America is engulfed in an opioid epidemic. Whether this is depicted through the tens of thousands of lives claimed by the number of drug overdoses each year, the unprecedentedly high and increasing rates of opiate abuse, or the broadening demographic profile of the addict, it is clear that the current issue is one that requires serious attention. As informed by the negative attitudes toward drug addiction that have prevailed since the War on Drugs was declared, it is hypothesized that much of the contemporary predicament is a result of this misinformation that did not resolve, but exacerbated the drug crisis. Despite the concurrent emergence of evidence asserting that addiction is a disease, instead, the idea that drug addiction is a failure prevails. As with many brain diseases, drug addiction displays both pathological alterations in the transmission of signals within the neural circuitries and the morphological defects associated with non-random regions of the brain. The alteration that is observed during opioid tolerance is the desensitization of mu opioid receptors to dopamine, resulting in the need of increased dosage of opiates to achieve the same high. During opioid dependence, key changes that are seen in the locus ceruleus and the mesolimbic reward system increase both the likelihood of an overdose event and withdrawal when an exogenous opioid is present or absent, respectively. There are two models that describe additional changes that occur during the transition from frequent abuse to addiction: (1) the “Changed Set Point Model” and (2) the “Cognitive Deficits Model.” All three variants of the “Changed Set Point Model” portray a shift in the physiological set points of dopamine and glutamate levels in the reward system and regions that control it. The “Cognitive Deficits Model” theorizes that the modifications localized to the prefrontal cortex are responsible for the ultimate transition. Once the abuser is thrust into the addiction cycle, additional changes in the neural networks are observed. These changes are seen in each of the three phases: (1) Binge and Intoxication, (2) Withdrawal and Negative Affect, and (3) Preoccupation and Anticipation. In the first phase, a process called drug-induced neuroplasticity occurs, resulting in the amplification of signals originating from dopaminergic neurons. Next, during Withdrawal and Negative Affect phase, among other changes, the amygdala is shown to be re-wired in such a way that the addict is more sensitive to stress. And finally in the last phase, the changes that occur, secondary to processes similar to drug-induced, are indicated in the prefrontal cortex. The current FDA-approved medication-assisted therapies include methadone, buprenorphine, and naltrexone. The single outstanding abstinence-based treatment is the 12-step program. In the evaluation of medical and non-medical interventions the relative efficacies were measured using the metrics: (1) rates of abstinence achievement, (2) rates of opioid use, and (3) retention in treatment. Individually, all therapies show moderate success when measured against each metric, which further validates the brain disease model for addiction, and also indicates that the future direction of addressing the opioid epidemic should point at combination therapies. What is most imperative now is for there to be more widespread recognition of the brain disease model for addiction.

Nearly 50% of Americans will meet the diagnostic criteria of some form of mental illness in their lifetime (Mehta & Edwards, 2018). However, only 40% of these individuals will seek treatment for them. Patients with mental illness have a lifespan that is, on average, 25 years shorter than individuals without mental illness and are at 2-3 times the risk of diabetes, heart, and lung disease than the average population but do not receive adequate treatment at a proportionate rate. As a country, there are very negative stereotypes held towards individuals struggling with mental illness and substance use disorders even though they are among the most common conditions in the population. This stigma against mental illness often prevents individuals from seeking care for their symptoms and causes medical providers to treat patients with mental illness differently than those without them. Stigma can be seen in the way providers speak about patients with mental illness, the way the medical record labels patients with mental illness, and even how health care providers themselves fail to seek treatment when suffering from mental illness themselves. This thesis examines the types of stigmas that exist, describes how it interferes with clinical care and causes adverse clinical outcomes for patients with mental illness and substance use disorders and provides recommendations for improving the treatment of individuals with mental illness and the importance of normalizing talking about mental illness. / Urban Bioethics

People who inject drugs, particularly opioids, are a growing population, especially in North Philadelphia. This population is at high risk for medical complications that require hospitalization. While hospitalized, this population poses unique challenges to the healthcare system, including high costs and readmission rates, as well as stress and burnout among providers and staff. These patients are at high risk of discharges against medical advice because of complicated social factors as well as inadequate recognition of pain and withdrawal. As the opioid epidemic evolves, previous strategies for managing these patients, which traditionally relied on referral to psychiatry or social work in addition to symptomatic treatment, need to be re-evaluated. Ethically, the decision-making capacity of these patients is frequently called into question, and there is a difficult-to-strike balance between respecting their autonomy and acting with beneficence to provide the best care. There are also public health concerns that come into play. Better acknowledgment of the issues that this population faces, and better management of pain and withdrawal, may improve their outcomes, as well as reduce provider stress and burnout. / Urban Bioethics

Bakgrund: Fetma är en medicinsk diagnos och många av kroppens biologiska funktioner är i obalans med ökad risk för följdtillstånd. För att motverka ohälsan är viktminskning ofta det enda alternativet. Fetmakirurgi är en hållbar viktminskningsmetod, vanligast är gastric bypass, med snabba långsiktiga effekter på följdtillstånd. I riket, liksom i Västmanlands län opereras en övervägande majoritet kvinnor. Varför män i Västmanland opereras i lägre utsträckning än kvinnor är okänt. Syfte: Studiens syfte var att erhålla och analysera mäns värderingar och drivkrafter bakom fetmakirurgi. Målet var även att studera mäns subjektiva uppfattningar av västerländska kroppsideal och dess roll bakom beslutet till fetmakirurgi, samt deras förväntningar av det kirurgiska ingreppet. Metod: Informanterna rekryterades genom Överviktigas riksförbund i Västmanland. Urvalet bestod av fem män i åldern 40-49 år som samtliga intervjuades om subjektiva erfarenheter av och attityder till fetma och fetmakirurgi. Intervjuerna utfördes med hjälp av ett intervjuschema och en tematisk tankekarta baserade på Hälsouppfattningsmodellen. Resultat: Den övergripande drivkraften bakom beslutet var männens hälsa och välbefinnande. Att orka jobba och vara aktiv med familj och vänner beskrevs även som avgörande. Rådande kroppsideal eftersträvades inte. Enligt männen var fetmakirurgi resultatet av insiktsprocesser och ett tillräckligt socialt stöd; fler bör se fetmakirurgi som en hållbar viktminskningsmetod

L’objectif de cette thèse d’articles était de préciser la place respective des mesures objectives (ex., durée et sévérité de la maladie, traitements reçus) et subjectives (ex., troubles psychiatriques, personnalité) en tant que déterminants potentiels de dépression, de qualité de vie (QV) et d’addiction à l’alimentation chez des patient(e)s souffrant de cancer du sein ou d’obésité sévère. En nous basant sur des modèles biopsychosociaux issus du modèle de Wilson et Cleary, nous avons démontré que : 1) La dépression était plus fortement associée aux caractéristiques psychopathologiques de l’individu (personnalité, dépression avant traitement) qu’à la sévérité de la maladie ou aux types de traitements reçus ; 2) Les facteurs associés à la QV dépendent de la dimension de QV considérée (association entre mesures objectives et QV physique ; association entre mesures subjectives et toutes les dimensions de QV) ; 3) Les patients obèses souffrant d’addiction à l’alimentation ont une vulnérabilité psychopathologique spécifique. Nos travaux suggèrent qu’en cas de maladie chronique, les mesures subjectives sont des déterminants potentiels importants de la santé / This article thesis aimed to assess risk factors for three different health outcome measures (depression, health-related quality of life and food addiction) in two populations (breast cancer patients and morbidly obese patients), by assessing the relative impact of biological and physiological variables (i.e., disease duration and severity, types of treatment used), and individual and psychological variables (i.e., psychiatric disorders, personality). By proposing and putting to the test several integrative biopsychosocial models based on Wilson and Cleary’s theoretical model, we demonstrated that : 1) Depression after breast cancer treatment is more strongly associated with variables related to the premorbid individual and psychological characteristics (i.e., personality and depression before treatment) than to biological and physiological variables (i.e., disease severity, types of treatment used) ; 2) Risk factors for lower quality of life are different depending on the quality of life dimension considered (e.g., physical, psychological or sexual) : biological and physiological variables are associated with physical quality of life ; individual and psychological factors are associated with all quality of life dimensions ; 3) Obese patients with food addiction exhibit some specific psychopathological risk factors. Our work suggest to systematically assess individual and psychological variables in patients with chronic diseases because these variables are important potential predictors for different health outcomes