Cover

ADDICTION NEUROETHICS

INTERNATIONAL RESEARCH MONOGRAPHS IN THE ADDICTIONS (IRMA)

Title

Copyright

Dedication

Contents

Preface

Acknowledgements

Abbreviations

1 Introduction

1.1. Introduction

1.1.1. Neuroethics: the promises and perils of neuroscience research

1.2. Addiction enters the neuroscientific era

1.3. Aims and overview

Part 1 The Science of Addiction

2 What is addiction?

2.1. Introduction

2.2. The phenomenology of addiction

2.2.1. Folk understanding of addiction

2.2.2. Clinical understanding of addictive behaviour

2.3. The social and economic costs of drug use and addiction

2.3.1. Prevalence of drug use and addiction in Australia

2.3.2. Drug use related harm

2.3.3. Burden of disease due to alcohol and drug use

2.4. Social response to drug abuse and addiction

2.5. Governing models of addiction

2.5.1. Moral vs. medical models of addiction

2.5.2. Neurobiological models of addiction

2.5.3. Potential consequences of neurobiological explanations of addiction

2.6. Conclusion

3 The neurobiology of addiction

3.1. Introduction

3.2. The neuroanatomy of addiction

3.2.1. Reward and reinforcement: the 'dopamine hypothesis'

Dopamine, reward and learning

Dopamine and withdrawal

3.2.2. The endogenous opioid system

3.3. Memory, learning and habits

3.4. Compulsion, craving and inhibitory control

3.5. Executive control and cognitive impairment

3.6. Representing bodily urges

3.7. Stress and drug use

3.8. Molecular and cellular changes in addiction

3.8.1. Synaptic plasticity in addiction

3.8.2. Epigenetic changes in addiction

3.9. Vulnerability to addiction: genetic and neuropsychological factors

3.9.1. Genetic susceptibility to addiction

3.9.2. Vulnerabilities to addiction: a confluence of the genetic and the social

3.10. Conclusion

4 Neurobiological treatment of addiction

4.1. Introduction

4.2. Pharmacological treatments that block drug binding

4.2.1. Agonists

4.2.2. Antagonists

4.2.3. Partial agonists

4.2.4. Duration of pharmacological treatment of addiction

4.3. Pharmacological treatments of withdrawal

4.4. Pharmacological treatments of craving and relapse

4.4.1. Dopaminergic mesolimbic reward pathway

Pharmacological treatments to reduce drug reinforcement

Pharmacological treatments to reduce cue-conditioned craving

4.5. Pharmacological interventions in systems related to the reward pathway

4.5.1. Opioids

4.5.2. The amino acid neurotransmitters: glutamate and GABA

4.5.3. Cannabinoids

4.5.4. Corticotropin-releasing factor and the stress response

4.5.5. Memory manipulators and cognitive enhancers

4.6. Pharmacogenetic treatment of addiction

4.7. Novel approaches to drug treatment

4.7.1. Immunotherapies

4.7.2. Long-acting or sustained-release medications

4.7.3. Neurosurgery and deep brain stimulation

4.7.4. Transcranial magnetic stimulation

4.7.5. Applications of neuroimaging and neurocognitive screening in addiction treatment

4.8. Psychosocial treatment of addiction

4.9. Conclusion

Part 2 The Ethical and Philosophical Implications of Neuroscientific Knowledge of Addiction

5 Autonomy, addiction and the public good

5.1. Introduction

5.2. Approaches to ethical analysis

5.2.1. Introduction to ethics

5.2.2. Principlism

Relationships between the principles

5.2.3. Human rights

5.2.4. A pragmatic approach to neuroethics

5.3. Ethical principles in the treatment of addiction

5.3.1. Autonomy and addiction

5.3.2. Addiction and the public good

5.4. The minimum conditions for the ethical treatment of addiction

5.5. Conclusion

6 Autonomy and the capacity to consent to addiction treatment

6.1. Introduction

6.2. The role of informed consent in addiction treatment

6.3. Can 'addicts' say 'no' to drugs?

6.3.1. Sceptical views of impaired autonomy in addicted individuals

6.3.2. Capacity to consent to abstinence-oriented treatment

6.4. Implications for obtaining informed consent to enter addiction treatment

6.5. Guidelines when admitting individuals into addiction treatment

6.6. Conclusion

7 The rights of individuals treated for addiction

7.1. Introduction

7.2. Addiction, drug policy and human rights

7.2.1. Basic human rights for addicted individuals

7.3. The right to access to effective treatment of addiction

7.3.1. The case for medical treatment of addiction

7.3.2. Effective treatment of addiction

7.3.3. The right to access harm reduction measures

7.3.4. The right to effective medical treatment

7.4. The use of unevaluated and risky treatments of addiction

7.5. Respecting human rights when treating under legal coercion

7.6. Human rights in the treatment of addicted prisoners

7.7. Human rights in the treatment of addicted pregnant women

7.8. Future challenges for human rights practitioners

7.9. Conclusions

8 Coerced treatment of addiction

8.1. Introduction

8.2. Approaches to coerced treatment

8.3. The case for legally coerced treatment

8.4. When is coerced treatment ethical?

8.5. Ethical issues in providing coerced addiction treatment

8.6. Is compulsory addiction treatment ethically acceptable?

8.7. Conclusion

9 Ethics of addiction research

9.1. Introduction

9.2. Informed consent to participate in addiction research

9.3. Paying addicted subjects

9.4. Privacy, confidentiality and anonymity

9.5. Administering addictive drugs in research studies

9.5.1. Why do neuroscientists give drugs to 'addicts'?

9.5.2. The risks of giving 'addicts' drugs in research settings

9.5.3. Research participation by treated vs. untreated 'addicts'

9.5.4. Recruiting subjects and obtaining consent

9.6. Conclusion

Part 3 The Ethical and Public Policy Implications of Novel Technologies for the Treatment of Addiction

10 New developments in the treatment of addiction

10.1. Introduction

10.2. Novel pharmacological treatments of addiction

10.2.1. Ethical and policy issues in pharmacological R&D in addiction

10.2.2. Anti-craving drugs

10.3. Novel relapse prevention treatments

10.3.1. Drug vaccines as a prophylaxis against relapse

10.3.2. Sustained-release treatments: depot medications and drug implants

10.3.3. The Australian naltrexone implant experience

10.3.4. Coerced use of depot naltrexone to 'restore autonomy'?

10.4. Conclusion

11 The search for a neurological 'cure' of addiction?

11.1. Introduction

11.2. A brief history of addiction 'cures'

11.2.1. Quacks and nostrums: 1830–1900

The Keeley Cure

Regulation of addiction treatments

11.2.2. Early medical treatments of drug withdrawal: 1900–1970

11.3. The modern era: neurobiologically inspired addiction 'cures'

11.3.1. Ibogaine therapy

11.3.2. Ultra-rapid opioid detoxification

11.3.3. Neurosurgical 'treatment' of addiction

11.4. Deep brain stimulation for intractable addiction?

11.5. Avoiding future therapeutic enthusiasms

12 Preventive medicine and personalised treatment of addiction

12.1. Introduction

12.2. Bioprediction of addiction liability

12.2.1. Predictive genetic testing of addiction liability

12.2.2. Using genetic information to increase abstinence from drug use

12.2.3. Genetic discrimination and third party uses of genetic information

12.2.4. Premature commercialisation of genetic testing

12.2.5. Preventive interventions: 'vaccinating' against addiction

12.2.6. Predictive uses of neuroimaging technologies

12.3. Personalised treatment of addiction

12.3.1. Pharmacogenetic treatment of addiction

12.3.2. Neuroimaging and cognitive tests in the clinic

12.4. Conclusion

13 Feeling better than well

13.1. Introduction

13.2. Memory modifiers, cognitive enhancers and mood modulators

13.3. What's wrong with neuroenhancement?

13.3.1. Concerns about safety and efficacy

13.3.2. Coerced neuroenhancement: a psychopharmacological 'arms race'

13.3.3. Equity of access to neuroenhancement technologies

13.3.4. Naturalistic objections to enhancement: morality and personhood

13.4. Lessons from recreational drug use and drug policy

13.5. The future of drug regulation

13.6. Conclusion

Part 4 The Future of Addiction Research and Policy

14 The social and policy implications of addiction neurobiology

14.1. Introduction

14.2. Implications for public health policies towards drug addiction

14.3. Medicalisation of addiction

14.4. Neuroscience, addiction treatment and public health policy

14.4.1. Competing population health strategies

14.4.2. Subversive uses of neuroscience research on addiction

14.5. Drug policy and double standards

14.6. The prospects of novel pharmacological harm reduction: engineering 'safer' recreational drugs?

14.7. Conclusions

15 Concluding remarks and summary

15.1. Introduction

15.2. Summary and conclusion

15.2.1. Key findings

Theme 1

Theme 2

Theme 3

Theme 4

Theme 5

Theme 6

Theme 7

Theme 8

Theme 9

Theme 10

15.2.2. Specific implications for the treatment of addiction

15.3. Neuroscience and the media: the role and responsibility of neuroscientists

15.4. The tasks ahead for ethicists and policy makers

15.5. Future directions for addiction neuroethics

15.5.1. Private and public understanding of addiction neuroscience

15.5.2. Capacity to consent in a research or treatment setting

15.5.3. Epidemiological modelling of addiction policy

15.5.4. Using incentives to reduce drug use and achieve better health outcomes

15.6. Conclusion

Glossary

Bibliography

Index