Addiction—25 Years Later

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In the 25 years since the inception of the Harvard Review of Psychiatry, enormous strides have been made in understanding the etiology and neurobiological underpinnings of addiction and in demonstrating evidence-based pharmacologic and behavioral treatments. Yet we have made minimal progress in closing the gap between the overall prevalence of substance use disorders (SUDs) and the proportion of individuals with these disorders who ever receive any treatment in the course of their lifetimes.1 When the first issue of HRP was published, the United States was just emerging from a cocaine epidemic, and now as the Review’s 25th anniversary volume goes to press, the United States is in the midst of a ravaging opioid epidemic. During this interval, the neurobiology underlying these disorders has become increasingly clarified; behavioral interventions such as cognitive-behavioral therapy (CBT), relapse prevention, motivational interviewing, brief interventions, 12-step facilitation, contingency management, and others have demonstrated effectiveness; and new medication-assisted treatments for alcohol, opioid, and nicotine use disorders have received approval from the Food and Drug Administration (FDA). However, the United States’ treatment system has struggled to disseminate these lifesaving treatments to the approximately 20% of the U.S. population who would benefit from them. The gap between available evidence-based treatments and the delivery of these treatments to the majority of patients in need of them is the focus of the 2016 landmark report Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.1
In its first publishing year, HRP published five articles on addiction that were emblematic of the state of the field at that time,2–6 including: evidence for adaptations to chronic drug administration in the brain’s ventral tegmental area and nucleus accumbens;2 clinical and preclinical studies of buprenorphine treatment of opioid and cocaine dependence;3 the role of psychotherapy in the treatment of substance use disorders;4 emerging evidence of gender differences in alcohol-related disorders;5 and the importance of treating co-occurring psychiatric disorders.6 There has been a rapid acceleration of new knowledge in each of these areas over the last two decades.
Basic and translational research has expanded our understanding of the reward circuitry underlying addiction, including brain circuits that mediate substance-induced reward pathways, stress-related changes during withdrawal, and craving and compulsion.7 These interconnected neural circuits are disrupted through the chronic use of substances, and affect the pathways of reward, learning, and control. A convergence of data over the past two decades also demonstrates that 40% to 60% of the risk for addiction is conferred by genetics. The array of gene variants implicated in the development of SUDs grows each year. In addition, in the past decade new research has highlighted epigenetic mechanisms that can switch on genes implicated in the development of addiction. Early childhood trauma may be a particularly powerful environmental stressor that produces potentially heritable epigenetic changes that confer greater risk for addiction in later life. To provide even greater understanding of the developmental risks for SUDs, a new ten-year longitudinal study, the Adolescent Brain Cognitive Development study, was launched by the National Institutes of Health in 2016 to investigate the effects of substance use at critical stages of adolescent brain development.
Parallel to discoveries in the areas of neuroscience and genetics, treatment research has expanded the evidence base for effective medications and behavioral treatments across different substances of abuse and levels of SUD severity.
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