Drug Prevention and Health Branch Division for Operations Gilberto Gerra

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%