By Dr. Mary Baker MBE (UK), PARTICIPANT, is Immediate Past President of the European Brain Council, Immediate Past President of the European Federation of Neurological Associations; Consultant to the World Health Organisation (WHO); Member of EFPIA Advisory Board and Chair of the Working Group on Parkinson’s Disease; and a member of the European Commission’s CONNECT Advisory Forum. Academic appointments include Associate Membership of the Health Services Research Unit, University of Oxford and Visiting Fellow within the Health Centre at London School of Economics (LSE).
By M.D. Kevin Bridgman (UK) PARTICIPANT, is a qualified clinician with extensive pharmaceutical industry experience in both prescription and consumer healthcare. He is currently Chief Medical Officer and Director of Compliance at Nicovations Ltd, a subsidiary of British American Tobacco, developing and commercialising innovative inhaled nicotine products that meet medicines standards, for smokers wishing to reduce, replace or stop smoking.
The ‘Brain Age’ is upon us. The race is on as we enter a new chapter in human history. Massive global investments in brain research and cognitive neuroscience from Beijing to Boston to Brussels are transforming our understanding of the human mind. The European Union’s Human Brain Project20 aims to develop new technology platforms dedicated to Neuroinformatics, Brain Simulation, High Performance Computing, Medical Informatics, Neuromorphic Computing and Neurorobotics. The United States’ Brain Initiative21 aims to understand the human brain and how individual cells and complex neural circuits interact in both time and space. These are just two of many bold new research efforts to revolutionise our understanding of the human mind and uncover new ways to treat, prevent and cure brain disorders like Alzheimer’s, schizophrenia, autism, epilepsy, and traumatic brain injury.
Advocates argue convincingly that a greater understanding of the human brain holds great promise for better prevention, diagnosis, treatment, care and rehabilitation of brain disorders. We save and improve lives. Sceptics worry about the social and ethical implications of altering brain function.
In much of the world we now recognise the real value antidepressants and antipsychotics can make to the lives of those with mental illness. Drugs are available that improve attention in those with attention deficit hyperactivity disorder (ADHD). Of course, some with no need other than to excel at sport, in the exam room or workplace use pharmacological agents to improve their performance, ‘cheating’ both physically and mentally. Others seek excitement and recreation in legal ‘highs’. Science allows us to modulate and manipulate brains, bodies, our moods and actions. It can bring relief to those who are ill and challenges to society as a whole.
The complexity of understanding brain function and brain disease brings responsibilities as well as opportunities for the neuroscience community for the benefit of society. Despite these major challenges and all the efforts of the scientific community, we are still struggling against the discrepancy between the huge societal impacts of brain diseases on the one hand, and the modest financial and time resources allocated for brain research, teaching and the care of brain diseases, on the other.
There is no way to escape from the fact that brain disorders are a major public health challenge. An analysis of the health economic studies of brain diseases in Europe, published by the European Brain Council in 2011, led to an estimate of €798 billion for the total cost of brain disease in Europe in 2010. This burden is bound to grow, largely because of the fact that the European population is rapidly ageing. Addressing these large costs requires intensified research, both basic and clinical, and the creation of novel solutions. Far too often is seems that different disease types are pitched against one another in a fight for existing research resources. We need to think about brain disease differently and keep our focus on the costs to society of not finding solutions. Without good brain health, function on so many levels can be impaired, and individuals often become unable to care for themselves properly. This inability to feed, wash or manage their comorbidities properly can quickly lead to reliance on others and the loss of independence, resulting in spiralling health economic costs. In this regard, we welcome the new initiative of the European Commission known as ‘The Semester’ which will highlight the importance of demonstrating the outcomes of interventions – ‘better outcomes with better data’. This is the new focus for all future projects and research.
We need to apply common sense & think outside the box
We must also beware, however, of relying more and more on prescriptions to deliver public health benefits rather than empowering individuals to change their lifestyles. Up to 60% of the UK’s health-spend goes on treating conditions rooted in poor lifestyle choices. Health education has helped many, particularly those from the more privileged strata in society, but as of March 2012 we still recorded a smoking prevalence of 28% in Europe, including 29% of young Europeans aged 15 to 24 years.22 The growing morbidity and mortality associated with obesity and Type II diabetes is a health tsunami just waiting to happen. We cannot tackle every addiction and their brain reward systems here. However, one of the clear messages to come out of our High-Level Consultation Event convened by SciCom is that if we do not place education, the humanities and ethics on the same pedestal as scientific endeavour, we will fail.
We are an aging society: thanks to good science, sanitation, security, education, a fine pharmaceutical industry and excellent clinicians, it is estimated that two thirds of the people who have ever lived to be 65 years-old in the history of mankind are alive today. We should see the glass as half full. Nevertheless, we are only now just beginning to factor the aged into our research. The elderly rarely if ever feature in clinical trials. Regulators are doing more to encourage this but there remains room for improvement. Better still, it would be good to see governments actually fund more clinical trials themselves, investigating issues with important implications for public health. Private researchers will logically invest in areas where profits can be made to fund them in the first place, while giving shareholder value.
When it comes to substance addictions, we must transfer some of this responsibility for society’s health and the prevention of disease to society. Across the globe, morbidity associated with sexually transmitted disease, smoking, drug and alcohol abuse etc. consume a significant portion of national health funds. As a society, we are forced to allocate a disproportionate percentage of our sovereign wealth, generated by hard-working tax payers, to tackling avoidable diseases linked to our poor lifestyle choices. As Deborah Arnott points out from pages 49-54 concerning low and middle income countries, these behaviours and addictions impact the most deprived segments of society the hardest.
That is not to say that we must blame the addicted person. On the contrary, we must better understand and address through informed social policy and better science, including brain research, the causes of addiction. Key to this is establishing whether addiction a is ‘weakness’ in the individual or a brain disease? How much is determined by our genes and how much by experiences and exposure, particularly in youth? How much is reinforced or aggravated by the peculiar pressures and stresses of modern day life?
In Volume II of this series titled “Addictions and their Brain-Reward Systems”, Dr. Wilson Compton of US-National Institutes of Health (NIH) states that addiction is a developmental disorder with an abuse trajectory that predominantly starts in one’s youth. Stunning advances in the neurosciences have shown that chronic substance use affects the brain in ways that undergird the stereotypic behavioural disruptions that characterise addicted individuals. This is because the drugs of abuse co-opt the brain’s neuronal circuits necessary for insight, reward, motivation, and social behaviours. Furthermore, Dr. Compton argues that: “These drug-induced changes are long-lasting, persisting even years after drug discontinuation, which has led to the recognition of addiction as a chronic and relapsing brain disease”. Importantly, they also point the way for the development of more effective interventions for the prevention and treatment of addiction.
Remarkable scientific advances being made in genetics, molecular biology, behavioural neuropharmacology, and brain imaging offer important new insights into how the human brain works and regulates behaviour. We can now investigate questions around addiction that were previously inaccessible, such as the role of genes and environmental factors. These really are exciting times.
In the same compendium, Professor Philippe de Witte and Mr. Andy Stonard assess what the latest research is telling us about young people’s brains and alcohol. They assert that the second decade of life is a time of physical maturation and continuing development of the brain. Emotions and motivations are thought to originate in the midbrain, whereas the frontal region of the brain exerts executive function and limitation of impulsive behaviour. Adolescents are vulnerable to the feeling of invincibility when drinking alcohol. Boys and especially girls are increasingly binge-drinking, creating problems in their daily lives. Both animal and human studies have shown that heavy drinking can cause cognitive defects, which further impair decision-making, problem solving, planning, attention and learning. Thus, early heavy drinking can interfere with school performance and create longer-lasting behavioural difficulties. It can also result in a wide range of costly health and social consequences, including fatal and non-fatal accidents, all types of inter-personal violence, risky sexual behaviour, academic problems and alcohol poisoning.
According to the WHO’s Global Status Report on Alcohol & Health 201423, in its 194 WHO Member States, alcohol is the world’s leading risk factor for death among males aged 15 to 59 years and is linked to over 200 diseases. Those who do drink consume, on average, 17 litres of pure alcohol annually. Alcohol kills 500,000 young people under the age of 30 every year. There are more deaths among men than among women from alcohol-related causes with 7.6% of all men’s deaths and 4% of all women’s deaths worldwide caused by alcohol.
The UK’s 2012 Alcohol Strategy24 estimates that the alcohol industry contributes around £29 billion to the UK’s economy, supporting over 1.8 million jobs. That said, 44% of all violent crimes in the UK are alcohol-related and there were 1.2 million alcohol-related hospital admissions in 2010/11 alone. National liver disease has risen 25% between 2001 and 2009. The latest crime statistics show that two-thirds of 17 to 30 year-olds arrested in a city in England claim to have ‘pre-loaded’. Up to one-third of alcohol-related A&E attendances are for under 18 year-olds. Interestingly, 83% of those who regularly drink above the guidelines do not think their drinking is putting their long term health at risk. Putting the Strategy forward, UK Prime Minister David Cameron argues that a minimum unit price of 40 pence “could mean 50,000 fewer crimes each year and 900 fewer alcohol-related deaths a year by the end of the decade”.
New brain research, allied to a growing acceptance worldwide that the social and direct costs of addictions necessitates a complete overhaul of our current thinking, is thankfully, slowly but surely, changing our approach to their prevention and treatment. We would argue that brain research + education + the humanities + ethics is giving us a better-rounded toolbox of responses. More importantly, it is allowing us to re-find the little bit of compassion for the addicted person that seems to have got lost along the way.
In tandem, an increasing number of front-line experts are challenging the notion that drinking, and indeed other addictions, is an unqualified right without any associated sense of responsibility. It is time to not only listen to, but to apply these findings to good clinical practice. The medical community often appears distant in the treatment of addiction because training and the tools to help are poor. We are heartened by Dr. Compton’s recommendation to the US National Institutes of Health (NIH) that basic undergraduate medical training, country-wide, should include more of an addictions focus. Others should learn from, and implement, his example. The pharmaceutical industry too still has much to do in developing new medications, while policy-makers should more actively encourage their development and licensing.
The science and society nexus remains challenging
When it comes to addictions and their brain reward systems, the policy landscape is still evolving rapidly. Our ‘brain age’ has just begun. Nevertheless, it is all the more crucial that scientists conduct and report their work to the highest standards. Any discovery to do with unlocking the brain or country league table of drug, alcohol or tobacco use easily makes the headlines. The air time given to confused scientific opinion undermines the real value science should bring to society and policy-making. One only has to think of the countless ‘Frankenstein Science’ reports around cloning, stem cells, GMOs, fracking etc. People are often cynical: “you can find an expert to support any position”.
The e-cigarette debate happening right now is a perfect, if not unique, example linked to nicotine addiction of how a novel and rapidly growing technology offering a smokefree delivery system has sprung up from nowhere and literally caught everybody by surprise. Across the globe, news coverage, specialised reports and political discourse have exploded on the subject. At the end of the day, this is a new technology, in an emotionally charged area, that with the right standards has the potential to save millions of lives.
According to the WHO, one billion preventable tobacco-related premature deaths are at stake in the 21st Century. Policy-makers should make sound epidemiological research a priority. Academics and regulators should be seeking ways to help set the required product and manufacturing standards in order to provide greater confidence without stifling innovation. Industrial researchers, i.e. those actually making the products, should also be at the table and willing to establish a regulatory framework that brings greater assurance and transparency to the consumer. In this way, the consumer will be able to make more informed choices, taking the right steps to improve their lifestyle as and when they are ready. Sound science, drawing on clinical, toxicological and epidemiological research, in conjunction with the social sciences must inform the e-cigarette/vaping debate.
Taking this thinking a step further, in preparation for the High-Level Consultation Event, we were both involved in a working group asked to address addiction under the microscope of ‘what do we expect from the scientific community?’ which resulted in 6 key recommendations which we would like to share:
- The integrity of science needs to be more positively asserted;
- Stronger emphasis must be given to the inclusion of social sciences to improve understanding of how the public may react or adapt;
- Scientists must learn to use established communication channels for providing policy advice more effectively and be less aloof and perhaps less arrogant;
- Scientific advice must be more involved in all stages of the policy cycle,particularly in harm reduction;
- Policy-making must learn to cope with the speed of scientific development and include greater foresight and policy anticipation;
- Investment in harm reduction science is “the right thing to do”.
- don’t start;
- don’t harm people around you; &
- don’t harm yourself.
What our Brussels discussions highlighted is that there exists in drugs, alcohol and tobacco an ethical battleground between many in policy, health and industry, built often upon contradictions not founded in science. Those who are addicted need our full support while living with their addictions and in finding more permanent solutions. We agree with our fellow thought-leaders that we must act with greater compassion in embracing and encouraging harm reduction strategies. It makes both societal and economic sense. To be successful, we need to embrace brain research, unlock the mind and tackle addiction.
REFERENCES IN THIS ARTICLE