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1 Table of Preface Acknowledgements List of abbreviations page xv xix xxi Chapter 1. Introduction Introduction Neuroethics: the promises and perils of neuroscience research Addiction enters the neuroscientific era Aims and overview 10 Part 1. The Science of Addiction Chapter 2. What is addiction? Introduction The phenomenology of addiction Folk understanding of addiction Clinical understanding of addictive behaviour The social and economic costs of drug use and addiction Prevalence of drug use and addiction in Australia Drug use related harm Burden of disease due to alcohol and drug use Social response to drug abuse and addiction Governing models of addiction Moral vs. medical models of addiction Neurobiological models of addiction Potential consequences of neurobiological explanations of addiction Conclusion 34 vii

2 Table of viii Chapter 3. The neurobiology of addiction Introduction The neuroanatomy of addiction Reward and reinforcement: the dopamine hypothesis The endogenous opioid system Memory, learning and habits Compulsion, craving and inhibitory control Executive control and cognitive impairment Representing bodily urges Stress and drug use Molecular and cellular changes in addiction Synaptic plasticity in addiction Epigenetic changes in addiction Vulnerability to addiction: genetic and neuropsychological factors Genetic susceptibility to addiction Vulnerabilities to addiction: a confluence of the genetic and the social Conclusion 59 Chapter 4. Neurobiological treatment of addiction Introduction Pharmacological treatments that block drug binding Agonists Antagonists Partial agonists Duration of pharmacological treatment of addiction Pharmacological treatments of withdrawal Pharmacological treatments of craving and relapse Dopaminergic mesolimbic reward pathway Pharmacological interventions in systems related to the reward pathway Opioids The amino acid neurotransmitters: glutamate and GABA Cannabinoids 74

3 Table of ix Corticotropin-releasing factor and the stress response Memory manipulators and cognitive enhancers Pharmacogenetic treatment of addiction Novel approaches to drug treatment Immunotherapies Long-acting or sustained-release medications Neurosurgery and deep brain stimulation Transcranial magnetic stimulation Applications of neuroimaging and neurocognitive screening in addiction treatment Psychosocial treatment of addiction Conclusion 81 Part 2. The Ethical and Philosophical Implications of Neuroscientific Knowledge of Addiction Chapter 5. Autonomy, addiction and the public good Introduction Approaches to ethical analysis Introduction to ethics Principlism Human rights A pragmatic approach to neuroethics Ethical principles in the treatment of addiction Autonomy and addiction Addiction and the public good The minimum conditions for the ethical treatment of addiction Conclusion 103 Chapter 6. Autonomy and the capacity to consent to addiction treatment Introduction The role of informed consent in addiction treatment Can addicts say no to drugs? Sceptical views of impaired autonomy in addicted individuals Capacity to consent to abstinence-oriented treatment 114

4 Table of x 6.4. Implications for obtaining informed consent to enter addiction treatment Guidelines when admitting individuals into addiction treatment Conclusion 119 Chapter 7. The rights of individuals treated for addiction Introduction Addiction, drug policy and human rights Basic human rights for addicted individuals The right to access to effective treatment of addiction The case for medical treatment of addiction Effective treatment of addiction The right to access harm reduction measures The right to effective medical treatment The use of unevaluated and risky treatments of addiction Respecting human rights when treating under legal coercion Human rights in the treatment of addicted prisoners Human rights in the treatment of addicted pregnant women Future challenges for human rights practitioners Conclusions 133 Chapter 8. Coerced treatment of addiction Introduction Approaches to coerced treatment The case for legally coerced treatment When is coerced treatment ethical? Ethical issues in providing coerced addiction treatment Is compulsory addiction treatment ethically acceptable? Conclusion 144 Chapter 9. Ethics of addiction research Introduction Informed consent to participate in addiction research Paying addicted subjects 150

5 Table of xi 9.4. Privacy, confidentiality and anonymity Administering addictive drugs in research studies Why do neuroscientists give drugs to addicts? The risks of giving addicts drugs in research settings Research participation by treated vs. untreated addicts Recruiting subjects and obtaining consent Conclusion 160 Part 3. The Ethical and Public Policy Implications of Novel Technologies for the Treatment of Addiction Chapter 10. New developments in the treatment of addiction Introduction Novel pharmacological treatments of addiction Ethical and policy issues in pharmacological R&D in addiction Anti-craving drugs Novel relapse prevention treatments Drug vaccines as a prophylaxis against relapse Sustained-release treatments: depot medications and drug implants The Australian naltrexone implant experience Coerced use of depot naltrexone to restore autonomy? Conclusion 179 Chapter 11. The search for a neurological cure of addiction? Introduction A brief history of addiction cures Quacks and nostrums: Early medical treatments of drug withdrawal: The modern era: neurobiologically inspired addiction cures Ibogaine therapy Ultra-rapid opioid detoxification 187

6 Table of xii Neurosurgical treatment of addiction Deep brain stimulation for intractable addiction? Avoiding future therapeutic enthusiasms 195 Chapter 12. Preventive medicine and personalised treatment of addiction Introduction Bioprediction of addiction liability Predictive genetic testing of addiction liability Using genetic information to increase abstinence from drug use Genetic discrimination and third party uses of genetic information Premature commercialisation of genetic testing Preventive interventions: vaccinating against addiction Predictive uses of neuroimaging technologies Personalised treatment of addiction Pharmacogenetic treatment of addiction Neuroimaging and cognitive tests in the clinic Conclusion 213 Chapter 13. Feeling better than well Introduction Memory modifiers, cognitive enhancers and mood modulators What s wrong with neuroenhancement? Concerns about safety and efficacy Coerced neuroenhancement: a psychopharmacological arms race Equity of access to neuroenhancement technologies Naturalistic objections to enhancement: morality and personhood Lessons from recreational drug use and drug policy The future of drug regulation Conclusion 225

7 Table of xiii Part 4. The Future of Addiction Research and Policy Chapter 14. The social and policy implications of addiction neurobiology Introduction Implications for public health policies towards drug addiction Medicalisation of addiction Neuroscience, addiction treatment and public health policy Competing population health strategies Subversive uses of neuroscience research on addiction Drug policy and double standards The prospects of novel pharmacological harm reduction: engineering safer recreational drugs? Conclusions 242 Chapter 15. Concluding remarks and summary Introduction Summary and conclusion Key findings Specific implications for the treatment of addiction Neuroscience and the media: the role and responsibility of neuroscientists The tasks ahead for ethicists and policy makers Future directions for addiction neuroethics Private and public understanding of addiction neuroscience Capacity to consent in a research or treatment setting Epidemiological modelling of addiction policy Using incentives to reduce drug use and achieve better health outcomes Conclusion 262 Glossary 264 Bibliography 275 Index 331

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