Audition de la Fédération Addiction

CONSEIL ECONOMIQUE, SOCIAL ET ENVIRONNEMENTAL 19 Septembre 2018

LES ADDICTIONS AU TABAC ET A L’ALCOOL

CHEZ LES PUBLICS JEUNES

Qui nous sommes? Unréseaunationalde210associations,

Soitprèsde19000professionnelset700établissements

200personnesphysiques

L’environnement

Brains, environments, and policy responses to addiction Keith Humphreys, Robert C. Malenka, Brian Knutson and Robert

J. MacCoun 10.1126/science.aan0655, Science 356 (6344), 1237-1238.

23 JUNE 2017 • VOL 356 ISSUE 6344 1237SCIENCE sciencemag.org

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By Keith Humphreys,1 Robert C. Malenka,2

Brian Knutson,2 Robert J. MacCoun2

With 1 in 8 deaths globally due to the

use of tobacco, alcohol, and other

drugs, the director-general of the

World Health Organization (1) re-

cently called for more scientifically

informed public policies regard-

ing addiction. In the United States, where

an average of 91 people per day die of opioid

overdose, a presidential task force is to pre-

sent, on 27 June, policy recommendations to

combat opioid addiction, although the House

of Representatives passed an Affordable Care

Act repeal bill that would withdraw health

insurance from two million people with ad-

dictions. Despite these urgent challenges,

research on the brain and its interactions

with the environment, which can help policy-

makers advance more effective and humane

policies than some traditional approaches to

addiction, has only occasionally been applied

in public policy.

Neuroscientific research validates the

centuries-old hypothesis that addiction lasts

beyond acute intoxication, which

suggests an enduring adaptation (2).

Repeated addictive drug use can in-

duce long-term changes in the brain’s

motivational and reward circuits, as

well as in the ability of the prefrontal

cortex to influence circuits that guide

decision-making. The widespread

practice of treating addiction only

with short-term medical “detoxifica-

tion” to help addicted patients cope

with withdrawal symptoms—a policy

reinforced by U.S. health insurance

providers—serves only to remove

the acute effects of the addictive

substance rather than treat the dis-

order (and may also increase risk of

future overdose by inducing loss of

tolerance). Treating addiction more

commonly requires longer-term in-

tervention, such as Alcoholics Anonymous,

methadone-buprenorphine maintenance,

“sober living” residential facilities, and ex-

tended case monitoring (3).

Motivational circuit alterations in addic-

tion must be accounted for in health care–

system design. Treatment programs that

require people to “prove they are motivated”

by abstaining for weeks or months before

entry will fail most of the population, who

relapse before that point. By contrast, con-

tingency management programs that change

behavior through the use of immediate, small

rewards (e.g., a meal voucher for a negative

urine test) have demonstrated impressive ef-

ficacy (3). Individuals with prefrontal cortex

impairment can exert control over their sub-

stance use for short periods and for defined

rewards as long as the clinical environment is

properly structured.

Within the criminal justice system, the

threat or experience of a long prison term

does not remove addiction, but offender mon-

itoring programs that directly and repeatedly

offer modest rewards or penalties in response

to cessation or continuation of substance use

can be effective (3). A good example is South

Dakota’s “24/7 Sobriety” program for individ-

uals convicted of repeated drunk driving and

other alcohol-involved offenses. Rather than

being imprisoned for a lengthy period as was

the norm before the program’s initiation, of-

fenders are sentenced to regular monitoring

of their alcohol use, with modest but certain,

immediate consequences for drinking (e.g.,

one night in jail). The human brain is more

sensitive to swift and certain environment

responses to behavior than to distant and

probabilistic ones, which suggests why this

program has significantly reduced alcohol-

related arrests and population mortality in

the state while simultaneously reducing the

number of individuals being sent to prison

for long terms (3).

SHAPED BY THE ENVIRONMENT

Explaining the rise of addiction in modern

societies requires looking beyond the brain

to the environments that shape it (2). Ad-

diction can only occur if a person engages in

certain behavior (drug consumption) within

certain environments (those with an avail-

able drug). The worldwide challenge of rising

substance addiction (3) reflects how the past

two centuries have ushered in technology to

produce ubiquitous, addictive substances.

For example, in the mid–19th century, it

took a factory worker about 1 minute to roll

a cigarette, and the resulting product was so

harsh that few people could inhale it deeply

enough to become addicted to nicotine, pre-

suming a person even lived in a region where

cigarettes were available. A modern cigarette-

rolling machine (see photo) can roll 20,000

cigarettes a minute. These are expertly sweet-

ened and blended to allow deep inhalation

that promotes nicotine addiction,

and they are available almost every-

where on Earth (4).

Exposing the human brain’s re-

ward circuitry, which evolved over

tens of thousands of years, to this

relatively new and variegated stew

of addictive substances has pro-

duced addiction on a scale that we

have never before experienced. Now

that these substances are among

the most widely produced and

traded commodities in the global

economy, there is a strong financial

incentive for both illegal and legal

sellers to produce and market these

substances ever more effectively. In

an unfettered free market, avail-

ability will increase, which trans-

lates into increased exposure and

addiction. These trends may be

fueled by economic development,

because as humans gain resources,

they commonly allocate them to

NEUROSCIENCE AND ADDICTION

Brains, environments, and policy responses to addictionReward and decision-making circuitry are critical

1Veterans Affairs Health Care System, Palo Alto, CA 94304, USA. 2Stanford University, Stanford, CA 94305, USA.Email: knh@stanford.edu

P O L I C Y F O RU M

Advances in technology, such as this cigarette-rolling machine, have

helped make addictive substances ubiquitous, fueling rising addiction.

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INSIGHTS | POLICY FORUM

psychoactive substances, as surging use of

alcohol, tobacco, and other drugs in devel-

oping countries (e.g., China, India, South

Africa, and Brazil) attests (5).

The policy implication is clear. Addiction

will do massive and increasing damage to

humanity if drugs with addictive liability

are treated as ordinary commodities, with a

lightly regulated free market left to sort out

supply and demand (5). The “invisible hand”

on which successful markets depend will fail

if the organ upon which putatively wise con-

sumer decision-making relies—the brain—

becomes unreliable. The liability of the

human brain to overvaluing addictive drugs

relative to their adaptive worth is precisely

what makes them attractive products to sell

and is equally what gives society an interest

in using as many policy tools as possible to

make them less available and attractive (e.g.,

high taxes or constraints on industry).

For example, consider that all eight U.S.

states that have legalized the sale of mari-

juana for recreational use tax it without

regard to product content. Neuroscience

research indicates that marijuana that is

higher in ∆9-tetrahydrocannabinol (THC) po-

tency and lower in cannabidiol (CBD) is more

harmful to the brain (6). A graduated tax

based on THC:CBD ratios rather than sales

price might encourage safer marijuana use.

Neuroscientific work on cue exposure sug-

gests further regulatory strategies for pro-

tecting public health. With repeated use of

addictive substances, previously neutral cues

associated with the drug experience grow

attractive in their own right, often generat-

ing powerful memories of and craving for

another drug experience. Multiple sensory

modes can activate the motivational circuits

that stimulate appetitive behavior, and com-

mercial marketing campaigns often seek to

leverage this interplay of sensory and motiva-

tional circuits (7). Saturation of environments

with rich multisensory cues (e.g., advertising

campaigns for beer and cigarettes) raises the

risk of continued drug use by addicted indi-

viduals. Conversely, drug use can be reduced

by curbing promotion of products with addic-

tive liability, including legal pharmaceuticals.

Policy-makers might also consider regulating

the combination of drugs with other already

attractive sensory compounds, such as sug-

ared cannabis-infused confections designed

to look or taste like cookies or candies (8).

The highest period of vulnerability for de-

velopment of addiction is when neuroplas-

ticity is high and the prefrontal cortex has

not fully developed, which neuroimaging

research suggests is characteristic of humans

before their early 20s (9). The resulting vul-

nerability is typically unimportant in early

development (e.g., before age 12) when expo-

sure to addictive substances is rare. However,

in modern industrial societies, adolescence

tends to be associated with increased access

to addictive substances, in part due to di-

minished contact with parents coupled with

participation in a robust, free-standing peer

culture (10). Adolescents are thus subject to

two converging risks for addiction: the physi-

ological reality of high neuroplasticity in mo-

tivational circuits and immaturity of control

circuits combined with a social reality of ex-

panded access to drugs of abuse (for some

youth, genetic factors may add yet a third

converging risk). This could explain why the

incidence for substance-use problems clus-

ters in adolescence and early adulthood (10).

Policies that reduce access to substances and

associated cues (e.g., advertising) during ado-

lescence are thus of paramount importance.

Fortunately, adolescence is also charac-

terized by emergence of reliable and valid

neural measures that can help track not only

brain changes due to drug intake but also

predictors of vulnerability (11). This raises

hope that in the future, neuroscience will in-

form policy-makers on how prevention and

early intervention efforts can be targeted to-

ward young people at particularly high risk

for addiction.

Policies focused on reducing addiction

need not all be substance-focused (1). Iceland

has achieved a sustained drop in adolescent

substance use in part through a national

policy of expanding access to competing re-

wards, including recreational and cultural ac-

tivities, as well as programs that strengthen

family and civic ties (12). Primate and rat

research suggests that positive social interac-

tions may provide potent competition for the

neural rewards of drug use and may be pro-

tective for adolescents and other vulnerable

groups (13, 14).

TRANSLATING SCIENCE FOR POLICY

For neuroscience to make an impact on pub-

lic policy, an active education and translation

effort must occur. Translation efforts must

involve active and tailored communication,

as well as spell out implications (i.e., describe

alternative policy options and their impact).

Industries that are successful at translating

science into policy and practice (e.g., phar-

maceutical companies) rarely send their

scientists into the political fray unaided and

alone. They have dedicated staff whose job

explicitly involves translation and who are re-

sourced to adopt specialized tactics for so do-

ing. Resources for such activities are harder

to find in efforts to translate neuroscience

to drug policy, because federal government

research funding focuses mainly on pure re-

search, whereas private funders often are in-

terested in a predetermined policy outcome

(e.g., legalizing marijuana).

That said, some funders are willing to bring

scientists, science translators, and policy-

makers together. The MacArthur Foundation

generously supported such an initiative for

years in mental health, and the authors of

this paper are part of a 5-year policy-maker–

scientist network focused on addiction

(Neurochoice). More efforts of this type are

needed, with the most likely source of sup-

port coming from scientific societies, which

are well positioned to serve as credible, non-

partisan suppliers of information that make

the personal contacts and translation efforts

to put useful science in policy-makers’ hands.

Even for some purely scientific policy-

relevant questions, the relevant body of

neuroscience may be less well developed or

useful than is research in a different field,

for example, genetics, psychology, or eco-

nomics (15). But those realities in no way

minimize neuroscience’s potential to guide

domestic and international leaders as they

strive to tackle the addictions that afflict

their populations. j

REFERENCES AND NOTES

1. M. Chan, Opening remarks at the 60th Session of the Commission on Narcotic Drugs, Vienna, Austria, 13 to 17 March 2017 (United Nations Office on Drugs and Crime, 2017); www.who.int/dg/speeches/2017/commission-narcotic-drugs/en/.

2. A. I. Leshner, Science 278, 45 (1997). 3. Office of the Surgeon General, “Facing addiction in America:

The Surgeon General’s report on alcohol, drugs and health” (U.S. Department of Health and Human Services, 2016); https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf.

4. R. N. Proctor, Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition (Univ. of California Press, Berkeley, 2011).

5. T. F. Babor et al., Alcohol: No Ordinary Commodity (Oxford Univ. Press, Oxford, ed. 2, 2010).

6. A. Englund, T. P. Freeman, R. M. Murray, P. McGuire, Lancet Psychiatr. 10.1016/S2215-0366(17)30075-5 (2017).

7. H. Plassmann, T. Z. Ramsøy, M. Milosavljevic, J. Consum. Psychol. 22, 18 (2012).

8. R. J. MacCoun, M. M. Mello, N. Engl. J. Med. 372, 989 (2015). 9. F. E. Jensen, A. E. Nutt, The Teenage Brain (Harper, New York,

2015). 10. R. J. MacCoun, P. Cook, C. Muschkin, J. Vigdor, Rev. Law

Econ. 4, 695 (2008). 11. C. Büchel et al., Nat. Commun. 8, 14140 (2017). 12. A. L. Kristjansson et al., Addiction 111, 645 (2016). 13. D. Morgan et al., Nat. Neurosci. 5, 169 (2002). 14. J. Panksepp, B. Herman, R. Conner, P. Bishop, J. P. Scott, Biol.

Psychiatry 13, 607 (1978). 15. H. Kalant, Addiction 105, 780 (2010).

ACKNOWLEDGMENTS

The authors are participants in the Neurochoice Initiative funded by the Stanford Neurosciences Institute. K.H. was supported by the Senior Research Career Scientist Award from the Veterans Affairs Health Services Research and Development Service. Some of these ideas were presented by K.H. at the 2016 World Economic Forum and by R.J.M. at the 2016 Neurochoice Symposium. None of the opinions in this article necessarily represent the policy views of any governmental organization for which the authors have worked or have advised.

10.1126/science.aan0655

“…as humans gain resources, they…allocate them to psychoactive substances…”

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«  E x p l i q u e r l a h a u s s e d e l’addiction dans les sociétés modernes suppose de regarder a u - d e l à d u c e r v e a u , l’environnement qui le forme et le modèle. (…) Le défi mondial de la hausse de l’addiction reflète la manière dont les deux derniers siècles ont poussé la technologie a produire toujours plus de substances addictives. »

Binge NPS Ecrans

Cannabis et ado

Unemodificationdelarencontre,del’offreautantquedelademande

Contexte addictogène

Crise de l’appartenance et de la transmission : angoisseDomination du « tout, tout de suite, tout le temps », intense et rapide : hédoniste

Perspectiveséconomiquesferméesdansunesociétéinégalitaire:exclusion

Compétition, stress et pression : dopage

Prendre en compte la diversité des comportements d’usage

Extension des usages

APIsur1mois1999-2011CANNABIS1993-2005

(OFDT)

Quel accompagnement pour ces jeunes usagers?

Tabac – un recul

•  Fumeurs de 17 ans quotidiens : •  2017 = 25,1%

è Baisse de 7 points •  Jeunes de 17 ayant essayé une fois au moins

•  2017 = 59 % è Baisse de 10 points Enquête ARAMIS

www.odft.fr

Sortir le tabac des produits de consommation courante, y compris avec l’outil « prix ».

Alcool – des taux très hauts

•  Jeunes de 17 ans ayant consommé dans le mois •  2017 = 66,5 % •  2014 = 72 %

•  Un produit toujours banalisé et culturellement présent

Enquête ARAMIS www.odft.fr

Sortir des hésitations en politique publique « Dénormaliser » et renforcer la parentalité

Cannabis, 2014-2017 et après

•  Jeunes de 17 ans fumant régulièrement du cannabis •  2017 = 7,2 % •  2014 = 9,2 %

•  Jeunes de 17 ans ayant déjà expérimenté le cannabis •  2017 = 39,1 % •  2014 = 47,8 % Enquête ARAMIS

www.odft.fr

Changer de messages Ne plus s’appuyer que sur la peur

Ecrans – le remplacement ?

•  Jeunes de 17 ans passant plusieurs heures par jour sur internet •  2017 = 83 % •  2003 = 23 %

•  Un gradiant social marqué •  Un remplacement d’autres activités Enquête ARAMIS

www.odft.fr

Optimiser la gouvernance de la prévention

Une stratégie globale

Une pluralité d’acteurs

VERS UNE LOGIQUE DE DISPOSITIFS

En proximité, dans la durée

En complémentarité

Un tronc commun validé

Les 4 piliers d’une prévention efficace

CONSTRUIRE DES REPONSES

Fonder la prévention et le soin sur les preuves scientifiques et les programmes de recherche M.Laventure

1 Penser l’intervention de prévention globalement, dans sa dimension multifactorielle

2 formaliser les programmes  

3 calibrer l’action en fonction du public

4 faire place aux parents et éducateurs 

5 s’appuyer sur l’intervenant et sa personnalité

CONSTRUIRE DES REPONSES

Mettre en place des actions qui fonctionnent – la logique de l’intervention précoce

CONSTRUIRE DES REPONSES

Mettre en place des actions qui fonctionnent – la logique de l’intervention précoce

Protection et régulation vis-à-vis de l’environnement

Implanter les logiques de programmes validés

Organiser la gouvernance et les mesures structurelles

La mission ressources des acteurs spécialisés = un appui et un levier !

Développer les innovations cliniques

Logique de dispositif et non d’opérateur, de collaboration et non de concurrence

Développer l’intervention précoce

Audition de la Fédération Addiction

Merci pour votre attention

LES ADDICTIONS AU TABAC ET A L’ALCOOL

CHEZ LES PUBLICS JEUNES

« il y a de mauvais et de bons produits : la drogue et le reste »

« La drogue est un

fléau contre lequel il

faut lutter »

« La seule solution est l’abstinence »

R  Abandonner les catégories de bonnes ou mauvaises drogues, par produit… R  Abandonner le pharmacocentrisme R  L’usage de drogues ne fait pas l’addiction R  Tenir compte de l’usager (expérience, motivation, environnement familial et social)

Les notions d’accompagnement, de réduction des dommages,

d’intervention précoce et d’éducation préventive doivent prendre le pas sur celles de la menace et de pénalisation

Développer une prévention et un soin validés

Littérature scientifique

Programmes et stratégies interventionnels

Créer les conditions d’une rencontre précoce avec le soin

Pour rencontrer ceux qui en ont besoin

En formant largement tous les acteurs

Fonder la prévention sur les 3 niveaux d’expertise

Celle de l’organisation, d’une gouvernance pérenne de la prévention structurée autour des missions spécialisées et de

l’ensemble des acteurs engagés

Fonder la prévention sur les 3 niveaux d’expertise

Celle des acteurs de la recherche interventionnelle, des expérimentations et des experts scientifiques qui

précisent les niveaux d’usage, les évolutions et les bonnes pratiques pour y répondre  

Celle de l’organisation, d’une gouvernance pérenne de la prévention structurée autour des missions spécialisées et de

l’ensemble des acteurs engagés

Fonder la prévention sur les 3 niveaux d’expertise

Celle du chercheur, pour objectiver les risques et dommages  des usages

Celle des acteurs de la recherche interventionnelle, des expérimentations et des experts scientifiques qui précisent les niveaux d’usage, les évolutions et les

bonnes pratiques pour y répondre  

Celle de l’organisation, d’une gouvernance pérenne de la prévention structurée autour des missions spécialisées et de

l’ensemble des acteurs engagés