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Operational Recommendations on drug demand reduction and related measures, including
prevention and treatment, as well as other health-related issues
Gilberto Gerra
Chief
Drug Prevention and Health Branch
A New Approach Based on Science, Compassion and Social Cohesion We recognize drug dependence as a complex, multifactorial health disorder characterized by chronic and relapsing nature with social causes and consequences that can be prevented and treated… (General Assembly Resolution 19-04-2016, page 6, i)
SCIENCE BASED APPROACH RECOGNIZED AS ESSENTIAL Effective scientific evidence based prevention programs Effective scientific evidence based drug treatment, care, and rehabilitation programs Civil society, as well as the scientific community and academia, plays an important role in addressing the world drug problem.
General Assembly 2016 Two CND resolutions (58th-59th Sess.) A continuous dialogue with the scientific community. The UNODC-WHO international informal scientific network
The complexity of drug use disorders
Gene variants Temperament
Impaired parent-child attachment
Early stress, trauma, neglect, abuse
Epigenetic changes
Pharmacogenetics
Abnormal associative learning, conditioned drug seeking behaviour
Motivational system, inhibitory control derangement
Neurobiological changes Mental health disorders
Health and social consequences
Drugs initiation
Continuous drug use
Poor social environment
Childhood neglect
Altered response to emotions
HPA axis dysfunction
Addiction Severity
Gerra et al., 2013
Mol Neurobiol. Epigenetics of Stress, Addiction, and Resilience: Therapeutic Implications. Cadet, 2016 Molecular Neuropsychiatry Research Branch, NIH/NIDA Intramural Research Program, National Institutes of Health
early and adult stressful life events are risks factors for the development of addiction and serve as cues that trigger relapses
stress drugs
A history of suffering, distress, neglect, social exclusion: vulnerability
Am J Addict. Hintz and Mann, 2006
Many practitioners continue to hold negative opinions about drug dependent patients:
"Substance Use disorders patients are only weak-minded“
What to do in practice? 1) Disseminate knowledge and dissipate ignorance: reliable information (media/fact sheets/social media) 2) Dismantling misleading views on drugs in public opinion 3) Engage public health institutions in dealing with substance use disorders (health disorder!) 4) Engage scientists to help designing policy lines at the national level. 5) Prepare a new generation of health and social policy makers/professionals with different vision
Prevention provide children with accurate information about the risk of drug use promote life skills and opportunities to choose healthy life styles develop supportive parenting and healthy social environments ensure equal access to education and vocational training
Prevention (General Assembly 2016)
The large framework of health, welfare and wellbeing
- Children social protection - Improving parental skills - Fighting school drop out
First prevention
Prevention activities in the community with good or very good level of efficacy
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2010-11 2012-13 2014-15 2010-11 2012-13 2014-15 2010-11 2012-13 2014-15 2010-11 2012-13 2014-15
Life Skills Education in Schools Workplace Family/ Parenting Skills Screening / Brief Interventions
Does not exist
Does exist
Evidence of a good level of efficacy
Evidence of a very good level of efficacy
Nu
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2013
What to do in practice?
reduce uptake or experimentation with smoking 32%. authoritative parenting: - strong interest in children - care for the children - rule setting - supervision different from - authoritarian parenting (do as I say) - neglectful parenting - unsupervised parenting
Cochrane Database Syst Rev. Family-based programmes for preventing smoking by children and adolescents. Thomas et al., 2015
32%
Fam Community Health. Youths as partners in a community participatory project for substance use prevention. Kulbok et al. 2015
The youths were integrally involved in all phases including - the community assessment - community leader interviews - selection of a substance use prevention program - program implementation Youths reported - sustained enthusiasm - experiences of authentic leadership - development of research skills - greater awareness of their community
What to do in practice? Reduce school drop out in 3 schools: Ministry of Education project. Organize a pilot experience of life skills education in 2 schools (urban-rural) and evaluate the outcome Disseminate parents supportive attitude/behaviours in 2 communities: aggregation of families. Promote UNODC Youth Initiative with students actively engaged in drug prevention and health education
A new attitude toward people using drugs Non-stigmatizing attitude No social marginalization Non-discriminatory access to treatment Community-based treatment Outreach programs Long-term recovery
General Assembly, 2016
Problem drug users receiving treatment for drug use disorders 1 in 6 at the global level 1 in 18 in Africa 1 in 11 in Latin America / Easter Europe 1 in 3 in the North America
World Drug Report 2014 (UNODC)
Gender imbalance in drug treatment and care
Ministry of Health coordinating interventions in treatment Small national budget devoted to substance use disorders Primary care prepared and engaged in screening and brief intervention 3 basic units for outpatient intervention: detoxification/relapse prevention: - 1 Physician for few hours a week - 1 Nurse - 1 Social worker or 1 Counsellor - 2 or more Volunteers 1 residential treatment program: therapeutic community (NGO)
What to do in practice?
Integrated treatment: psychosocial, behavioural and medication-assisted treatment
General Assembly , 2016
J Addict Med. A Systematic Review on the Use of Psychosocial Interventions in Conjunction With Medications for the Treatment of Opioid Addiction. Dugosh et al., 2016
the efficacy of providing psychosocial interventions in combination with medications to treat opioid addiction
Contingency management
Cognitive behavioural therapy
Opioid agonist treatment
J Addict Med. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. Kampman and Jarvis, 2015
combining psychosocial treatment with medications
Slow-release naltrexone effectiveness
Brooks, 2011
Promising medication
for stimulants dependence treatment
Topiramate
Adderall
Methylphenidate
Modafinil
Baclofen
SRNI antidepressants
Bupropion
Non-pharmacological treatment modalities:
- brief intervention
- individual psychotherapy
- group psychotherapy
- family psychotherapy
- cognitive-behavioural interventions
- therapeutic community
- motivational interviewing
- contingency management
- self-help groups
- job skills education
PSYCHOSOCIAL TREATMENT
OF DRUG USE
DISORDERS
J Dual Diagn. 2016 Co-Occurring Disorders: A Challenge For Mexican Community-Based Residential Care Facilities For Substance Use. Marín-Navarrete et al., 2016
The prevalence of any co-occurring disorder was 62.6%: - Antisocial personality disorder (43.8%) - Major depressive disorder (30.9%). higher severity of psychiatric symptoms: - more days of substance use - current suicidal ideation and attempts - more sexual risk behaviours; - more contact with professional services
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Baseline Week 2 Week 4 Week 6 Week 8 Week 10 Week 12
week
pro
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Group 1
Group 2
Overdose prevention
Take-home emergency naloxone to prevent deaths from heroin overdose BMJ 2014; 349 Strang J, Bird SM, Dietze P, Gerra G, McLellan AT.
What to do in practice?
University centre working on treatment/research/data collection of substance use disorders (tween centres) Include psychosocial and pharmacological treatment methods into medical and social professionals university curricula Start a pilot programs with elements of Cognitive Behavioural Therapy + methadone / buprenorphine / naltrexone … Start a cooperation with the mental health department for co-occurring mental health disorders Distribute naloxone everywhere and to everyone
Encourage people affected by drug use disorders to engage in long-term recovery Voluntary participation of individual with drug use disorders in treatment programs, with informed consent General Assembly, 2016
Alternative or additional measures with regard to conviction and punishment: - treatment - rehabilitation - social reintegration
General Assembly, 2016
Proportionate sentencing
Non-discriminatory access to health, care, social services, treatment programs offered to persons in prison equal to those available in the community
General Assembly, 2016
Treatment as a result of the cooperation between criminal justice and health care administrations
Ministry of Justice and Ministry of Health/Social Affairs: integrated team Start treatment for substance use disorders in 1 prison: a small team coming from addiction treatment in the community Start diversion of people convicted for possession of controlled drugs for personal consumption from criminal justice to health care system 1 outpatient service x prison 1 therapeutic community x prison 1 laboratory for job skill training and social reintegration.
What to do in practice?
Accreditation of services at the domestic level To ensure qualified and evidence based responses
General Assembly, 2016
What to do in practice?
Treatment and health care response tailored for women…
General Assembly, 2016
What to do in practice?
Revise treatment methods paying attention to gender issues Fight double stigma affecting women Facilitate access (open hours / prepared professionals) Children management Sexual reproductive health care Start specific outreach for women (home visiting)
Public health
institutions NGOs civil society
agencies
The integrated model
Treatment of substance use disorders
A historical perspective
2009-2016
