EDITORIAL
Addiction's research in developing countries: adjusting abounding questions to limited resources
Pesquisa sobre adição a drogas em países em desenvolvimento: ajustando problemas abundantes a recursos limitados
In the addiction field new tenants cohabit with old unresolved ones. Synthetic drugs now compete with traditional options like cocaine and marijuana. Meanwhile the implications of abuse widespread substances like caffeine remain largely undetermined. It may sound strange to raise suspicion over coffee, tea and caffeine rich soda-pops, but it does not mean the topic lacks potential relevance. For instance, the view on tobacco changed from elegant behavior to societal concern when research demonstrated its burden on public health. The common association between alcohol and nicotine addiction holds risks ignored until recently. Smoking alcoholics are less likely to die from an alcohol related problem than from a tobacco related one.1 Likewise, common associations between caffeine, nicotine, gambling and alcohol may have important impact on health so far not reported.
Another challenge is the search for the determinants of the addictive behavior. Excessive gambling with or without concurrent substance use is classified as an impulse control disorder, but is treated as an addiction. The struggle for self-control is a hallmark of today's Western culture in which new reward promising products and services are created every day.2 Accordingly, impulsivity as a personality feature is receiving increasing attention as a vulnerability factor for addictions.3 Excessive behaviors (sex, shopping, eating, gambling, etc.) and substance abuse share elements of loss of control, and persistent pursuit of gratification despite negative consequences. This fact suggests that addiction is a behavior not exclusively facilitated by mood altering substances. The so-called behavioral addictions cast greater attention on the role of culture and individual variability.
The capacity for generating research questions is unlimited, but the resources are not. Therefore, priorities have to be set. Below, we suggest five points that we consider critical to overcome barriers in the way of developing countries and to advance addiction's research:
1) Overcoming the resource shortage: international organizations like the World Psychiatric Association, the International Society for Addiction Medicine, National Institute on Drug Abuse - USA, World Health Organization, etc., aim to facilitate access to funding and training sources. In exchange, beneficiary countries must ensure that professionals trained abroad will find appropriate conditions to develop the newly acquired skills and knowledge in their country of origin, and produce reports on the local situation.
2) Recognizing the problem: there is a paucity of epidemiologic studies outside developed countries. A public health perspective is fundamental. If large home surveys are unfeasible, then priority must be given to prevention amongst youth as well as special target populations.4 Culturally-sensitive research can identify interesting profiles. For example, the abuse of stimulants and Sildenafil (as recently reported by Brazilian media) during rave parties deserves a different approach from the one directed to middle aged smoking, and drinking gamblers. Also, surveys of specific locations can be a shortcut to smaller but still representative samples, like investigating drug use in elementary and high school, or frequency of pathological gamblers and shoppers among credit protection agencies' lists.
3) Embracing the community and the social sciences: exclusion and incarceration are two traditional social approaches to the drug problem. Government agencies and NGOs devoted to social aid and drug abuse prevention should work together. Finding alternative activities other than drug production or trafficking is an absolute need for poor communities. Also incarcerating minor offenders is providing new students for organized crime schools. Decriminalization of drug use, alternative penalties, and education aiming at new job skills have been shown to be better cost effective options. This is where social scientists must be welcomed, to help develop the means for regulation and community enrollment. So far, addiction's research in Brazil has relied almost only on psychiatrists and psychologists.
4) Rationalizing clinical resources: research on new treatment techniques is growing, but their cost-effectiveness remains relatively unexplored, living space for researchers initiating in the field. These studies increase familiarity with new techniques and applications. Establishing a sequential and progressive assignment of psycho-social and medical interventions is a major goal when trying to adjust resources to clinical demand. The scope of addiction clinics ranges from abuse to dependence. Individuals closer to the abuse pole might recover with simpler psycho-educational interventions, whereas severe dependence requires additional medical assistance. Anti-craving medications are now a reality, but their role in treatment is undetermined. Practice guidelines as to whom they should be prescribed, under what clinical criteria, and for how long are still missing.
5) Looking for what has been overlooked: nicotine and caffeine are probably the most common abused drugs throughout the world. However, the former is frequently neglected if any other addiction is associated, and the latter is not even recognized as a psychoactive substance by the majority of clinicians. The more prevalent an addictive behavior is, the harder it is to acknowledge it. The same rational applies to the so-called behavioral addictions. Pathological gambling is more prevalent than marijuana or cocaine addiction in both adult and young populations,5 so is overeating and obesity. Shame and secrecy probably keep compulsive sex and compulsive shopping underreported. Behavioral addictions are unique natural models for an appraisal of the roles of culture and personality in addiction.
The addiction enigma is far from being solved. Its dynamic nature poses new questions faster than our current capacity to respond, yet keeping up our efforts to answer them is critical. Those considering entering the field must be comfortable with the unknown and will find many of the problems related to human nature both rewarding and challenging.
Nady el-Guebaly
Department of Psychiatry, University of Calgary, Canada
International Society of Addiction Medicine [ISAM]
Section of Addiction Psychiatry, World Psychiatric Association [WPA]
Hermano Tavares
Behavioral Addictions Outpatient Unit
Department of Psychiatry, University of São Paulo, Brazil
References
1. Hurt RD, Offord KP, Croghan IT, Gomez-Dahl L, Kottke TE, Morse RM, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. JAMA. 1996;275(14):1097-103.
2. Stearns PN. Battleground of desire: the struggle for self-control in modern America. New York: New York University Press; 1999.
3. Robinson TE, Berridge KC. Addiction. Annu Rev Psychol. 2003;54:25-53.
4. Silva VA da, Aguiar AS de, Felix F, Rebello GP, Andrade RC, Mattos HF. Brazilian study on substance misuse in adolescents: associated factors and adherence to treatment. Rev Bras Psiquiatr. 2003;25(3):133-8.
5. Derevensky JL, Gupta R. Prevalence estimates of adolescent gambling: a comparison of the SOGS-RA, DSM-IV-J, and the GA 20 questions. J Gambl Stud. 2000;16(2-3):227-51.
Original version accepted in English
Publication Dates
-
Publication in this collection
14 Apr 2005 -
Date of issue
Mar 2005
