drug prevention and health branch division for operations gilberto gerra
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Drug Prevention and Health Branch Division for Operations Gilberto Gerra. The drug control system: health and social implications. …from the dangerous effects of illicit drugs. Protect the health of the new generations…. …among adolescents. Prepare a future of freedom, - PowerPoint PPT PresentationTRANSCRIPT
Drug Prevention and Health Branch Division for Operations
Gilberto Gerra
The drug control system: health and social implicationsThe drug control system: health and social implications
Protectthe healthof the new generations…
…from the dangerouseffects of illicit drugs
Preparea future of freedom,social engagementand success…
…among adolescents
Change the trajectory of adolescent at risk…
...and adolescentsexperimenting with drugs
Develop specific treatment programsfor very young drug dependent individuals
Children using drugsat the age of 6-11Children using drugsat the age of 6-11
Implement science-baseddrug dependencetreatment programs
Prevent the spreadof HIV-Hepatitis-TB epidemicsamong drug users
Treat HIV-AIDS
Offer drug dependencetreatmentprogramsand HIVprevention in prison
Support thefamiliesof farmersinvolvedincropseradication
The Political Declaration 2009confirmed the validity of the UN Conventions on Narcotic Drugsand Psychotropic Substances (unanimously)
The drugs listed in the Conventionsare licit only when used for medical and scientific purposes
These drugs are illicit because they aredangerous, not dangerous because they are illicit
Pulmonary Emboli in a User of Crack Cocaine
methamphetamines
heroin overdoses1990–2006
between 6 400 and 8 500 drug-induced deaths were reported each year by EU Member States,
non-fatal overdoses (estimates 50.- 60.000)
EMCDDA
LancetAdverse health effects of non-medical cannabis use.
Hall and Degenhardt, 2009
a dependence syndrome
increased risk of motor vehicle
crashesimpaired respiratory function
cardiovascular disease
adverse effects on adolescent psychosocial development
and mental health
Illicit Drug Use at the Global Level Illicit Drug Use at the Global Level * Data from UNODC World Drug Report 2009* Data from UNODC World Drug Report 2009
Estimated coverage of drug education in schools based ONLY on information
Data from selected key countries in Asia, Latin America and Africa
20%
80%
Receive information Do NOT receive information
training in resistance skills
normative education
life skills: decision making
life skills: emotional communication
life skills: impulse control
family skills
trained teacher
interactive methods
WHAT IS WORKING IN PREVENTION
Faggiano et al., Cochrane 2005Molgaard & Spoth, 2001
Estimated coverage of drug education in schools that is EVIDENCE-BASED
Data from selected key countries in Asia, Latin America and Africa
5%
95%
Covered by evidence-based drug education
NOT covered by evidence-based drug education
Data from UNODC World Drug Report 2009Data from UNODC World Drug Report 2009
4.3 million receiving treatment (out from 18-38)
WHAT IS WORKING IN TREATMENT
Brief interventionVocational trainingMotivational therapyCognitive-behavioural therapyContingency therapyFamily therapySelf help 12 stepTherapeutic community
Long term opioid-agonistsSlow release opioid-antagonistsAlpha-adrenergic agonists
VaccineModafinilDA D3 antagonistAntiepileptic GVGN-acetylcysteineCRF-antagonists
Promising medications
Estimated variety and coverage of treatment offered
0 20 40 60 80 100
Asia
Africa
Latin America
Variety Coverage
Data from selected key countries in Asia, Latin America and Africa
MalariaTuberculosisHIV/AIDS
Illicit drugs dependencePrescription drugs abuseAlcoholism
Global FundWorld Bank
$
?
Counteracting production and trafficking and health protection are not contradictorystrategies
A well balanced integrated approach
Single Convention on Narcotic Drugs,1961, Article 38
“the Parties shall give special attention to and take all practicable measures for the prevention of abuse of drugs and for the early identification, treatment, education, after-care, rehabilitation and social reintegration of the persons involved”
Single Convention on Narcotic Drugs,1961, Article 36 b
“abusers shall undergo measures of treatment, education, after-care, rehabilitation and social reintegration”
Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, 1988, Article 14 (4)
“…parties shall adopt appropriate measures aimed at eliminating or reducing illicit demand for narcotic drugs and psychotropic substances, with the view to reducing human suffering…”
INCB Report 2007 (EN/INCB/2007/1) “with offences involving the possession, purchase or cultivation of illicit drugs for the offender’s personal use, the measures can be applied as complete alternatives to conviction and punishment”.
Political Declaration, 2009
promote, develop, review or strengtheneffective, comprehensive, integrated drug demand reduction programmes, based on scientific evidence including … early intervention, treatment, care, rehabilitation, social reintegration and related support services, aimed at promoting health and social well-being among individuals, families and communities and reducing the adverse consequences ofdrug abuse …
promote, develop, review or strengtheneffective, comprehensive, integrated drug demand reduction programmes, based on scientific evidence including … early intervention, treatment, care, rehabilitation, social reintegration and related support services, aimed at promoting health and social well-being among individuals, families and communities and reducing the adverse consequences ofdrug abuse …
Prevention Treatment Rehabilitation Section
Improvingparenting to preventdrug use, risk behaviors and crime
Disseminatereliable information,prevent substance abuse,fight stigma and inspiresolidarity in the workplace
Disseminatereliable information,prevent substance abuse,fight stigma and inspiresolidarity in the workplace
Prevention Treatment Rehabilitation Section
Latin AmericaBrazilHaitiColombiaPeruNicaragua
Central Asia:AfghanistanKazakhstanKyrgyzstanPakistanTajikistanTurkmenistanUzbekistan
Europe:AlbaniaSerbia
North Africa:EgyptIran
JordanLebanonMorocco
United Arab Emirates
UNODC treatment programme countries
Africa:Nigeria, Mozambique, Cote d’Ivoire,
Tanzania, Sierra Leone, Kenya, Zambia, Ethiopia, Uganda, Madagascar, South Africa,
Seychelles, Cape Verde
South East Asia:CambodiaMyanmarViet Nam
Prevention Treatment Rehabilitation Section
Content of the program
UNODC-WHO Programme on Drug Dependence Treatment and care
Haiti
SerbiaAlbania
Pakistan
4 countries
UNODC HIV Section 70 professionals in 35 countries, covering 70 countries
National staff International staffSeptember 2010
A comprehensive package of measuresto prevent HIV in the community and in prison
Antiretroviraltherapyof AIDS
Sustainable LivelihoodsUnit
Alternativedevelopmentin 7 countries
First line social assistance to drug usersin the cities
Moving from asanction-oriented approach ...
to a health-oriented approach
A heroin addict was shackled on arrival at a detoxification shelter.
The chains prevent flight whenwithdrawal sets in.
Social exclusion
re-educationand working therapy
Detoxificationmethods
neuroadaptive processes in the brain reward system: allostasis
usurpation of emotional memory
willpower dysfunction
stress-induced and drug cue-induced craving states
Drug dependence is a multi-factorial chronic disease
Childress et al.,
2008
Activation of the reward/motivation systemwith drug related stimuli of 33 mSec.
To explore in depth the pathogenesis of the disease
Is initiation to drugs related to a free-choice?
Is continuous use due to a simple decision/preference?
Is development of dependence a conscious free process?
Gene variants:temperaments
Adverse childhood experiences
Psychiatric disorders
Substance use disorderssusceptibility
Adverse childhood experiences
Gene variants
G X E
Gene X Environment interaction in addiction pathogenesis
.Gorwood et al., 2007
+
EARLY SOCIALDEPRIVATIONEARLY SOCIALDEPRIVATION
GENE VARIANTSEROTONINE T.GENE VARIANTSEROTONINE T.
Alcohol preference and proneness to use
reduced maternalcare perception was found to represent a key intermediate factor ofthe association between the gene variant and drug use among adolescents
Gerra et al., 2010
The genetic epidemiology of cannabis use, abuse and dependence.
the substantial evidence for the heritability of cannabis use, abuse and dependence
a genetic basis to each stage of cannabis involvement
Agrawal and Lynskey, 2006
Kostelecky, 2005
Parental attachment was the only variablethat accounted for a significant portion of the variance in adolescent marijuana use
The effects of perceived parenting style on the propensity for illicit drug use: the importance of parental warmth and control.
Compared to non-users, a greater proportion of ecstasy/polydrug users characterized their parents' style as neglectful.
The modal style endorsed by non-users was authoritative.
Montgomery et al., 2008
Isolation and Social Status Can Change NeurobiologyIsolation and Social Status Can Change Neurobiology
IndividuallyHoused
GroupHoused
Becomes DominantNo longer stressed
Becomes SubordinateStress remains
Morgan, D. et al. Nature Neuroscience, 5: 169-174, 2002.
Brain DA D2 Receptors
Drug use among street children and non--street children in the Philippines.
street children with little or no contact with their families were 2.0 times more likely to smoke tobacco 1.3 times more likely to use alcohol 36.7 times more likely to use inhalants5.5 times more likely to use illegal drugs than their non-street
Njord et al., 2010
results showed that low-income youth were 63% more likely to have tried marijuana at least once
Lemstra et al., 2009
PovertySocial exclusionInstability/migrationLack of bonding to family/supervisionLack of school connectednessCoping with stress and violenceHunger Work overload
SOCIAL FACTORS CONTRIBUTING TO DRUG USE VULNERABILITY
children smoking crack in the street
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
The use of alcohol and drugs to self-medicate symptoms of post-traumatic stress disorder. Leeies et al.,2010
Conroy et al., 2009, NDARC
Physical abuse % 36.4 57.5 control case
Child maltreatment among opioid-dependent cases and matched non-opioid dependent controls
Sexual abuse % 56.3 71.8Penetrative % 27.6 56.2 control case
males
females
physical abuse
prescription drugs abuseand poly-drug use
prison and maltreatmentduring childhood
Gilbert et al., Lancet. 2009 Danielson et al., J Psychiatr Pract. 2006Widom et al., Psychol Addict Behav. 2006
substance abuse, HIVtuberculosis
Is it possible to change the trajectory of children at risk?
trauma
abuse
neglect
affectionless control
lack of supervision
adverse experiences
protection and support
warm childrearing style
monitoring and supervision
acceptance
rewarding psychological autonomy
clear rules
genotype – temperament - personality traits
pregnancy
RISK RESILIENCE
Kaufman, 2009 Biological Psychiatry
stress during childhood
structural and functional alterations in brain regions: vulnerability
long-term effects of early stress can be moderated by the quality of the subsequent care-giving environment
DEPRESSION / SUBSTANCE ABUSE
- Schizophrenia illogic behaviour- ASPD violation of the rules- Bipolar disorder aggressive/manic reaction
Recognizing substance use disorders asa chronic brain disease
Advocacy for
- Addictive behaviour…
A continuum of care recovery-orientedA continuum of care recovery-oriented
Helping member states to create integrated treatment systems
Nothing less than would be expected any other chronic disease
1) Medical standards2) Social standards3) Case by case approach4) Respect for human rights and dignity5) A variety of treatment methods available
Advocating against discrimination
Mainstreaming into the public health system
Integrating public treatment system with NGOs
Involving the government / promoting ownership
Involving the universities
Adopting a multidisciplinary approach
Drug dependence treatment system
One stop shop
Detoxificationnaltrexone
Methadonemaintenance Buprenorphine
maintenance
Pharmacotherapyfor stimulants users
Self-help groups AA - NA
PsychotherapyCBT
Mental health care
Family therapy
Follow up in prison
Social assistance
Measures to preventHIV and Hepatitis
Health care
Antiretroviral therapy
Dentist
Overdose prevention
Counselling
Vocational skillsand reintegration
Outreach andhome visiting
Principle 1: Availability and Accessibility of/to Drug Dependence Treatment
Principle 2: Screening, Assessment, Diagnosis and Treatment Planning
Principle 3: Evidence-informed Drug Dependence Treatment
Principle 4: Drug Dependence Treatment, Human Rights, and Patient Dignity
Principle 5: Targeting Special Subgroups and Conditions
Principle 6: Addiction Treatment and the Criminal Justice System
Principle 7: Community Involvement, Participation and Patient Orientation
Principle 8: Clinical Governance of Drug Dependence Treatment Services
Principle 9: Treatment Systems: Policy Development, Strategic Planning and Coordination of Services
An unnecessary conflict between harm reduction and demand reduction
A.M. Costa
RESPONSE TO RISK REDUCTION MEASURESPREDICTS ABSTINENCE Meyer et al., 1998
Prevention and treatment, stopping or reducing
the use of drugs, are also preventing health and
social consequences
Harm reduction measures are not only protecting health,
but contributing to restore dignity and motivation to treatment
combined prevention measures—but not the use of needle exchange program or methadone alone—
might contribute to the reduction of the spread of HCV and HIV infection
Van Den Berg et al., 2007
The Amsterdam cohort: a prospective studyThe Amsterdam cohort: a prospective study
PHA, g/ml
3H-t
hym
idin
e in
corp
orat
ion
(cpm
)
0
10000
20000
30000
40000
50000 CTRheroinmethadonebuprenorphine
0.25 1 4
*
*
*
No differences insocio-demographic conditions betweenheroin addicts and patients in treatment
Paola Sacerdote,Silvia Franchi Gilberto Gerra Vincenzo Leccese Alberto E. Panerai Lorenzo Somaini
SUSTAINABLELIVELIHOODFOOD
SHELTER
CLEAN DRESSES
VOUCHERS
HEAT – ELECTRICITY – WATER
TEMPORARY JOB OPPORTUNITIES
PROTECTED JOBS
SUPPORT TO RENT A HOUSE/ROOM
From help on the streetto treatment seeking…
Unconditioned interventions
Drug dependence treatment per se can reduce the spread of HIV and AIDS among those coming to the attention of the criminal justice system
Re-arrest: does HIV serostatus make a difference? HIV-positive individuals appeared to be more vulnerable to re-arrest
HIV-AIDS reducing measures
Inciardi, 1996, Harris et al, 2002
The urgent need of pharmacological interventions for stimulants dependence
Addict Biol. 2003 Jun;8(2):123-39.Biological markers of cocaine addiction: implications for medications development.Elkashef and Vocci, 2003
poor understanding of the underlying biology both in the premorbid condition and following the disease state of chronic cocaine use
population heterogeneity
specific biological changes/markers that could be used to characterize subgroups among chronic cocaine users
targeting specific pharmacological agents to subgroups of patients
Patients empowerment:
- consent to treatment
- therapeutic alliance
- social reintegration
- participation in planning and evaluating the interventions
Non-medical use of prescription drugs
Data collection on a voluntary basis
89
Pharmaceutical Drug Abuse, USA
Pharmaceutical Drug Abuse, USA
Past Month Use of Illicit Drugs among Persons Aged 12+ in 2007
Numbers in Millions
Psychotherapeutics
Inhalants
Heroin
Hallucinogens
Cocaine
Marijuana
0.2
0.6
1.0
2.1
6.9
14.4
19.9
0 5 10 15 20 25
Illicit Drugs
Source: SAMHSA, 2007 National Survey on Drug Use and Health
8.0%
5.8%
2.8%
0.8%0.4%
0.3%
0.1%