Editorial

Over the past decade, articles published in the Addictive Disorders section of Current Opinion in Psychiatry have been centred on a theme. In this period, we have covered topics such as substance use and comorbid mental health disorders, sex considerations in substance use, emerging drugs, epidemiology of drug use and innovative treatment approaches. This year, we have selected the topic of international collaborative research in addictive disorders, with an emphasis on research collaborations fostered by the US National Institute of Drug Abuse (NIDA) and the European Union. Eight review articles are presented and as is standard practice, they focus on studies published in a 2-year publication window, in this case 2016–end-2017. They are written by authors from seven countries, namely Spain (two articles), the United Kingdom, Italy, the United States, Mexico, Taiwan and Malaysia (one each). NIDA is well-recognized to be the major source of funding for research in drug abuse worldwide and for 25 years, it has run its International Program which has funded multiple initiatives, including international collaborative studies, training in research methods of international scientists through scholarships and fellowships, and has hosted an annual meeting at the College of problems in Drug Dependence meetings (CPDD) where NIDA supported scientists both in their early careers and more established researchers have presented their work to their peers. The European Union has several mechanisms for supporting research within its member countries and involving in many cases collaborating investigators from countries in other regions. The articles published in this year's section represent those who have been supported through the NIDA International Program and those who have been funded through European Union mechanisms. The WHO also undertakes and promotes international collaborative research and an example of this is the ATLAS-SU Project which is summarized in the article by Marín-Navarrete and colleagues (pp. 306–314). The section begins with a review of the NIDA International Program by its longstanding Director, Dr Steven Gust, and a program contractor, Judy McCormally. The extent of the NIDA International Program is evident from the highlighted section in their article, which notes that NIDA has supported more than 485 researchers since 1990 in the fields of public health, treatment, health services, criminal justice and drug control policies related to psychoactive substance use. Of relevance to Current Opinion in Psychiatry is that 26% of authors who have published their work in the last 10 years have presented their research at the NIDA International Forum and they include some of the pivotal work on extended release naltrexone, an approach which is under active investigation at present for the treatment of opioid dependence in comparison with agonist treatment such as buprenorphine. The current activity from former NIDA fellows is clear from the analysis that in the 2016–2017 publication window, 26% of all former NIDA fellows published a research article in this period which was indexed in PubMed. In their review article, which focuses on preventive and treatment responses to the epidemic of opioid use (principally of pharmaceutical opioids) in the United States and many other countries, Gust and McCormally (pp. 287–293) identified former NIDA fellows who have contributed and are referenced in their review article, from Australia, China, France, India, Ireland, Morocco, Russia, Ukraine and Vietnam. Wang and Chen (pp. 294–299) examine the upswing in alcohol consumption in many Asian countries and identify the extent and impact of alcohol consumption among Asian countries and especially in young people. They note the wide variation which is related to the prevailing culture and, with the highest estimates for alcohol consumption and hazardous drinking being in Hong Kong, Taiwan and South Korea but also increasing in many provinces in China including rural areas. Of particular note is binge drinking which is starting to be reported among adolescents in the 12–15 year age range. Investigations are underway on the effect of exposure to alcohol advertising on various types of media platforms. Certain countries in Asia, Thailand being an example, have implemented national policies to reduce the access of young people to alcohol outlets and such initiatives are of vital importance given as the authors comment that ‘Asia has the largest adolescent population in the world’ and that worldwide it is one of the leading risk factors for premature morbidity and mortality. Policy approaches by government are the subject of a review article by Vicknasingam and colleagues (pp. 300–305) and the subject of their review is decriminalization of drug use. This represents a fundamental policy shift from the prohibitionist approach that has been enshrined in the various United Nations single conventions on narcotic and psychotropic drugs. At the beginning of their article, the authors note that the United Nations General Assembly in 2016 concluded that drug dependence is a ‘complex, multifactorial health disorder…with social causes and consequences that can be prevented and treated’. They provide their evidence for decriminalization approaches to be considered with this being defined by the authors as ‘a policy that make consumption and possession of drugs for personal use not a criminal offence’. Given that decriminalization was first introduced as a part of national policy in Portugal in 2001 and de facto decriminalization was introduced in the Netherlands in the mid-1970s, one might think that there would be flourishing research efforts on the impact of decriminalization on psychoactive substance use, on problems relating to such use but also the potential adverse effects of such policies. Yet, Vicknasingam and colleagues (pp. 300–305) were able to identify only seven articles that reported data on the effects of decriminalization. In the same period, there were no fewer than 57 published articles on legalization of psychoactive substances, focusing on the United States where states are beginning to legalized cannabis for nonmedical, recreational purposes. The authors also compare harm reduction, which does not specifically focus on the legal status of a psychoactive substance but recognizes that many substance users, including those who inject drugs, are not likely to cease their use and engage in treatment at any particular time. The focus here is on accepting that their substance use is likely to continue but emphasizing ways of reducing specific harms including deaths such as the provision of opioid maintenance programs, injecting equipment (needle-syringe) availability programs to reduce the spread of blood borne virus infections such as HIV and Hepatitis C. The paucity of publications on key topics is also a theme developed by a review by Marín-Navarrete and colleagues (pp. 306–314) from the National Institute of Psychiatry in Mexico City. They review the recent literature on the development and evaluation of addiction treatment programs in Latin America. This is clearly an important topic; yet, despite this, the authors identified through their literature search only six articles relevant to the topic that were published in the 2016–2017 publication window. Four were randomized controlled trials and two were cross-sectional studies. They included a prevention program to reduce cannabis, alcohol and inhalant use in adolescents, therapy for cocaine dependence and brief intervention in primary care settings. The authors explore reasons for the lack of evaluations for addiction treatment programs and highlight the very high costs of randomized controlled trials for efficacy, effectiveness and implementation science. More broadly, they note that research and development expenditures represents less than 0.5% of the gross domestic product in Latin American countries compared with 2–3% of countries in North America and the European Union. An important component of this review comprises findings from the ATLAS-SU project coordinated by the WHO. Their review identifies the public health resources for substance use intervention in 19 Latin American countries and a valuable table notes the variability of information systems, prevention program, primary care interventions, opioid substitution, training programs, program evaluations and prevalence studies. There is considerable variation even between countries which share borders yet program evaluation is being undertaken by only two countries. The article provides the valuable function of identifying gaps in the present literature and in the present national-level approaches. The remaining four articles derive from Europe and reflect the availability of not only national research funding but also funding from the European Union, which has supported the work undertaken in three of these. The four articles focus on population-level strategies which seek through a comprehensive approach to develop and intervene at a policy, primary care or multisector approach. From Barcelona, Spain, Judit Tirado-Muñoz and colleagues (pp. 315–323) review interventions for the prevention and reduction of cannabis use that were published in the 2016–2017 publication window. They focus on 13 studies, of which six were systematic reviews on prevention of cannabis use in adolescence, psychological interventions for cannabis dependence such as combined motivation enhancement therapy and cognitive behaviour therapy and brief interventions which reported an effect in reducing cannabis use among nondaily smokers and younger cannabis users. Noting the acceptability of computerized interventions in younger young people, the authors found beneficial effects of online feedback. Of note, the role of pharmacological interventions is being investigated vigorously. The medications include various cannabinoids (individual compounds and combinations), intranasal oxytocin and topiramate. The cannabis antagonist rimonabant was investigated 15–20 years ago but was withdrawn from clinical trials because of side-effects. Primary healthcare is the setting for a review by Lidia Segura Garcia and colleagues (pp. 324–332) who work in three European countries, Spain, the Netherlands and the United Kingdom. They review the 2016–2017 published literature on screening and brief intervention for harmful alcohol use, having noted the continuing detrimental effects of excessive consumption on ill health and premature mortality. Sixty-two articles were reviewed of which seven were systematic reviews. A US supported screening and brief intervention approach and the ODHIN randomized trial showed that brief advice reduced hazardous alcohol consumption compared with a control condition and importantly the effects were maintained for up to 1 year. This supports the findings from scores of brief intervention trials which have been undertaken in primary healthcare over the past 30 years. Further support comes from the findings of a Cochrane systematic review [1] which was published after the end of the publication window. The ODHIN study was a sophisticated cluster randomized factorial trial comprising 120 primary healthcare facilities which were assigned to a training and support condition with some financial reimbursement. The implementation strategy resulted in a higher proportion of patients attending primary healthcare being screened for harmful alcohol use and given advice. In the US SAMHSA-supported study, more than one million patients were screened and brief intervention was associated with positive outcomes and proved to be the more cost-effective approach for alcohol and other substance use. The review also considers comorbidities including hypertension, infectious diseases with screening and brief intervention in specific demographic groups such as older people and pregnant women. What is missing from the screening and brief intervention approach is an understanding of how best these interventions can be supported in local communities and so they are seen as a person centered and community engaged. A further cross-European study comes from Anderson and colleagues (pp. 333–341) who are based in the United Kingdom, Spain and Germany (and Canada) and explores government policy and population-level approaches to reducing harm from addictive substances, comprising alcohol, illicit drugs and nicotine. The authors note that worldwide these substances caused 10 million deaths in 2016 with smoking being the leading risk factor for ill health and premature death among men, with alcohol being the fourth and drug use the 18th. Among women, smoking was the ninth most common cause of morbidity and mortality, alcohol was the 19th and drug use was the 25th. The authors explore issues that represent novel concepts for the addictions field including an evolutionary perspective on the development of alcohol metabolizing enzymes when fermenting fruit was consumed. We should note the invention of delivery mechanisms such as the hypodermic syringe and the automatic cigarette rolling machine, with the latter being responsible for the epidemic of cigarette smoking and cigarette-related deaths in the 20th century and beyond. The authors describe a novel approach of using the margin of exposure calculation which is the ratio of a toxic dose of a drug with a dose consumed by an individual and note that using this measure the ratio is only 1.5 for alcohol at a population level, which reflects the high proportion of people who consume alcohol at levels which are known to increase the risk of harm. The authors then review the effect of various population-level approaches to reducing harm including taxation of alcohol and tobacco products and electronic nicotine delivery systems such as e-cigarettes in reducing harm from cigarettes given that the carcinogenic and other injurious compounds are removed from the nicotine in these delivery systems. In the final review article, Allamani (pp. 342–347) notes the overall strong and well-documented relationship between overall consumption of alcohol in a community and the prevalence of alcohol dependence and alcohol-related harm. He notes that in some European countries, notably France and Italy, per capita consumption has declined by 25–30% in the absence of specific policies to reduce consumption. From this finding, which may seem to be counterintuitive, he emphasizes the importance of the cultural context which may reflect broader changes in society than are related to alcohol policy. These include a shift from an agrarian society to an urban society and also the time people in the work force spend commuting to work, which makes more circumscribed the opportunities for alcohol consumption. A central message from this article is the need to understand these potent cultural influences and potentially capitalize on them to tailor interventions to the population-level. The eight reviews demonstrate the wealth of research which is undertaken but also highlight that key research questions that are still unanswered. The articles recognize that it is vital that we collectively tackle these difficult questions which require substantial financial means to undertake and to be cautious about undertaking work which may be repetitive or in the case of drug legalization an opportunity for polemic. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.

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