A Hard Look at Addiction in Society: An Interview with Dr. Jürgen Rehm

A Hard Look at Addiction in Society: An Interview with Dr. Jürgen Rehm

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Dr. Jürgen Rehm
Senior Director, Institute of Mental Health Policy Research, CAMH
Professor and Inaugural Chair of Addiction Policy, Dalla Lana School of Public Health
Professor, Department of Psychiatry
Associate Member, Institute of Medical Science

By: Yousef Manialawy

An addiction is not something that is easily overcome. Many challenges lie in effectively counteracting the biochemical changes in the brain observed in countless studies of people with addictions. But just as difficult is identifying the aspects of our society that put people at risk of addictive behaviours and coming to terms with the changes needed to address them. As a leading expert on addictions and health risk management, Dr. Jürgen Rehm is tasked with ensuring that public health policy remains well-informed when making decisions that affect the lives of people in Canada and beyond.

Dr. Rehm has spent a long and illustrious career influencing public health policy through quantitative social research. He obtained his PhD in Philosophy of Science and Statistics in his native Germany before joining the nation’s Federal Health Office. He quickly rose up through the ranks to become Director for Risk Evaluation, where he was responsible for evaluating the significance of various health risks within the population, chief among them alcohol and tobacco use. After a few years working in Germany, he was recruited to the University of Toronto in 1994 as an executive member of the Addiction Research Foundation (which eventually was one of the hospitals merged into the Centre for Addiction and Mental Health). In 2010, he was made Senior Director of the Institute for Mental Health Policy Research. In addition to being an Associate Member of IMS since 1998, he also holds appointments within the Department of Psychiatry and Dalla Lana School of Public Health.

Despite his role as a leading expert on addiction, he confesses that it wasn’t an interest in addictions per se that originally got him into the field, but rather the psychology of risk. “There are a number of very interesting questions around why our society accepts certain risks in some behaviours, but not in others. If the state is producing a risk like radon in your house, you will shout and go to the street even if the risk of lifetime death is one in a million” Dr. Rehm explains. “If you inflict much higher health risks on yourself such as binge drinking with a risk of lifetime death of lower than one in a hundred, you do not care. We tend to underestimate any self-inflicted risk and overestimate any risk others do to us.”

Perhaps one of Dr. Rehm’s most significant research contributions to date is his work clarifying the link between alcohol and dementia risk. In 2016, the high-profile journal The Lancet published a study describing the six biggest risk factors for dementia. To Dr. Rehm’s surprise, the article did not so much as mention alcohol as a risk factor, despite his group’s certainty of the existence of a relationship. “It made us so mad because we knew there was a risk, it just couldn’t be easily quantified” he explains. “So, we teamed up with a group of French researchers and studied the hospital data of 42 million French patients over four years1. We found that the dementia risk associated with alcohol was actually higher than for any of the other risk factors in the original Lancet publication.” How could such a major risk factor have been overlooked in The Lancet study? Dr. Rehm believes it reflects a major issue with the hyper-specialization of science today. “Science is compartmentalized, and people unfortunately don’t always look over the borders of their own field.”

As an expert in risk management, Dr. Rehm is often called on by government bodies such as the Ministry of Health to help them make informed decisions on policies regarding Canadian health. More so than in other scientific fields, his line of work often forces him to address socioeconomic realities of addiction and illness that may not always be easy to acknowledge. A major topic that has gradually emerged within public discourse is the stigmatization of people with mental illness and addictions, to which Dr. Rehm offers some personal insight. “I’m seeing with addiction this self-righteous categorization into ‘us and them,’ between people who use and people who become addicted… it’s not a line, it’s a continuum.”

Despite these challenges, Dr. Rehm believes that public perception on addictions has the potential to change the way it has for depression. “Depression 25 years ago was to just say ‘Oh, all they have to do is think a little and be happy, but now it’s much less common to hear that. There is more education and better realization, but it’s a slow process; it took about 15, 20 years but it was an achievement for depression.” Unfortunately, however, he doesn’t believe that society is progressing quickly enough in their negative perceptions of addictions, such as alcohol abuse. “It’s still not there for alcohol, and the surveys don’t say [that perception is changing]. I think we have to treat it like hypertension, without big judgments [about lifestyle].”

One of the most pressing topics surrounding substance abuse comes in the wake of Canada’s legalization of cannabis in October 2018, with many Canadians wondering if and how this will change Canadian society and their daily lives. Dr. Rehm believes legalization to be a step in the right direction, but argues that it depends on how we choose to proceed with it. He explains that optimally, cannabis should be sold in locations where they check I.D., with clear, plain packaging that properly displays the THC and CBD content with an explanation. “But unfortunately, in some politics–including in this province–they basically say, ‘the goal of cannabis legalization is to make the biggest profit for companies and make our companies the strongest in the world’,” says Dr. Rehm. “Cannabis is not, say, as dangerous as alcohol; however, if we treat cannabis like an ordinary commodity (i.e., unrestricted marketing and advertisements, no enforcement of minimal age, no control of THC content) there may be problems of risky use patterns and use disorders.”

With much to learn about cannabis following legalization, Dr. Rehm also stresses the importance of effectively assessing the benefits and drawbacks without jumping to conclusions. One example is a study that his team recently published identifying a decreased likelihood of developing diabetes among both long-term and 12-month cannabis users relative to non-users2. “Research would indicate that there is a chance [that cannabis use decreases diabetes risk] but this is still just a correlation. So, we cannot establish causality, but I think it’s an interesting proposition and it has to be tested more rigorously.”

With addiction and mental health research more pertinent than ever, the field is quickly evolving to adapt to a rapidly changing society. “Currently life expectancy is declining for the first time since 1945 in the US. If you look more closely you see that the life expectancy of the well-off is still increasing, but it’s actually the life expectancy of the poor that’s decreasing because of greater inequality between socioeconomic classes.”

So how can this issue be effectively addressed? Dr. Rehm believes outside-the-box thinking is the solution. “I’m all for an experimental society where we explore certain things like a minimum income,” he explains. This is pertinent considering the recently scrapped Ontario Basic Income Pilot program3, which was set to explore providing a minimal income to eligible couples or individuals, regardless of employment status. For example, someone who was working but earning below the basic income level would receive monthly payments for up to a 3-year period, and impacts on education, housing, health, and employment would be assessed. “Do we know what comes out of it? No, but how could we know without trying?” asks Dr. Rehm. “It makes no sense [for the Ontario government] to have stopped the universal basic income pilot…even if it was wrong it doesn’t matter, we needed to have learned from it.”

How society chooses to address these socioeconomic issues going forward ultimately rests in the hands of aspiring public health researchers, to whom Dr. Rehm offers some encouraging advice. “Currently we have more funding in our field than ever before…and the overall chance of being able to establish research has never been better. People should be passionate about what they’re doing and try to do it because this is an up and coming field. We believe that people are now more willing to admit to having mental health issues… and it allows us to do something about those numbers.”

References

  1. Schwarzinger M, Pollock BG, Hasan OSM, Dufouil C, Rehm J, QalyDays Study Group. Contribution of alcohol use disorders to the burden of dementia in France 2008-13: a nationwide retrospective cohort study. Lancet Public Health. 2018 Mar;3(3):e124–32.
  2. Imtiaz S, Rehm J. The relationship between cannabis use and diabetes: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. Drug Alcohol Rev. 2018;37(7):897–902.
  3. Ontario government defends move to cancel basic income pilot project | Globalnews.ca [Internet]. 2018. Available from: https://globalnews.ca/news/4365399/ontario-cancels-basic-income-pilot-project/