On prisons, pot, and the DSM-V.
(The “Five-Question Interview” series.)
Our latest participant is Professor Michael Farrell, director of the National Drug and Alcohol Research Centre (NDARC) at the University of New South Wales in Sydney, Australia. Before that, he was Professor of Addiction Psychiatry at the Institute of Psychiatry at Kings College, London. He has been a member of the WHO Expert Committee on Drug and Alcohol Dependence since 1995, and chaired the Scientific Advisory Committee of the European Monitoring Centre on Drugs and Drug Abuse (EMCDDA) in 2008 for three years. The NDARC does a wide variety of research and data collection on drug abuse, including longitudinal studies of heroin dependence, studies on the prevalence of ADHD among addicts, and evaluation studies of inner city youth at risk. Professor Farrell is a recognized expert on drug abuse in Europe, and was kind enough to share some of his thoughts with Addiction Inbox.
1. Does the National Drug and Alcohol Research Centre (NDARC) of Australia have a specific research slant, or area or interest, or do you try to cover the waterfront?
Michael Farrell: The research base of NDARC is very broad. The Australian Federal Government provides a fifth of our funding under the National Drug Strategy and this includes a brief for national monitoring of drug trends among illicit drug users and improving the evidence base around effective treatment and prevention. Our projects cover the majority of illicit drugs as well as alcohol, prescription drugs and more recently tobacco, and we have a strong international presence through our collaborations with the United Nations, the World Health Organisation and the Global Burden of Disease project.
Our current research programs include prevention, treatment evaluation, policy, law enforcement, health economics and epidemiology. NDARC has two “Centres within the Centre”—NCPIC (see below) and the Drug Policy Modelling Program (DPMP). We have teams working with school-aged children, mothers and babies, and injecting drug users. So it would be fair to say that we are covering the waterfront!
2. You have been critical of proposed revisions in the Diagnostic and Statistical Manual of Mental Disorders (DSM), particularly as they relate to alcoholism. What do you think is going wrong, and what’s going right, when it comes to DSM-V changes?
Farrell: The change in overall terminology is probably the most controversial with the reintroduction of “addiction” into the terminology. Personally I prefer “dependence” and think the measurement of dependence has continued to improve over the years. It is important that we use terms that we can measure carefully and be confident that we are all talking the same language. Alcohol abuse and alcohol dependence have been combined into a single disorder of graded severity, the criterion reflecting substance-related legal problems has been removed, and a new diagnostic criterion representing craving has been included. Finally, new diagnostic thresholds for alcohol use disorder (AUD) have been proposed. It seems that there is strong support for the first three changes. However, there is little published literature regarding the impact of the revised diagnostic threshold. Using data from a survey of over 10,000 people in the Australian general population, Mewton and colleagues at NDARC (2010) demonstrated that the prevalence of alcohol use disorder defined according to the DSM-5 was 60 per cent higher than the prevalence of the same disorder according to DSM-IV. A disorder which increases so dramatically in prevalence after applying a new definition is surely problematic.
3. Increasingly, the study of addiction has moved away from traditional medicine and psychiatry, becoming a recognized area of study in molecular biology and neuroscience. How do you personally view this shift in emphasis toward hard science?
Farrell: In reality, no professional groups have been jumping at the chance to handle addiction problems. In the early phases of treatment development it was often religious groups and humanitarian social activist groups who pioneered helping responses for marginalised groups. As the size of the problem and response has grown, thankfully it has been possible to get mainstream health and social care professionals more involved. There is still a need for more involvement. Modern young doctors need addiction treatment skills if they are to be properly equipped to practice in the 21st century.
Greater involvement of the biological sciences in the study of addiction holds out the possibility that we might get some exciting breakthroughs in understanding of behaviour, prevention, and treatment. Goodness knows we could do with some new breakthroughs or advances in treatment! A focus on biological sciences does not need to be at the expense of the other social and epidemiological approaches, and ideally, with further investment in research around drugs, we might better understand the interactions between genes and environment.
4. NDARC also houses the National Cannabis Prevention and Information Centre (NCPIC). What is the mission there, and do you see marijuana as an addictive drug?
Farrell: NDARC is privileged to have NCPIC funded by the Federal Government as a “Centre within a Centre” and to the best of my knowledge there is nowhere like it anywhere else in the world. The mission of NCPIC is to reduce the use of cannabis in Australia. Cannabis is the most commonly consumed illicit drug in the country, with one in three (33.5%, 5.8 million) Australians aged 14 years and older reporting having used it in their lifetime. Just over one in ten (10.3%, 1.9 million) had used it in the previous twelve months. The burden of disease associated with cannabis is substantial. I have no doubt that cannabis can result in dependence, and that the stronger, more potent forms of cannabis give rise to more physical and mental health problems. Cannabis dependence seems to occur at rates similar to alcohol, but the effects of cannabis dependence can be mild, and may be associated with otherwise high levels of social function. Equally, dependence at the severe end is associated with significant harms, including poor social functioning and reduced participation in the education and the workforce.
5. You have a long-standing interest in the question of substance abuse in the prison system. Why can’t prison officials eliminate the drug trade behind bars?
Farrell: The prison authorities cannot eliminate drugs from behind bars because nearly half of all prisoners have a history of serious drug involvement. It is no more likely that we will have a drug free prison than it is that we will have a drug free society. The serious gaps in response in prisons are often quite shocking. The near complete absence of methadone or buprenorphine treatment in American prisons is hard to understand, when you see what a great contribution US research and treatment with methadone and buprenorphine has had globally. Now there are over 300,000 people on methadone in China as part of HIV and AIDS prevention. Most countries in Europe have methadone in their prisons, and many emerging countries have developed prison methadone programmes. But in the US there are only a handful of programmes. There is a need for real change in this area as it is an incredible gap that could be readily addressed.
Overall we still have a long way to go in building an evidenced-based approach to drug prevention and treatment. We have come a fair distance in the past twenty years, but the road remains long and winding.
Photo Credit: http://ndarc.med.unsw.edu.au/
