Transcript Sophia training Gerra

Prevention and treatment of drug dependence:
new challenges and perspectives
Gilberto Gerra
Chief
Health and Human Development Section
UNODC
PREVENT METHAMPHETAMINES USE
AND TREAT METHAMPHETAMINES
USE DISORDERS
PREVENT
COCAINE USE
AND TREAT
COCAINE
DEPENDENCE
PREVENT PRESCRIPTION
DRUGS USE AND TREAT
DEPENDENCE
hydrocodone
BZDs
UNDERSTAND AND PREVENT
combinations of psychedelics
‘…..Similar to combining DMT/DPT/5-MeO-DMT with ketamine,
combining 4-acetoxy-DET with ketamine also provides an
incredible synergy. Highly recommended for the cosmic-mystical
near-death inclined!..... Xenon gas while on mushrooms or
LSD comes in at a close second. ’
N,N-dimethyltryptamine (DMT)
N,N-dipropyltryptamine (DPT)
N,N-diethyltryptamine (DET)
5-methoxy-DMT (5-MeO-DMT)
F. Schifano, 2008
CANNABINOID AGONISTS DESIGNERS?
Delay the age of onset
significantly elevated ORs for a cannabis use disorder
at each of teenage years (ages 12-18; range of ORs=3.9-7.2),
(Winters and Lee, 2008)
youths aged 12 to 17
have constituted about
two thirds of the
new marijuana users
(OAS, 2001)
PREVENT THE USE
OF
LEGAL DRUGS
ALCOHOL
AND
TOBACCO
Have
drug dependence
recognized
as a disease
Isolation and Social Status Can Change Neurobiology
Brain DA D2 Receptors
Becomes Dominant
No longer stressed
Individually
Housed
Group
Housed
Becomes Subordinate
Stress remains
Morgan, D. et al. Nature Neuroscience, 5: 169-174, 2002.
LL
SL
SS
NOVELTY SEEKING
15,72
19,41
21,75*
BDHI DIRECT AGGRESSION
51,03
55,70
59,58*
LL
SL
SS
smokers
26.53%
50.00%
23.47%
neversmoking
subjects
37.63%
52.69%
9.68% *
* chi2=7.33, p<0.05
DRD2-TaqI A1
allele polymorphisms
30%
methamphetamines
abusers
controls
Higher
novelty
seeking scores
among
meth-abusers
with allele A1
Han et al., 2008
DAT genotypes among heroin dependent patients
Genotypes
9-9
10-10
9-10
9-11
10-11
Offenders
17.3%
42.3%
36.5%
0%
3.8%
Non-offenders
3.8%
48.1%
44.3%
5.8%
0%
2= 4.39
p= 0.04
n.s.
n.s
n.s.
n.s.
Gerra et al., Addiction Biology, 2005
Heroin abuse was significantly associated
with proenkephalin (PENK) polymorphic
3' UTR dinucleotide (CA) repeats
79% of subjects homozygous
for the 79-bp allele were heroin abusers
Nikoshkov et al., 2008
Genetic risk
Environmental risk
substance use
low levels of environmental risk
may buffer against
the potentially unfavorable effects
of high familial risk
temperament predicted substance use
only through shared environmental
factors
Legrand et al., 1999
Relevance of childhood neglect, 5-HTT gene variants
and hypothalamus-pituitary-adrenal axis dysregulation
to substance abuse susceptibility
5HTT
SS
neglect
HPA
axis
Risk of experimenting with illicit drugs
Gerra et al.,
In press
Gerra et al., in press
reduced maternal care perception
was found to represent
a key intermediate factor
of the association between SS polymorphism
and drug use, suggesting that genetic factors
and parental behavior concur to drug use
susceptibility
Once controlled for CECA-Q scores the relative risk associated
to the SS genotype drops strikingly
Nilsson et al., 2005
adolescents with the S allele of the 5-HTT gene
and with family relations being "neutral"
or "bad" had a 12- to 14-fold increased risk
for high alcohol intoxication frequency
American Journal of Medical Genetics Part B (Neuropsychiatric Genetics) 141B:1–7 (2007)
_____________________________________________________________________________
Perceived Parenting Behavior in the Childhood of
Cocaine Users: Relationship With Genotype and
Personality Traits
G. Gerra,1* A. Zaimovic,1 L. Garofano,2 F. Ciusa,1 G. Moi,1 P. Avanzini,3 E. Talarico,3 F. Gardini,4 F.
Brambilla,1 M. Manfredini,5 and C. Donnini5
1Centro Studi Farmaco-tossicodipendenze, Ser.T., AUSL, Parma, Italy
2Reparto Investigazioni Scientifiche (RIS), Carabinieri di Parma, Parma, Italy
3Servizio Immuno-trasfusionale, Azienda Universita`-Ospedale di Parma, Italy
4Dipartimento di Medicina Interna, Azienda Universita`-Ospedale di Parma, Italy
5Dipartimento di Genetica Antropologia Evoluzione, Universita` degli Studi di Parma, Parma, Italy
Perceived parenting behaviour in the childhood of cocaine users:
relationship with genotype and personality traits (Gerra et al., 2007)
PBI
Paternal care
PBI
Maternal care
BDHI
Direct
aggression
25,490,42
27,590,38
45.32.9
cocaine users
LL-SL 5-HTT
genotypes
22,560.9
24.610.5
59.32.9
cocaine users
SS 5-HTT
genotypes
18.780.4
18.890.45
63.252.5
abstinent
subjects
27
- 10% risk
PBI SCORE
- 20% risk
- 90% risk
18
PERCEPTION OF PARENTAL CARE
RISK OF COCAINE USE IN THE ADULT
Adverse childhood experiences
neglect
abuse
Monkeys who suffer maternal deprivation in childhood
tend to be fearful, more aggressive, less exploratory,
and subject to binge drinking on exposure to alcohol
Early maternal deprivation
reduces serotonin transporter
Ichise et al., 2006
- Childhood psychiatric disorders
- Early onset adult psychiatric disorders
Self-medication mechanism
Addiction and premorbid psychiatric disorders:
- social phobia
- bipolar affective disorder
- depression
- anxiety
- conduct disorder
- oppositional defiant disorders
were strongly associated
with the subsequent development
of substance dependence
(attributable risks ranging from 44 to 86%)
Merikangas and Avenevoli, 2000
Arch Gen Psychiatry
Prospective effects of attention-deficit/hyperactivity disorder,
conduct disorder, and sex on adolescent substance use and
abuse.
Elkins et al., 2007
Hyperactivity/impulsivity predicts
later substance problems,
even after growth in later-emerging CD
is considered
Inattention alone poses less risk
ADDICTION CAN BE TREATED
Partial Recovery of Brain Dopamine Transporters
in Methamphetamine (METH)
Abuser After Protracted Abstinence
Normal Control
METH Abuser
(1 month detox)
METH Abuser
(24 months detox)
Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.
Midbrain SERT density significantly increased during psychotherapy
Baseline
12 months
DRUG USE IS ONE OF THE
TOP 20 RISK FACTORS TO HEALTH WORLDWIDE
TOP 10 IN HIGH INCOME COUNTRIES
HIV/AIDS HEPATITIS
TUBERCULOSIS
SUICIDE – PSYCHIATRIC DISORDERS
CARDIOVASCULAR DISEASES
OVERDOSE DEATHS
30% of HIV infection is due to injecting drug users
when criminal activities related to drugs are included
THE COST OF DRUG DEPENDENCE
CAN AMOUNT TO 2% OF THE GDP
…eliminating or reducing illicit demand
for narcotic drugs and psychotropic substances
with a view of reducing human suffering
STOP PUNISHMENT
AND UNETHICAL TREATMENT METHODS
STOP VIOLATION
OF HUMAN RIGHTS
PRESENTED AS TREATMENT
STOP MARGINALIZATION AND DISCRIMINATION
- Reach individuals not motivated to treatment
- Protect their health and respond to HIV epidemic
- Provide unconditioned social assistance
- Offer low threshold, accessible treatment
for drug dependence
Provide a comprehensive package of
harm reduction measures
a. reliable information and counseling
b. low-threshold pharmacological interventions (example opioid-agonists and antagonist
drugs) easily accessible
c. adequate social assistance for marginalized drug dependents
d. vaccination programmes against Hepatitis to all drug abusers
e. medication and emergency kits for management of overdoses in appropriate places
f. needle/syringe exchange programmes under sound medical practice
g. voluntary HIV counseling and testing, and antiretroviral treatment
h. prevention and services for the management of sexually transmitted infections for
drug abusers involved in sex work;
i. availability of measures to prevent acute consequences of stimulants abuse (free water…)
j. interventions in emergency rooms
k. well-equipped street-workers and peer outreach workers units
l. measures to prevent car and workplace accidents
m. social assistance for children of drug dependent individuals
NOT IN ALTERNATIVE TO DEMAND REDUCTION
BUT COMPLEMENTARY TO DEMAND REDUCTION
BASIC FIRST LINE
HEALTH/ SOCIAL
ASSISTANCE
SCHOOL INSTEAD OF STREET
SUSTAINABLE
LIVELIHOOD OPPORTUNITIES
TREATMENT OF
CONCOMITANT
PSYCHIATRIC DISORDERS
Estimated coverage of drug education in
schools based ONLY on information
20%
80%
Receive information
Do NOT receive information
Data from selected key countries in Asia, Latin America and Africa
Estimated coverage of drug education
in schools that is EVIDENCE-BASED
5%
95%
Covered by evidence-based drug education
NOT covered by evidence-based drug education
Data from selected key countries in Asia, Latin America and Africa
WHAT IS NOT WORKING IN PREVENTION
scare tactics and moralistic appeals
curricula that rely solely on information about drugs and their dangers
curricula that only work to promote self-esteem and emotional well-being
single shot assemblies
testimonials by former addicts
counseling in peer-group context
recreation and community service activities
Levine et al. 1999
WHAT IS WORKING IN SCHOOL PREVENTION
training in resistance skills
normative education
life skills: communication
life skills: decision making
life skills: emotional communication
life skills: impulse control
life skills: self esteem
trained teacher
interactive method
Faggiano et al., Cochrane 2005
interactive approaches
life skill practice
normative education, which
portrays true use rates and
corrects misperceptions
positive school climates:
a combination of clear policies
and procedures, training and
support for school staff,
students and families and
partnerships with community
members
Nancy Tobler (1992)
Linda Dusenbury (1995)
Parental care/neglect
Trauma/abuse
School connectedness
RISK
RESILIENCE
Stress, post conflict,
instability, poverty
Bonding to the community
Values and believes
Return on Investment
(Benefit-cost ratios) of Selected Programs
• Pre-school education
– Early Childhood Education.........................................$2.36
• Child welfare
– Nurse Family Partnership...........................................$2.88
• Youth development
– Guiding Good Choices (PDFY)...............................$11.07
• Juvenile offender programs
– Dialectical behavior therapy....................................$38.05
*Source: Aos, Lieb, Mayfield, Miller & Pennucci (2004)
Future Annual Benefits
from Preventing a Single Alcohol Use Disorder
7000
6000
5000
4000
3000
2000
1000
0
18
26
34
42
50
Years of age
58
66
74
Estimated variety and coverage
of treatment offered
Latin America
Africa
Asia
0
20
40
Variety
60
80
100
Coverage
Data from selected key countries in Asia, Latin America and Africa
Main problem drugs as reflected in treatment demand in
2006
(or latest year available)
26 million problem drug users
4.9 million persons treated in 2006
ESTIMATES CONCERNING THE COST
OF DRUG DEPENDENCE TREATMENT AND CARE
IN LOW AND MIDDLE INCOME COUNTRIES
the highest estimate: 52bn
0.4 % of GDP
US$ 21 bn
0.16% of GDP
the lowest estimate: 4 bn
0.03 % of GDP
UNODC, unpublished data
Addictive Disease core
Compulsive behaviors/drug seeking
in spite of adverse consequences
Behavioral under-control – risk
taking
Reduced reward perception
Impairment of emotional perception
and communication
Inability to cope with stress
Social isolation, low self esteem
and depressive traits
Unstable mood and affects, anxiety
Barriers to drug dependence treatment and care
No services available
Lack of professional
competence
Stigma/discrimination
Services not incorporated
in the health care system
Services far from home
Punishment
Consequences of registration
Services not for free
or high threshold
No complementary
sustainable livelihood measures
MAKE A VARIETY OF TREATMENT METHODS ACCESSIBLE
WHAT IS WORKING IN TREATMENT
Brief intervention
Vocational training
Motivational therapy
Cognitive-behavioural therapy
Contingency therapy
Family therapy
Self help 12 step
Long term opioid-agonists
Slow release opioid-antagonists
Alpha-adrenergic agonists
Vaccine
Modafinil
DA D3 antagonist
Antiepileptic GVG
N-acetylcysteine
CRF-antagonists
Promising tools
100
Addiction Treatment Does Work
90
80
40
30
20
50 to 70%
50
30 to 50%
60
50 to 70%
70
40 to 60%
Percent of Patients Who Relapse
Relapse Rates Are Similar for Drug Dependence
And Other Chronic Illnesses
10
0
Drug
Dependence
Type I Hypertension Asthma
Diabetes
Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.
Evaluation of A Hypothetical Treatment
Symptom Severity
10
HYPERTENSION
9
8
7
6
5
4
3
2
1
0
Pre
During
Symptom Severity
10
During
During
Post
ADDICTION
9
8
Just Like Hypertension,
Addiction Is A
Chronic Disease That
Requires Continued Care
7
6
5
4
3
2
1
0
Pre
During
During
During
Stage of Treatment
Post
Source: McLellan, AT, Addiction 2002.
Mobilization for drug dependence
treatment and care:
a large partnership…
…starting from
UNODC and WHO
1) Advocacy
2) Training, good practice dissemination
3) Low cost treatment centers
4) Evaluation and research
5) National-regional networks
6) Guidelines and therapeutic tools
2009-2013
20 developing countries
in the first biennium
30 developing countries
in the second biennium
A partnership for
drug dependence treatment and care
Low cost treatment centres /
non-professional teams
Counselling/brief intervention/vocational therapy
Medications: nurses/primary care
Social assistance
Families involvement
Health care-HIV-Hepatitis prevention
Outreach/ low threshold interventions
mainstreaming addiction
treatment and
HIV/Hepatitis prevention
in health care system
and municipalities social
programs
FROM HOPELESSNESS
TO HOPE