Download Harm Reduction Approaches to Injecting Drug Use

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,
social engagement
and success…
...and adolescents
experimenting
with drugs
Change the
trajectory
of adolescent at risk…
Develop specific
treatment programs
for very young
drug dependent
individuals
Children using drugs
at the age of 6-11
Implement
science-based
drug dependence
treatment programs
Prevent the spread
of HIV-Hepatitis-TB
epidemics
among drug users
Treat HIV-AIDS
Offer drug
dependence
treatment
programs
and HIV
prevention
in prison
Support the
families
of farmers
involved
in
crops
eradication
The Political Declaration 2009
confirmed the validity of the
UN Conventions on Narcotic Drugs
and Psychotropic Substances (unanimously)
The drugs listed in the Conventions
are licit only when used for medical
and scientific purposes
These drugs are illicit because they are
dangerous, not dangerous because they are illicit
Pulmonary Emboli in a User of Crack Cocaine
methamphetamines
heroin overdoses
1990–2006
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
Lancet
Adverse health effects of non-medical cannabis use.
a dependence
syndrome
increased risk
of motor vehicle
crashes
impaired
respiratory
function
cardiovascular
disease
adverse effects on
adolescent psychosocial development
and mental health
Hall and Degenhardt, 2009
Illicit Drug Use at the Global Level
* Data from UNODC World Drug Report 2009
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
WHAT IS WORKING IN PREVENTION
training in resistance skills
normative education
life skills: decision making
life skills: emotional communication
life skills: impulse control
family skills
trained teacher
interactive methods
Faggiano et al., Cochrane 2005
Molgaard & Spoth, 2001
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
Data from UNODC World Drug Report 2009
4.3 million receiving treatment (out from 18-38)
WHAT IS WORKING IN TREATMENT
Brief intervention
Vocational training
Motivational therapy
Cognitive-behavioural therapy
Contingency therapy
Family therapy
Self help 12 step
Therapeutic community
Long term opioid-agonists
Slow release opioid-antagonists
Alpha-adrenergic agonists
Vaccine
Modafinil
DA D3 antagonist
Antiepileptic GVG
N-acetylcysteine
CRF-antagonists
Promising medications
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
Global Fund
World Bank
?
$
Malaria
Tuberculosis
HIV/AIDS
Illicit drugs dependence
Prescription drugs abuse
Alcoholism
Counteracting production and trafficking
and health protection are not contradictory
strategies
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 strengthen
effective, 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 of
drug abuse …
Prevention Treatment Rehabilitation Section
Improving
parenting to prevent
drug use, risk behaviors
and crime
Disseminate
reliable information,
prevent
substance abuse,
fight stigma
and inspire
solidarity
in the workplace
Prevention Treatment Rehabilitation Section
UNODC treatment programme countries
Europe:
Albania
Serbia
North Africa:
Egypt
Iran
Jordan
Lebanon
Morocco
United Arab
Emirates
Latin America
Brazil
Haiti
Colombia
Peru
Nicaragua
Central Asia:
Afghanistan
Kazakhstan
Kyrgyzstan
Pakistan
Tajikistan
Turkmenistan
Uzbekistan
South East Asia:
Cambodia
Myanmar
Viet Nam
Africa:
Nigeria, Mozambique, Cote d’Ivoire,
Tanzania, Sierra Leone, Kenya,
Zambia, Ethiopia, Uganda,
Madagascar, South Africa, Seychelles,
Cape Verde
Prevention Treatment Rehabilitation Section
Content of the program
Serbia
Albania
Haiti
Pakistan
4 countries
UNODC-WHO Programme on
Drug Dependence Treatment and care
UNODC HIV Section
70 professionals in 35 countries, covering 70 countries
National staff
International staff
September 2010
Antiretroviral
therapy
of AIDS
A comprehensive package of measures
to prevent HIV in the community and in prison
Sustainable Livelihoods
Unit
First line social
assistance to drug users
in the cities
Alternative
development
in 7 countries
Moving from a
sanction-oriented
approach ...
to a health-oriented approach
A heroin addict
was shackled
on arrival at a
detoxification shelter.
The chains prevent
flight when
withdrawal sets in.
Social exclusion
re-education
and working therapy
Detoxification
methods
Drug dependence is a multi-factorial chronic disease
neuroadaptive processes
in the brain reward system: allostasis
usurpation of emotional memory
willpower dysfunction
stress-induced
and drug cue-induced craving states
Activation of the reward/motivation system
with drug related stimuli of 33 mSec.
Childress et al.,
2008
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?
GXE
Gene variants:
temperaments
Adverse childhood
experiences
Substance use disorders
susceptibility
Gene variants
Psychiatric
disorders
Adverse childhood
experiences
Gene X Environment interaction in addiction pathogenesis
+
EARLY SOCIAL
DEPRIVATION
GENE VARIANT
SEROTONINE T.
Alcohol preference and proneness to use
.
Gorwood et al., 2007
reduced maternal
care perception was found to represent
a key intermediate factor of
the 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
Parental attachment was the only variable
that accounted for a significant portion
of the variance in adolescent marijuana use
Kostelecky, 2005
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 Neurobiology
Becomes Dominant
No longer stressed
Individually
Housed
Brain DA D2 Receptors
Group
Housed
Becomes Subordinate
Stress remains
Morgan, D. et al. Nature Neuroscience, 5: 169-174, 2002.
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 inhalants
5.5 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
SOCIAL FACTORS CONTRIBUTING
TO DRUG USE VULNERABILITY
Poverty
Social exclusion
Instability/migration
Lack of bonding to family/supervision
Lack of school connectedness
Coping with stress and violence
Hunger
Work overload
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%)
The use of alcohol and drugs to self-medicate
symptoms of post-traumatic stress disorder.
Merikangas and
Avenevoli, 2000
Leeies et al.,2010
Child maltreatment among
opioid-dependent cases
and matched non-opioid dependent controls
males
Physical abuse % 36.4
control
females
Sexual abuse % 56.3
Penetrative % 27.6
control
57.5
case
71.8
56.2
case
Conroy et al., 2009, NDARC
prescription drugs abuse
and poly-drug use
physical abuse
prison and maltreatment
during childhood
Gilbert et al., Lancet. 2009
Danielson et al., J Psychiatr Pract. 2006
Widom et al., Psychol Addict Behav. 2006
substance abuse, HIV
tuberculosis
Is it possible to change the trajectory of children at risk?
genotype – temperament - personality traits
pregnancy
trauma
abuse
neglect
affectionless control
lack of supervision
adverse
experiences
RISK
protection and support
warm childrearing style
monitoring and supervision
acceptance
rewarding psychological
autonomy
clear rules
RESILIENCE
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
Kaufman, 2009
Biological Psychiatry
Advocacy for
Recognizing substance use disorders as
a chronic brain disease
- Addictive behaviour…
- Schizophrenia illogic behaviour
- ASPD violation of the rules
- Bipolar disorder aggressive/manic reaction
Helping member states to create
integrated treatment systems
A continuum of care recovery-oriented
Nothing less than would be expected
any other chronic disease
1) Medical standards
2) Social standards
3) Case by case approach
4) Respect for human rights and dignity
5) 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
Detoxification
naltrexone
Pharmacotherapy
for stimulants users
Measures to prevent
HIV and Hepatitis
Methadone
maintenance
Buprenorphine
maintenance
Counselling
Mental health care
Health care
One stop shop
Dentist
Antiretroviral therapy
Psychotherapy
CBT
Social assistance
Family therapy
Outreach and
home visiting
Vocational skills
and reintegration
Overdose prevention
Self-help groups
AA - NA
Follow up in prison
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
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
RESPONSE TO RISK REDUCTION MEASURES
PREDICTS ABSTINENCE
Meyer et al., 1998
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 study
3H-thymidine incorporation (cpm)
50000
CTR
heroin
methadone
buprenorphine
40000
No differences in
socio-demographic
conditions between
heroin addicts and
patients in treatment
30000
20000
*
*
*
10000
0
0.25
1
PHA, g/ml
4
Paola Sacerdote,
Silvia Franchi
Gilberto Gerra
Vincenzo Leccese
Alberto E. Panerai
Lorenzo Somaini
SUSTAINABLE
LIVELIHOOD
FOOD
SHELTER
CLEAN DRESSES
VOUCHERS
From help on the street
to treatment seeking…
HEAT – ELECTRICITY – WATER
TEMPORARY JOB OPPORTUNITIES
PROTECTED JOBS
SUPPORT TO RENT A HOUSE/ROOM
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
HIV-AIDS reducing
measures
Inciardi, 1996, Harris et al, 2002
Re-arrest: does HIV serostatus
make a difference?
HIV-positive individuals
appeared to be more vulnerable
to re-arrest
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
Pharmaceutical Drug Abuse, USA
Past Month Use of Illicit Drugs among Persons Aged 12+ in 2007
Illicit Drugs
19.9
Marijuana
14.4
Psychotherapeutics
6.9
8.0%
5.8%
2.8%
0.8%
1.0 0.4%
0.6 0.3%
Cocaine
2.1
Hallucinogens
Inhalants
Heroin
0.2
0
0.1%
5
10
15
Numbers in Millions
20
25
89
Source: SAMHSA, 2007 National Survey on Drug Use and Health