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NEUROSCIENCE OF PSYCHOACTIVE SUBSTANCE USE AND DEPENDENCE

Substitution therapy—using a medicine that is pharmacologically
related to the dependence-producing substance—has often been contro-
versial, with the argument stated in ethical terms. On the one hand, it is stated
to be unethical for the state, or a treatment professional, to contribute to the
continuation of the dependence, even if on a substitute regime. On the other
hand, the counter-arguments of the demonstrated reductions in harm to
society (e.g. criminal activity) or to the individual (e.g. HIV infection) from
the substitute therapy are also ethical at their core. The general acceptance
of nicotine replacement therapy might be regarded as indicating a gradual
shift away from regarding the dependence itself as the harm, and towards a
public health focus on the health and social harm which come from the use,
whether dependent or not.
It should be noted that the topics discussed here and in Chapter 7 do not
exhaust the range of ethical issues around psychoactive substances in the
context of health practice and research. For instance, special ethical problems
arise when psychoactive medications are used to treat behavioural problems
in children; this may set up lifelong problems (i.e. predisposing them to later
problematic drug use) and may reflect over-prescription of these substances.
Another example is the ethics of “wash-out” studies to study psychoactive
medications, in which patients in treatment facilities are entered into trials
in which they are first taken off all the psychoactive medications they have
been taking (whether as self-medication or by prescription), to evaluate their
“baseline” condition.
A number of conceptual and policy issues might be addressed by scientific
organizations and intergovernmental agencies in light of these developments
in neuro-scientific and other research. These include such matters as the
conceptual basis and empirical findings relevant to definitions of dependence
and other substance use disorders in the International Classification of
Diseases (ICD-10) and the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV); the effectiveness of treatments for substance use
disorders, and their place in systems of health and social services; and in
particular the effectiveness, availability, and ethics of the use of medications
and other biomedical interventions in treatment. As discussed earlier in this
chapter, each such therapy which is currently in effect or still on the horizon,
carries its own set of ethical issues, and these should be considered in the
context of developing international standards for human rights in health
services.
WHO already plays the role of a scientific arbiter on “scientific and medical”
aspects in the classification of controlled substances under the international
drug control treaties (Bruun, Pan & Rexed, 1975; Bayer & Ghodse, 1999). It
exercises this role primarily through an Expert Committee on Drug
Dependence, which meets every two years. As the intergovernmental agency
with primary responsibility for global public health, WHO has responsibilities
and interests concerning psychoactive substances which extend beyond the
scope of the international treaties. One means for addressing these wider

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