drug addiction and ADHD and identifies how small animal PET can more effectively be used to model complex psychiatric disorders involving at their core impaired behavioural self-control.

Why people change? The role of cognitive-control processes in the onset and cessation of substance abuse disorders

BACKGROUND

The current effectiveness of preventative and therapeutic interventions for substance use disorders (SUDs) is less than satisfying. Progress in understanding the processes related to the onset, course, and cessation of SUDs merits top priority, given the high prevalence and the severe negative consequences.

AIMS

This position paper, after summarizing major factors related to onset and cessation processes, discusses the possible role of cognitive-control dysfunctions in the complex interaction between mechanisms of change (mediators) and risk factors (moderators).

FINDINGS

In past decades, research has expanded our knowledge about the impact of SUDs on human behaviour. Formal interventions are effective, but there is limited information about the mechanisms responsible for change during the onset and cessation of SUDs and for individual differences related to them. Preliminary results suggest that impairments in higher order control functions play a role in SUDs.

CONCLUSIONS

Deficiencies in our understanding of behaviour-change processes during the onset and cessation of SUDs require that research have a different focus. A better understanding of the relevance of impairments in executive-control functions might help to improve formal preventative and therapeutic interventions and social conditions. Such interventions might reduce the chances that a SUD will develop or increase the likelihood of recovery from it.

Economic costs of full-blown and subthreshold panic disorder

BACKGROUND

Data on the societal costs of mental disorders are necessary to inform health policies.

METHODS

This study assessed the costs of panic disorder and subthreshold panic disorder, compared these with costs of other mental disorders, and assessed the effects of (psychiatric and somatic) comorbidity and agoraphobia on the costs of panic. Using a large, population-based study in The Netherlands (n=5504), both medical and production costs were estimated from a societal perspective within a one-year timeframe.

RESULTS

Annual per capita costs of panic disorder were 10,269 euros, while subthreshold panic disorder generated 6384 euros. These costs were higher than those of the other mental disorders studied. About one quarter of the costs could be attributed to comorbidity. Agoraphobia was associated with higher costs.

LIMITATIONS

Methodological choices influence cost estimates. In the present study most of these will result in conservative cost estimates.

CONCLUSIONS

Panic thus causes substantial societal costs. Given the availability of effective treatment, treatment may not only benefit individual patients, but also have economic returns for society.

Economic costs of drug abuse: financial, cost of illness, and services

This article examines costs as they relate to the financial costs of providing drug abuse treatment in private and public health plans, costs to society relating to drug abuse, and many smaller costing studies of various stakeholders in the health care system. A bibliography is developed from searches across PubMed, Web of Science, and other bibliographic sources. The review indicates that a wide collection of cost findings is available to policy makers. For example, the financial aspects of health plans have been dominated by considerations of actuarial costs of parity for drug abuse treatment. Cost-of-illness methods have been developed and extended to drug abuse costing to measure the national level of burden and are important to the economic evaluation of interventions at the program level. Costing is done in many small and focused studies, reflecting the interests of different stakeholders in the health care system. For costs in programs and health plans, as well as cost offsets of the impact of substance abuse treatment on medical expenditures, findings are surprisingly important to policy makers. Maintaining ongoing research that is highly policy relevant from the point of view of health services, more is needed on costing concepts and measurement applications.

The global economic burden of alcohol: a review and some suggestions

Economic arguments for acting for health are increasingly important for policymakers, yet to date there has been no consideration of the likely economic burden of alcohol on the global level. A review of existing cost estimates was conducted, with each study disaggregated into different cost areas and the methodology of each element evaluated. The range of figures produced from more robust studies was then applied tentatively on the global level. The reviewed studies suggested a range of estimates of 1.3-3.3% of total health costs, 6.4-14.4% of total public order and safety costs, 0.3 - 1.4 per thousand of GDP for criminal damage costs, 1.0-1.7 per thousand of GDP for drink-driving costs, and 2.7-10.9 per thousand of GDP for work-place costs (absenteeism, unemployment and premature mortality). On a global level, this suggests costs in the range of US dollars 210-665 billion in 2002. These figures cannot be understood without considering simultaneously six key problems: (i) the methods used by each study; (ii) who pays these costs; (iii) the 'economic benefits' of premature deaths; (iv) establishing causality; (v) omitted costs; and (vi) the applicability of developed country estimates to developing countries. Alcohol exerts a considerable economic burden worldwide, although the exact level of this burden is a matter of debate and further research. Policymakers should consider economic issues alongside evidence of the cost-effectiveness of particular policy options in improving health, such as in the WHO's CHOICE project.

Avoidable burden of disease: conceptual and methodological issues in substance abuse epidemiology

Determining the proportion of avoidable disease burden attributable to substance use is important for both policy development and intervention implementation. Current epidemiological theory has in principle provided a method to estimate avoidable burden of disease and the available statistical tools can provide first rough estimates. The method described in this paper, and its statistical procedures, are exemplified to estimate avoidable burden of tobacco-related disease in Canada. However, further effort is needed to find solutions in the methodological details, namely exposure measurement, risk factor multidimensionality, estimation of changes in exposure distribution over time, and estimation of risk relationships from multiple exposures changing over time with multiple endpoints (causal webs). The impetus to begin refining methods to obtain better starting points for estimating avoidable burden of disease is obvious and should be carried through in order to see real changes through evidence-based policy and intervention.