Addiction – is it a disease or is it a choice? With the United States currently in the grip of an opioid epidemic, this is a distinction of great significance. Dr Samuel Ball, President and CEO at The National Center on Addiction and Substance Abuse believes that improving our collective understanding of addiction as a disease rather than a moral failing is a crucial step in the right direction.
Research Features recently spoke to Dr Ball about this and some of the other major challenges within his field.
Hi Samuel! Can you tell us what The National Center on Addiction and Substance Abuse (CASA) does? What is your role within the centre?
Our interdisciplinary team of experts work closely with academic, government, and service organisations to improve the understanding, prevention, and treatment of substance use and addiction. We accomplish this through the dissemination of knowledge, creation of resources, training of providers, and evaluation of systems of care. We are best known for our major reports, our evaluation of service systems, and our education of parents and policymakers about what works to prevent and treat substance use and addiction. I have been President and CEO for the past three years and am also a Professor of Psychiatry at Yale School of Medicine.
Can you tell us about CASA’s background and the aims of the centre?
We were founded 25 years ago by Joseph A Califano, Jr, former Secretary of Health Education and Welfare, as a nonprofit organisation in New York City affiliated with Columbia University. We have a well-established reputation as a leading addiction policy and research organisation. Our mission is to connect science with policy and practice to better the lives of all people impacted by substance use and addiction. We do this by conducting and synthesising research; informing and guiding the public; evaluating and improving healthcare, and analysing and recommending policy.
Can you explain how research is conducted at CASA?
We engage in various forms of research. In addition to analysing national surveys and summarising major areas of research, we conduct our own survey research on attitudes, behaviours and problems related to substance use and other addictive behaviours. Our programme of health services research evaluates evidenced-based practices in the community delivered to people with mental health, HIV, and substance use problems. This involves both innovative and established interventions designed to improve outcomes within a rapidly changing healthcare environment. Our programme of research on adolescents and families includes randomised clinical trials that test integrative methods of treating patients, and rigorous evaluation of practical methods of training service providers.
What are the organisation’s key research focuses over the next two years?
Major work is underway evaluating the practical assessment and intervention methods in various clinical settings for adults and adolescents who have mental health, HIV, substance use, and criminal justice problems. We are also evaluating the rates and correlates of tobacco and other nicotine product (e-cigarettes) use in college students and studying brain-imaging changes among youth who are addicted to opioids and receiving medication-assisted treatment. Other research will examine the effects of marijuana legalisation to inform policy decisions that reduce the risk of exposure to children and teens.
Can you tell us about CASA’s collaborative relationship with substance use and addiction researchers at various universities?
The National Center on Addiction and Substance Abuse was founded as an affiliate of Columbia University. We continue to collaborate with their researchers in the evaluation of juvenile justice agency processes for identifying mental health and substance use problems and getting teens into treatment. Another Columbia clinic is helping us evaluate different family-based approaches to treating substance use and attention deficit hyperactivity disorder in adolescents. Our more recent academic collaborations have been with Yale University, New York University, Northwell Health, and City University of New York faculty and staff and include a wide range of studies on substance use, addiction and addictive behaviour. These research projects occur in diverse service settings including community addiction treatment programmes, patient-centered medical homes, primary care centers, emergency rooms, colleges, medical specialty and behavioral health clinics.
Addiction is the USA’s number one public health problem. What are the key considerations when addressing this issue?
The two overarching considerations for promoting effective policies and practices are to reduce access to addictive substances and expand access to effective prevention and treatment. Although our country has effectively reduced cigarette smoking, many other addictive substances have increased accessibility in ways that pose an especially high risk for young people. The greater availability of prescription pain medicine and heroin fuelled our current opioid epidemic. The greater availability of marijuana is already having a negative health impact in states where it is legalised. The greater availability of e-cigarettes seems to be translating into greater use of other tobacco products. Stronger regulatory policies and practices are needed to reduce the harms associated with all substances, whether legal or illegal. With regard to increasing access to prevention and treatment, our systems of education, healthcare and justice still do not provide adequate access to the interventions which research shows are effective. Here again, the risks to young people are especially high. If substance use is not prevented, delayed, or stopped at an early age, the risk of it progressing to a chronic addiction in adulthood is magnified. Not enough is being done early enough to keep young people healthy and addiction-free.
What are the greatest addiction challenges at this time? What are CASA’s strategies for addressing these issues?
In my opinion, there are three great challenges to our public health when it comes to addiction and one great threat when it comes to how we prevent and treat the problem. The three great challenges are: 1) implementing a comprehensive, rather than piecemeal, strategy to control and end our current opioid epidemic; 2) voting to legalise marijuana for recreational and medical use while ignoring or distorting the research-proven risks and benefits; 3) limited access to and payment for evidence-based prevention and treatment.
How responsive is federal policy to changes in addiction behaviour? What involvement does CASA have in the formation of addiction policy?
For the past 10 years, the federal government has been unacceptably slow in its response to the opioid epidemic and unacceptably non-responsive to the rapid expansion of state legalisation of marijuana. Both forms of non-responsiveness were powerfully influenced by corporate interests that expanded opioid and marijuana access. The slow federal responsiveness on opioid regulations has contributed to thousands of deaths over recent years. Federal non-response to state marijuana legalisation will result in increased rates of addiction. Our Center released major reports in the past year aimed at educating policymakers about the extent of the problem and offered strong, science-based recommendations to improve the education, healthcare, and justice system response to our addiction crisis.
On the CASA website, you state that in 2016, ‘great progress has been made in improving our collective understanding of addiction as a disease instead of a moral failing’. What is the significance of this change in perception? What part did CASA play in bringing about this change?
Attempts to change the view of addiction from a moral failing to a disease began 250 years ago, and we still have a long way to go. Continued emphasis on addiction as a disease is necessary to reduce the shame affected people and their families feel, which often prevents them from admitting they have a problem and seeking and accepting help. Understanding addiction as a disease is also necessary for maintaining a public health approach that provides health interventions instead of a criminal justice approach that punishes the sick. Our Center has supported the view of addiction as a disease by promoting awareness of the role of the brain in developing addiction and promoting knowledge about effective medicines and professional therapies to support recovery and prevent relapse.
How do you see the landscape of addiction changing over the next ten years?
Our country has cycled through various addiction crises since its founding. There have been several opioid epidemics and, although the current one is our worst to date, it will likely recede in a few years and another substance will become a crisis. I am concerned that our next major drug crisis will be marijuana fuelled by the unchecked spreading of state legalisation and greater access to higher potency products with greater addiction and mental health risk. I am concerned that we are not going to know how to counteract this and undo the damage to individuals and society.
Many people describe themselves as coffee addicts, but you do not think coffee should be described as an addiction. Can you explain why?
I believe the term “addiction” is grossly overused by the general public and by some experts when they are trying to increase interest in their work. Physical withdrawal symptoms can occur when one cuts back or eliminates regular coffee drinking. But there are many other symptoms that are needed before calling something an addictive disease. Addiction is a very serious, potentially life threatening medical condition characterised by a severe loss of control and continued use despite experiencing significant damage to one’s health, relationships, and the ability to learn and contribute to society. If someone drinking an excessive amount of coffee on a daily basis experiences some value from calling themselves a “coffee addict” and then adopts healthier habits, that may be helpful. But as an addiction expert, I think their use of the term “addiction” trivialises a serious disease from which people suffer devastating consequences and sometimes die if they do not get help.
633 Third Avenue, 19th Floor
New York, NY 10017-6706