If Tool Theory is buttressed by fundamental concepts of conditioned reinforcement and extinction, a dependence on Drug Theory may not be necessary. (Published Online April 5 2006).

Introducción: Se presenta un análisis cualitativo del acompañamiento psicosocial a jóvenes en condiciones de vulnerabilidad desde la ecología humana durante 12 meses entre 2010 a 2011; utilizando técnicas pedagógicas evaluativas participativas. Éstas, son una alternativa para crear espacios reflexivos con el propósito de potenciar la resiliencia en las relaciones comunicativas y formar en el respeto. Objetivo: Generar bienestar, prevenir la farmacodependencia y contribuir a la promoción de la salud. Material y Métodos: Se revisaron los antecedentes temáticos, fueron seleccionados 100 estudiantes (...) entre 11 y 19 años de dos instituciones educativas públicas en condiciones vulnerables;se desarrollaron cuatro talleres reflexivos y cuatro prácticas lúdicas y se realizaron tres grupos focales con estudiantes, profesores y padres de familia. Resultados y Discusión: El contexto social de la población intervenida, revela problemas de abuso sexual, violencia intrafamiliar y eventos violentos en el vecindario por grupos armados ilegales, entre otros, que constituyen factores de riesgo importantes para la farmacodependencia. Conclusión: Se infiere que lo psicosocial incide en la farmacodependencia, afectando la convivencia de la población estudiada por múltiples causas del orden psicoafectivo, sociocultural, económico y político que van desde el consumo cultural hasta la seguridad alimentaria. Introduction: A qualitative analysis of the psycho-social support to young people in situations of vulnerability from human ecology is presented for 12 months between 2010 to 2011; using participatory evaluative pedagogical techniques. These are an alternative to create reflective spaces with the purpose of enhancing resilience in communicative relationships and working in respect. Objective: to generate well-being, prevent drug abuse and contribute to the health promotion. Material aids and methods: the thematic background was reviewed, 100 students between 11 and 19 years of two public schools in vulnerable conditionswere selected; four reflective workshops and four playful practices were developed and three focus groups with students, teachers and parentswere conducted. Results and discussion: the social context of the manipulated population reveals sexual abuse problems, domestic violence and violent events in the neighborhood by illegal armed groups, among others, which constitutemajor risk factors for drug abuse. Conclusion: It can be inferred that the psychosocial factors impact on drug dependence, affecting the coexistence of the population studied by multiple causes of the psychological, socio-cultural, economic and political order, ranging from cultural consumption to food security. (shrink)

Scholars usually distinguish between testimonial and hermeneutical epistemic injustice in healthcare. The former arises from negative stereotyping and stigmatization, while the latter occurs when the hermeneutical resources of the dominant community are inadequate for articulating the experience of one’s illness. However, the heuristics provided by these two types of epistemic predicaments tend to overlook salient forms of epistemic injustice. In this paper, we prove this argument on the example of the temporality of patients with drug dependence. We identify (...) three temporal dimensions of epistemic injustice affecting drug-dependent patients: the temporal features of their cognitive processes, their individual temporal experience, and the mismatch of social temporality. Notably, the last aspect, which highlights the disparity between the availability of care and its accessibility, does not fit neatly into the categories of testimonial or hermeneutical injustice. (We should note that the International Network of People Who Use Drugs (INPUD) and The Asian Network of People who use Drugs (ANPUD) consider the term “drug addiction” to be associated with disempowerment and negative stereotyping. Instead, they suggest the expression “drug dependence” (INPUD 2020). However, the concept of “drug addiction” is still being used in the current public health, philosophy, and sociology debates that concern the specific field of addiction studies. Replacing the notion of drug addiction with “drug dependence” would not eliminate existing epistemic injustices or allow us to avoid creating new ones, such as those related to ignoring pain claims (O’Brien 2011). Still, for the sake of clarity we will use the notion “drug dependence” when speaking of people while retaining the term “drug addiction” for labelling healthcare practices and the topic for philosophy of healthcare.). (shrink)

I support the major theme of Heyman's target article that behavioral choice theory can enhance our understanding of drug dependence, but I raise concerns about the critique of the operant model of drug dependence, the underscoring of melioration to the exclusion of other theories of choice, and assertions about the unique effects of drug reinforcement.

Previous studies suggest that psychopathic traits commonly present as comorbid with substance use disorders. Moreover, neuroimaging and psychometric findings suggest that psychopathic traits may predispose individuals to a sensitized reward response to drugs. Given that substance use disorders are characterized by a neurocognitive bias toward drug-reward relative to non-drug reward, it is possible that heightened psychopathic characteristics may further predispose to this processing bias. To evaluate this possibility, we assessed psychopathic traits (measured using the PCL-R; Hare, 2003 ) (...) in 105 probationers/parolees and evaluated the relationship between PCL-R scores, lifetime duration of drug use, and biases in neural response to drug- compared to food-related videos. Psychopathic traits (potentially driven by interpersonal/affective traits) were positively correlated with drug > food reactivity within the right insula and left amygdala. In addition, psychopathic traits modulated the relationship between drug use and drug > food reactivity within the left dorsomedial prefrontal cortex, right insula, and left caudate nucleus. Specifically, lifetime duration of drug use correlated positively with drug > food reactivity in participants with lower levels of psychopathic traits and correlated negatively with drug > food reactivity in individuals with higher levels of psychopathic traits. These results help reconcile prior studies on psychopathy and drug-stimulus processing and provide neurocognitive support for the notion that psychopathic traits serve as an underlying risk factor for substance use disorders. These results suggest that different treatment regimens for substance abuse for individuals with higher or lower levels of psychopathy may be beneficial and suggest that reduction of neurocognitive biases to drug-related stimuli may offer useful targets for future treatment protocols. (shrink)

Supervised injectable opioid assisted treament prescribes injectable opioids to individuals for whom other forms of addiction treatment have been ineffective. In this article, we examine arguments that opioid-dependent people should be assumed incompetent to voluntarily consent to clinical research on siOAT unless proven otherwise. We agree that concerns about competence and voluntary consent deserve careful attention in this context. But we oppose framing the issue solely as a matter of the competence of opioid-dependent people and emphasize that it should be (...) considered in the context of inequities in access to siOAT as a medical treatment. Consequently, we suggest that bioethics literature on nonexploitation, which focuses on clinical research in low-income countries, is helpful due to locating ethical issues within systemic social conditions. Finally, we consider the implications of our argument for the ethics of clinical research on siOAT. (shrink)

Different immunotherapeutic approaches are in the pipeline for the treatment of drug dependence. “Drug vaccines” aim to induce the immune system to produce antibodies that bind to drugs and prevent them from inducing rewarding effects in the brain. Drugs of abuse currently being tested using these new approaches are opioids, nicotine, cocaine, and methamphetamine. In human clinical trials, “cocaine and nicotine vaccines” have been shown to induce sufficient antibody levels while producing few side effects. Studies in humans, (...) determining how these vaccines interact in combination with their target drug, are underway. However, although vaccines can become a reasonable treatment option for drugs of abuse, there are several disadvantages that must be considered. These include i) great individual variability in the formation of antibodies, ii) the lack of protection against a structurally dissimilar drug that produces the same effects as the drug of choice, and iii) the lack of an effect on the drug desire that may predispose an addict to relapse. In addition, a comprehensive overview of several crucial ethical issues has not yet been widely discussed in order to have not only a biological approach to immunotherapy of addiction. Overall, immunotherapy offers a range of possible treatment options: the pharmacological treatment of addiction, the treatment of overdoses, the prevention of toxicity to the brain or the heart, and the protection of the fetus during pregnancy. So far, the results obtained from a small-scale experiment using vaccines against cocaine and nicotine suggest that a number of important technical challenges still need to be overcome before such vaccines can be approved for clinical use. (shrink)

Programs of drug testing welfare recipients are increasingly common in US states and have been considered elsewhere. Though often intensely debated, such programs are complicated to evaluate because their aims are ambiguous – aims like saving money may be in tension with aims like referring people to treatment. We assess such programs using a proportionality approach, which requires that for ethical acceptability a practice must be: reasonably likely to meet its aims, sufficiently important in purpose as to outweigh harms (...) incurred, and lower in costs than feasible alternatives. In the light of empirical findings, we argue that the programs fail the three requirements. Pursuing recreational drug users is not important in the light of costs incurred, while dependent users who may require referral are usually identifiable without testing and typically need a broader approach than one focussing on drugs. Drug testing of welfare recipients is therefore not ethically acceptable policy. (shrink)

Drug exceptional access programs (DEAPs) exist across Canada to address gaps in access to pharmaceuticals. These programs circumvent standard procedures, raising epistemic, economic, social and political issues. This commentary provides insights into these issues by revealing the context and procedures on which these programs depend.

The COVID-19 pandemic has revealed the vulnerability of the US generic drug supply chain to foreign production. Many policies have been proposed to mitigate this vulnerability. In this article, we argue that nonprofit drug manufacturers have the potential to make important contributions.

This paper discusses the economic, legal, moral, and political difficulties in developing drugs for the developing world. It argues that large, global pharmaceutical companies have social responsibilities to the developing world, and that they may exercise these responsibilities by investing in research and development related to diseases that affect developing nations, offering discounts on drug prices, and initiating drug giveaways. However, these social responsibilities are not absolute requirements and may be balanced against other obligations and commitments in light (...) of economic, social, legal, political, and other conditions. How a company decides to exercise its social responsibilities to the developing world depends on the prospects for a reasonable profit and the prospects for a productive business environment. Developing nations can either help or hinder the pharmaceutical industry’s efforts to exercise social responsibility through various policies and practices. To insure that companies can make a reasonable profit, developing nations should honor pharmaceutical product patents and adhere to international intellectual property treaties, such as the Trade‐Related Aspects of Intellectual Property Rights agreement. To insure the companies have a good business environment, developing nations should try to promote the rule of law, ethical business practices, stable currencies, reliable banking systems, free and open markets, democracy, and other conditions conducive to business. Overall, this paper advocates for reciprocity and cooperation between pharmaceutical companies and developing nations to address the problem of developing drugs for the developing world. In pursuing this cooperative approach, developing nations may use a variety of other techniques to encourage pharmaceutical companies to act responsibly, such as subsidizing pharmaceutical research, helping to design and implement research protocols, providing a guaranteed market, and bulk buying. (shrink)

The profession of medicine is predicated upon an ethical mandate: first do no harm. However, critics charge that the medical profession’s culture and its public health mission are being undermined by the pharmaceutical industry’s wide-ranging influence. In this article, we analyze how drug firms influence psychiatric taxonomy and treatment guidelines such that these resources may serve commercial rather than public health interests. Moving beyond a conflict-ofinterest model, we use the conceptual and normative framework of institutional corruption to examine how (...) organized psychiatry’s dependence on drug firms has distorted science. We suggest that academic-industry relationships have led to the corruption of the evidence base upon which accurate diagnosis and sound treatment depend. We describe the current dependency corruption and argue that transparency alone is not a solution — and sometimes even produces iatrogenic effects. Furthermore, we argue that the corruption of the evidence base for diagnostic and practice guidelines renders obsolete the traditional informed consent process, and we offer suggestions for reforming this process. (shrink)

While the Value-Free Ideal of science has suffered compelling criticism, some advocates like Gregor Betz continue to argue that science policy advisors should avoid value judgments by hedging their hypotheses. This approach depends on a mistaken understanding of the relations between facts and values in regulatory science. My case study involves the morning-after pill Plan B and the “Drug Fact” that it “may” prevent implantation. I analyze the operative values, which I call zygote-centrism, responsible for this hedged drug (...) label. Then, I explain my twofold account of value-ladenness, involving the constitutive role of value judgments in science and the social function of facts as political tools. Because this drug fact is ineliminably value-laden in both senses, I conclude that hedged hypotheses are not necessarily value-free. (shrink)

Drug development regularly has to deal with complex circumstances on two levels: the local level of pharmacological intervention on specific target proteins, and the systems level of the effects of pharmacological intervention on the organism. Different development strategies in the recent history of early drug development can be understood as competing attempts at coming to grips with these multi-level complexities. Both rational drug design and high-throughput screening concentrate on the local level, while traditional empirical search strategies as (...) well as recent systems biology approaches focus on the systems level. The analysis of these strategies reveals serious obstacles to integrating the study of interventive and systems complexity in a systematic, methodical way. Due to some fairly general properties of biological networks and the available options for pharmaceutical intervention, drug development is captured in an obstinate methodological dilemma. It is argued that at least in typical cases, drug development therefore remains dependent on coincidence, serendipity or plain luck to bridge the gap between development methodology and actual therapeutic success. (shrink)

Science has needed a dispassionate valuation of psychoactive drugs, but a motivational analysis should be conducted with respect to long-term reward rather than reproductive fitness. Because of hyperbolic overvaluation of short-term rewards, an individual's valuation depends on the time she forms it and the times she will revisit it, sometimes making her best long-term interest lie in total abstinence.

Biology incorporated into other disciplines is often distorted, alarmingly so in some areas of medicine. Together with other forms of bias, this may have detrimental effects for patients depending on medical research for their health. A case study concerning omeprazole (Losec), one of the acid-suppressive drugs against gastric ulcers, and NSAIDs, non-steroid anti-inflammatory drugs, confirms that distorted biology together with biased health care policies foster disasters in current biomedicine and medical practice. In our country, The Netherlands, omeprazole is presumably the (...) most commonly used medication. NSAIDs are also used in large quantities, increasingly since they have become available as analgesic over-the-counter drugs. Unofficial and official sources tend to inform the general public that the drugs promote human health. We argue that their being used on a massive scale is actually a medical disaster. The health of many patients would be served better if the drugs they take were replaced by proper forms of diet, but the pharmaceutical industry, the most potent force affecting medication policies, appears to prevent a shift in the balance from over-medicalization towards healthy life styles. The shift should come from government agencies responsible for regulation in the medication market. Policies of these agencies are now a dismal failure. (shrink)

The mental illness of substance dependence or addiction is responsible for major economic, social, and personal costs. If we are to elucidate its etiology, understand its mechanisms, and eventually bring it under control, scientific investigation is essential. Research in animals and humans has enhanced our understanding of this disease through examination of genetic, neurophysiological, biochemical, and behavioral factors. But because animals cannot verbalize their subjective responses to drugs and because significant symptoms of addiction cannot be observed in non-drug-dependent (...) humans, it is not surprising that certain investigations of substance dependence have required the participation of addicted or substance-dependent humans. (shrink)

Herbert, Michael The World Health Organization and the UN reports indicate the need of an integrated approach to tackle the dependence on legal psychoactive substances, such as tobacco and alcohol, as well as illegal ones. The effective clinical and societal responses to the existence of substance misuse are discussed, suggesting that realistic, timely investment, influenced by the best scientific evidence indicating what works, for whom, under what circumstances, and an increased degree of collaboration within and between governments and their (...) agencies are essential. (shrink)

Effectiveness is a key criterion in assessing the justification of antibiotic resistance interventions. Depending on an intervention’s effectiveness, burdens and costs will be more or less justified, which is especially important for large scale population-level interventions with high running costs and pronounced risks to individuals in terms of wellbeing, integrity and autonomy. In this paper, we assess the case of routine hospital screening for multi-drug-resistant Gram-negative bacteria (MDRGN) from this perspective. Utilizing a comparison to screening programs for Methicillin-Resistant Staphylococcus (...) aureus (MRSA) we argue that current screening programmes for MDRGN in low endemic settings should be reconsidered, as its effectiveness is in doubt, while general downsides to screening programs remain. To accomplish justifiable antibiotic stewardship, MDRGN screening should not be viewed as a separate measure, but rather as part of a comprehensive approach. The program should be redesigned to focus on those at risk of developing symptomatic infections with MDRGN rather than merely detecting those colonised. (shrink)

Should Students Take Smart Drugs? If this were a straightforward question, you would not be reading about it in a philosophy magazine. But you are, so it makes sense that we try to clarify the terms of the discussion before wading in too far. Unfortunately (or fortunately depending on how you look at it), when philosophers set out to de-obfuscate what look to be relatively forthright questions, things usually get more complicated rather than less: each of the operative terms at (...) stake in the question, ‘should students take smart drugs?’ opens us up onto larger debates about the nature of medicine, health, education, learning, and creativity as well as economic, political and social structures and norms. So, in a sense, a seemingly rather narrow question about a relatively peripheral issue in the education sector morphs into a much larger question about how we think about and value learning; what constitutes psychiatric illness and in what ways should we deal with it; and what sort of productivity should educational institutions like universities, but also secondary and even primary schools value and be oriented towards? (shrink)

There is a long history and growing evidence base that the use of drugs, such as anabolic-androgenic steroids, to enhance human performance is common amongst armed forces, including in Australia. We should not be surprised that this might have occurred for it has long been predicted by observers. It is a commonplace of many recent discussion of the future of warfare and future military technology to proclaim the imminent arrival of Super Soldiers, whose capacities are modified via drugs, digital technology (...) and genetic engineering, in ways that increase their performance exponentially. This is what some observers have referred to as the “Gladiator Model” wherein the aim is to create soldiers able to perform feats of which ordinary citizens are not capable. One key aspect of this “gladiator project” is the use of illicit drugs to enhance performance. Could we use drugs, such as steroids or amphetamines, to enhance performance? Should we use such drugs? In this paper we explore the ethics of creating Super Soldiers, and raise issues of consent, coercion and the extent to which such use is permitted or condemned by just war theory. We conclude that much will depend on the extent to which such use is harmful to the soldiers themselves and this is still an open question. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Feminist Studies 45, no. 1. © 2019 by Feminist Studies, Inc. 209 Trysh Travis Toward a Feminist History of the Drug-Using Woman— and Her Recovery In 1995, public health scholars Laura Schmidt and Constance Weisner published “The Emergence of Problem-Drinking Women as a Special Population in Need of Treatment.”1 The article, aimed at specialists in the growing field of behavioral sciences, explored the history of medpsych attitudes toward (...) women drinkers. That history had been characterized, until the 1970s, by ignorance and neglect, but it began to shift in the wake of Second Wave feminism and what Schmidt and Weisner called “the women’s alcoholism movement.”2 To be fair, attitudes toward male drinkers had also long been inchoate. But beginning in the 1940s, advocacy by a handful of scientific and legal professionals, as well as the mutual aid group Alcoholics Anonymous (founded in 1935) and the National Council on Alcoholism (founded in 1944), created a new vision, which went on to be underwritten by federal funding and private insurance.3 “Alcoholism is a disease 1. Laura Schmidt and Constance Weisner, “The Emergence of Problem-Drinking Women as a Special Population in Need of Treatment,” in Recent Developments in Alcoholism, Vol. 12: Women and Alcoholism, ed. Marc Galanter (New York: Plenum Press, 1995), 309–334. 2. Ibid., 310. 3. The organization was originally called the National Committee for Education on Alcoholism; it became the National Council on Alcoholism in 1950 and changed to the current National Council on Alcoholism and Drug Dependence in 1990. 210 Trysh Travis Books Discussed in This Essay Lady Lushes: Gender, Alcoholism, and Medicine in Modern America. By Michelle L. McClellan. New Brunswick, NJ: Rutgers University Press, 2017. The Recovery Revolution: The Battle over Addiction Treatment in the United States. By Claire D. Clark. New York: Columbia University Press, 2017. Addicted to Rehab: Race, Gender, and Drugs in the Era of Mass Incarceration. By Allison McKim. New Brunswick, NJ: Rutgers University Press, 2017. Through a Trauma Lens: Transforming Health and Behavioral Health Systems. By Vivian Barnett Brown. New York: Routledge, 2017. and the alcoholic a sick person,” argued National Council on Alcoholism founder Marty Mann in a host of magazine articles beginning in the late 1940s. From that assertion followed the beliefs that “the alcoholic can be helped and is worth helping” and that “alcoholism is a public health problem and therefore a public responsibility” (29).4 Behind Mann’s carefully gender-neutral language lay an image of the alcoholic as a white man from the respectable middle classes. The mid-century legitimation of that man’s problems, Schmidt and Weisner argue, paved the way for “problem-drinking women” to finally come into focus half a century later. Schmidt and Weisner’s article centers on the ways the Great Society funding streams that first steered funds to community-based alcohol and drug treatment changed during the 1980s. But along the way, they briefly explore organized feminism’s views of alcohol- and drug-using women. They note that Second Wave feminists had dealt aggressively with behavioral health issues such as domestic violence, child sexual 4. Marty Mann, “Can We Conquer Alcoholism?” Health (1947): 12–13, 29–30. Trysh Travis 211 abuse, and rape—all of which correlated closely with substance use and abuse. But they see no feminist activism around alcohol or drugs. Instead, “representatives from organizations in the broader feminist and women ’s health movements” were “conspicuously absent” from the women’s alcoholism movement, which consisted chiefly of activists motivated by alcohol issues, not gender.5 Interest in—and action on—women’s alcohol and other drug use consequently became the province chiefly of clinicians and policy makers, not movement women. Although many of those professionals saw substance-using women’s needs as important and worthy of services, few viewed them through the lenses of gender and power. The blind spot that Schmidt and Weisner observe among feminist activists is interesting not only for what it tells us about a conceptual boundary of Second Wave feminism (both liberal and radical) but also for the way it points to a gap in the feminist scholarship that is ostensibly a central legacy of the earlier movement. Like... (shrink)

Aim Genetic research representative of the population is crucial to understanding the underlying causes of many diseases. In a prospective evaluation of informed consent we assessed the willingness of individuals of different ethnicities, gender and drug dependence history to participate in genetic studies in which their genetic sample could be shared with a repository at the National Institutes of Health. Methods Potential subjects were recruited from the general population through the use of flyers and referrals from previous participants (...) and clinicians with knowledge of our study. They could consent to 11 separate choices so that they could specify how and with whom their genetic sample could be shared. Rates of affirmative consent were then analysed by gender, ethnicity and drug dependence history. Results Of 1416 volunteers enrolled, 99.7% gave affirmative informed consent for studies of addiction conducted in our laboratory. No significant difference was found for participation in genetic studies conducted in our laboratory by gender, ethnicity or drug dependence history. Over all 11 questions, individuals with a history of drug use were more likely to agree to consent to participate in our study than were healthy volunteers. Conclusion A high percentage of each category of gender, ethnicity and drug history, gave affirmative consent at all levels. The level of detail in and the amount of time spent reviewing the informed consent, and a relationship of trust with the clinical investigator may contribute to this outcome. (shrink)

The war on drugs is widely criticized as unjust. The idea that the laws prohibiting drugs are unjust can easily lead to the conclusion that those laws do not deserve our respect, so that our only moral reason to obey them flows from a general moral obligation to obey the law, rather than from anything morally troubling about drug use itself. In this paper, I argue that this line of thinking is mistaken. I begin by arguing that the (...) class='Hi'>drug laws are indeed unjust. However, so long as they remain prohibited, I argue that we have strong moral reasons to avoid drug use. First, drug users are partly responsible for the violent and exploitative conditions in which many drugs are produced and distributed. Second, the unequal ways in which drug laws are enforced make drug use by many an unethical exercise of privilege. These reasons do not depend on the existence of a general moral obligation to obey the law; we ought to refrain from illegal drug use even if prohibition is unjust and even if we have no general obligation to obey the law. In fact, drug laws turn out to represent an interesting exception case within the broader debate about this obligation, and I argue that it is the very injustice of the law that generates the reasons not to violate it. (shrink)

Should the use of performance-enhancing drugs be banned in sport? A proper response to this question depends upon ideas of the meaning and value of sport. To a certain extent, sport is associated with ideal values such as equality of opportunity, fair play, performance and progress. PED use is considered contrary to these values. On the other hand, critics see sport as an expression of non-sustainable and competitive individualism that threatens human welfare and development. PED use is considered a logical (...) consequence of these values. I challenge both views as simplistic and inadequate. I develop what I refer to as the normative structure of sport consisting of self-imposed constraints at three levels: in the formal rules, in norms for fair play, and in the interpretation of athletic excellence as a morally relevant instantiation of human excellence. I argue that the question of a ban on PED should be discussed at the third level and depends upon interpretations of athletic excellence as a form of human excellence. I conclude that, in the current situation of elite sport, proponents of a ban on PED seem to have the strongest arguments. (shrink)

The psychopharmacology of alcohol dependence is today poised at interesting crossroads. Three major drugs Naltrexone, Disulfiram and Acamprosate have been tried and tested in various trials and have many meta-analyses each to support them. While Naltrexone may reduce craving, Acamprosate scores on cost effectiveness worldwide with Disulfiram being an alcohol deterrent drug. Studies support, refute and criticize the use of each of these drugs. Combining one or more of them is also a trend seen. The most important factor (...) in efficacy has been the combination of psychosocial treatment with medication. Studies from the early 1970s to date have been reviewed and the findings presented in a manner useful for the busy clinician to judge the best pharmacological option in the management of alcohol dependence. The role of depot disulfiram, naltrexone, and medications like Topiramate and SSRIs under research for alcohol dependence, are also addressed. (shrink)

Research suggests that reducing rates of drug addiction requires a range of physical spaces where drug users and counselors can meet, build community, and work together. The efficacy of this ‘social infrastructure,’ however, depends not just on how its shared spaces facilitate access to social networks, but on how institutional rules and norms govern the social interaction that takes place in those spaces. I suggest that institutional norms nurture sobriety to the extent that the social arrangements they foster (...) are (i) discretionary, since individuals trying to re-establish sobriety have heterogeneous social preferences; (ii) unconditional, since individuals’ efforts to re-achieve sobriety frequently involve setbacks; and (iii) low-pressure, since individuals may find extraneous turmoil damaging to their renascent sobriety. To the extent that institutional norms facilitate contrary social arrangements, shared settings are liable to backfire—to undermine or at least fail to nurture sobriety—which I illustrate using the case of sobriety-oriented organizations in the Boston area. Critically, while the first two aspects are governed largely by intra-organizational norms, the third is governed by norms between multiple sobriety-oriented organizations. Upholding healthful local norms, then, demands commitment at both the organization and system levels. (shrink)

In the United States, screening the urine of employees or job applicants for the presence of drugs has become commonplace. A survey of 794 large- and mediumsized companies, conducted by the American Management Association in January 1994, found that 87 percent of them now test job applicants for drug use. In 1987, a similar survey found that 22 percent screened job applicants. Federally mandated drug testing programs with random testing requirements affect millions of workers in the transportation industry, (...) the nuclear power industry, and the United States civil and military services.As some of these programs pass their fifth anniversary since being instituted, it is important to assess the forces that led to their creation. Whether or not these programs are considered successful depends on what one expects to achieve by such widespread testing. (shrink)

Intellectual autonomy has long been identified as an epistemic virtue, one that has been championed influentially by Kant, Hume and Emerson. Manifesting intellectual autonomy, at least, in a virtuous way, does not require that we form our beliefs in cognitive isolation. Rather, as Roberts and Wood note, intellectually virtuous autonomy involves reliance and outsourcing to an appropriate extent, while at the same time maintaining intellectual self-direction. In this essay, I want to investigate the ramifications for intellectual autonomy of a particular (...) kind of epistemic dependence: cognitive enhancement. Cognitive enhancements involve the use of technology and medicine to improve cognitive capacities in healthy individuals, through mechanisms ranging from smart drugs to brain-computer interfaces. With reference to case studies in bioethics, as well as the philosophy of mind and cognitive science, it is shown that epistemic dependence, in this extreme form, poses a prima facie threat to the retention of intellectual autonomy, specifically, by threatening to undermine our intellectual self-direction. My aim will be to show why certain kinds of cognitive enhancements are subject to this objection from self-direction, while others are not. Once this is established, we’ll see that even some extreme kinds of cognitive enhancement might be not merely compatible with, but constitutive of, virtuous intellectual autonomy. (shrink)

Intellectual autonomy has long been identified as an epistemic virtue, one that has been championed influentially by (among others) Kant, Hume and Emerson. Manifesting intellectual autonomy, at least, in a virtuous way, does not require that we form our beliefs in cognitive isolation. Rather, as Roberts and Wood (Intellectual virtues: an essay in regulative epistemology, OUP Oxford, Oxford, pp. 259–260, 2007) note, intellectually virtuous autonomy involves reliance and outsourcing (e.g., on other individuals, technology, medicine, etc.) to an appropriate extent, while (...) at the same time maintaining intellectual self-direction. In this essay, I want to investigate the ramifications for intellectual autonomy of a particular kind of epistemic dependence: cognitive enhancement. Cognitive enhancements (as opposed to therapeutic cognitive improvements) involve the use of technology and medicine to improve cognitive capacities in healthy individuals, through mechanisms ranging from smart drugs to brain-computer interfaces. With reference to case studies in bioethics, as well as the philosophy of mind and cognitive science, it is shown that epistemic dependence, in this extreme form, poses a prima facie threat to the retention of intellectual autonomy, specifically, by threatening to undermine our intellectual self-direction. My aim will be to show why certain kinds of cognitive enhancements are subject to this objection from self-direction, while others are not. Once this is established, we’ll see that even some extreme kinds of cognitive enhancement might be not merely compatible with, but constitutive of, virtuous intellectual autonomy. (shrink)

In the last decade, the organization of pharmaceutical research on neglected tropical diseases has undergone transformative change. In a context of perceived “market failure,” the development of new medicines is increasingly handled by public-private partnerships. This shift toward hybrid organizational models depends on a particular form of exchange: the sharing of proprietary assets in general and of intellectual property rights in particular. This article explores the paradoxical role of private property in this new configuration of global health research and development. (...) Rather than a tool to block potential competitors, proprietary assets function as a lever to attract others into risky collaborative ventures; instead of demarcating public and private domains, the sharing of property rights is used to increase the porosity of that boundary. This reimagination of the value of property is connected to the peculiar timescape of global health drug development, a promissory orientation to the future that takes its clearest form in the centrality of “virtual” business models and the proliferation of strategies of deferral. Drawing on the anthropological literature on inalienable possessions, we reconsider property’s traditional exclusionary role and discuss the possibility that the new pharmaceutical “commons” proclaimed by contemporary global health partnerships might be the precursor of future enclosures. (shrink)

Using longitudinal, ethnographic data, the authors examine how the pursuit of self-sufficiency in the context of welfare reform may unintentionally encourage some women to develop alternative dangerous dependencies on abusive or potentially abusive men. In this article, the authors document how women ended up relying on men who have been abusive to them either for instrumental assistance or for more direct financial assistance as they struggled to move from welfare to work. The authors also document how some extremely disadvantaged and (...) vulnerable women became enmeshed in even more dangerous dependencies as they hit time limits and fell through public and private safety nets into drug addiction and sex work. The authors frame this discussion of dangerous dependencies with the recognition that dependency relations are necessary and inevitable components of carework. They argue that the discourse of self-sufficiency should acknowledge the fact that careworkers are productive citizens to the same extent as paid laborers and grapple with the question of the means through which they can support that productivity when personal resources are limited and paid labor is temporarily or permanently impossible. (shrink)

Institutional corruption is a normative concept of growing importance that embodies the systemic dependencies and informal practices that distort an institution’s societal mission. An extensive range of studies and lawsuits already documents strategies by which pharmaceutical companies hide, ignore, or misrepresent evidence about new drugs; distort the medical literature; and misrepresent products to prescribing physicians. We focus on the consequences for patients: millions of adverse reactions. After defining institutional corruption, we focus on evidence that it lies behind the epidemic of (...) harms and the paucity of benefits. (shrink)

Regulators rely on clinical trials for drug approval and labeling decisions. Health systems and clinicians rely on the evidence from trials to determine treatment, and patients rely on it to decide which courses of care to undertake. Many of these stakeholders presume that the careful review of individual studies is enough to address the ethical and scientific questions that arise in clinical trials. In what follows, however, we demonstrate that explicit consideration of trial portfolios—series of trials that are interrelated (...) by a common set of objectives—is crucial. the ethical acceptability and evidentiary probity of individual trials can change depending on the characteristics of the portfolios in which they are embedded. Second, how trial portfolios are composed, how well they are coordinated, and how efficiently they use information determines the balance of risks and benefits they present as well as their different prospects for generating socially valuable information; these three factors also raise distinct questions of justice. (shrink)

Howard Brody identifies “drug-centered care” as a contrast to “patient-centered care” and asks whether drug-centered care promotes the same outcomes that justify patient-centered care—health and dignity for patients and virtue in providers. Answering in the negative, Brody provides a sobering account of how the pharmaceutical industry molds our disease concepts and our perspectives on medications as medical tools. Brody’s new concept was set up to fail, much as if he had named it “money-centered care” or simply “bad care.” (...) This essay asks whether there is a way to reconceptualize drug-centered care such that, even if it does not promote health, dignity, and virtue, it is at least not obviously at odds with these goals. I identify four ways to show that drug-centered care has, in limited cases, morally legitimate application. I show that whether the morally legitimate application of drug-centered care is in the service of health per se, enhancement or quality of life depends on the theoretical background adopted. (shrink)

The psychopharmacology of alcohol dependence is today poised at interesting crossroads. Three major drugs Naltrexone, Disulfiram and Acamprosate have been tried and tested in various trials and have many meta-analyses each to support them. While Naltrexone may reduce craving, Acamprosate scores on cost effectiveness worldwide with Disulfiram being an alcohol deterrent drug. Studies support, refute and criticize the use of each of these drugs. Combining one or more of them is also a trend seen. The most important factor (...) in efficacy has been the combination of psychosocial treatment with medication. Studies from the early 1970s to date have been reviewed and the findings presented in a manner useful for the busy clinician to judge the best pharmacological option in the management of alcohol dependence. The role of depot disulfiram, naltrexone, and medications like Topiramate and SSRIs under research for alcohol dependence, are also addressed. (shrink)

The rapid evolution of drug resistance remains a major obstacle for HIV therapy. The capacity of the virus for recombination is widely believed to facilitate the evolution of drug resistance. Here, we challenge this intuitive view. We develop a population genetic model of HIV replication that incorporates the processes of mutation, cellular superinfection, and recombination. We show that cellular superinfection increases the abundance of low fitness viruses at the expense of the fittest strains due to the mixing of (...) viral proteins during virion assembly. Moreover, we argue that whether recombination facilitates the evolution of drug resistance depends critically on how resistance mutations interact to determine viral fitness. Contrary to the commonly held belief, we find that, under the most plausible biological assumptions, recombination is expected to slow down the rate of evolution of multi‐drug‐resistant virus during therapy. BioEssays 26:180–188, 2004. © 2004 Wiley Periodicals, Inc. (shrink)

This essay argues that policies aimed at suppressing drug use exacerbate the nation's opioid problem. It neither endorses drug use nor advocates legalizing the consumption and sale of all substances in all circumstances. Instead, it contends that trying to suppress drug markets is the wrong goal, and in the midst of an addiction crisis it can be deadly. There is no single, correct drug policy; the right approach depends crucially on the substance at issue, the patterns (...) of use and supply, and the jurisdiction's culture, institutions, and material resources. Decriminalization is no panacea for a nation's drug problems. Nevertheless, either de jure or de facto decriminalization of personal drug possession is a necessary condition for mitigating this crisis. (shrink)

This article examines the case of Insite, North America’s only supervised injection facility, to consider the relationship between dependence, relational autonomy, and vulnerability. At state-funded Insite, users inject illicit drugs under medical supervision. By conceiving of Insite as a health-care facility and addiction as disease, advocates evoke a shared sense of vulnerability among the nonusing public and users, garnering considerable support for the site. Through Insite, the state responds to vulnerability by reshaping the meaning of dependence and conferring (...) recognition upon users, in turn fostering users’ autonomy. However, the medicalized discourse surrounding Insite may obscure drug users’ vulnerabilities emerging not from “disease,” but from stigma and criminalization. Vulnerability analysis must emphasize not merely a naturalized conception of vulnerability, but the socially constructed nature of human beings’ experiences of vulnerability. (shrink)

This article examines how scientists and regulators distribute the benefit of the doubt about drug safety under conditions of scientific uncertainty. The focus of the empirical research is the regulatory controversy over the hepatorenal toxicity of benoxaprofen in the United Kingdom and the United States. By scrutinizing the technical coherence of the arguments put forward by industrial and government scientists, it is concluded that these scientists are willing to award the commercial interests of the pharmaceutical industry an enormous benefit (...) of the sccentific doubt, which is not consistent with the best interests of patients. Interpretative flexibility, the burden of proof falling on regulators and their trust in, and dependence on, industrial scientists facilitates that distribution of the benefit of the scientific doubt. However, regulatory authorities' need for viability and the rationality common to opposing scientific views suggest that it is possible, in principle, to alter this dominant trend. To achieve adequate patient protection, drug regulation in the United Kingdom and the United States requires extensive reform. Some preliminary policy changes are sketched. (shrink)

Pharmaceutical firms seek to fulfill their responsibilities to stakeholders by developing drugs that treat diseases. We evaluate the social and financial costs of developing new drugs relative to the realized benefits and find the industry falls short of its potential. This is primarily due to legislation-mandated reliance on animal test results in early stages of the drug development process, leading to a mere 10 percent success rate for new drugs entering human clinical trials. We cite hundreds of biomedical studies (...) from journals including Nature, Science, and the Journal of the American Medical Association to show animal modeling is ineffective, misleading to scientists, unable to prevent the development of dangerous drugs, and prone to prevent the development of useful drugs. Legislation still requires animal testing prior to human testing even though the pharmaceutical sector has better options that were unavailable when animal modeling was first mandated. We propose that the U.S. Food and Drug Administration and Congress should work together to abolish regulations and policies that require animal use. Doing so will benefit pharmaceutical industry stakeholders, including patients whose health depends on drugs and the many people who rely on the financial well-being of pharmaceutical firms. (shrink)

Ventricular Fibrillation is responsible for a majority of sudden cardiac death, but little is known about how ventricular tachycardia (VT) degenerates into ventricular fibrillation. Several clinical studies focused only on preventing VT with a class III antiarrhythmic drug resulted in many deaths. Our simulations investigate the interactions between an antiarrhythmic drug likely to suppress a VT and a Figure 8 reentry. A parameter AAR is introduced to increase the action potential duration and therefore simulate various Class III drugs. (...) Simulations are ran under several conditions (phases of the reentry, values of AAR, durations). They show that a VT can be suppressed whatever the phase of the reentry but it strongly depends on the duration of the effect. It confirms that a drug which can suppress a reentry can also worsen it. It also shows a great variety of activation patterns and thus the complexity of antiarrhythmic drugs effects. Simulations also demonstrate that suppressing VT is an increasing function of AAR. (shrink)

Recent research conducted in Australia shows that many oncologists withhold information about expensive unfunded drugs in what the authors of the study suggest is unacceptable medical paternalism. Surprised by the Australian results, we ran a version of the study in New Zealand and received very different results. While the percentages of clinicians who would prescribe the drugs described in the scenarios were very similar (73–99% in New Zealand and 72–94% in Australia depending on the scenario) the percentage who would not (...) discuss expensive unfunded drugs was substantially lower in New Zealand (6.4–11.1%) than it was in Australia (28–41%). This seems surprising given the substantial similarities between the two countries, and the extensive interaction between their medical professions. We use the contrast between the two studies to examine the generalisability of the Australian results, to identify influences on clinicians' decisions about what treatment information to give patients, and so the tendency towards medical paternalism and, more pragmatically, about how such decisions might be influenced. (shrink)

Two days following her arrest, a forty-four-year-old woman died in jail from aspiration pneumonia secondary to Untreated opiate withdrawal. The New York State Commission of Corrections concluded in its final report that had adequate medical evaluation and treatment been afforded, her death would have been prevented. A forty-six-year-old male with a history of alcohol dependence was arrested for trespassing and held in the county jail. Three days later he became agitated and aggressive. Following physician orders, deputies placed him in (...) restraints. He subsequently vomited and seized. Fifteen minutes later, he experienced respiratory arrest and died.These cases highlight a serious, but neglected problem in jails across the country: inadequate assessment and treatment of drug and alcohol withdrawal among arrestees. In this article, we show that untreated drug or alcohol withdrawal is associated with adverse outcomes including needless pain and suffering, medical morbidity, and in some instances, death. (shrink)