Harm Reduction Approaches to Injecting Drug Use

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Le dipendenze da sostanze Terapia significati e
risultati
Gilberto GerraDrug Prevention and Health Branch
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Decreased Heart Metabolism in Heart Disease
Patient
N.Volkow
Healthy Heart
Diseased Heart
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ADDICTION IS A DEVELOPMENTAL DISEASE starts in
adolescence and childhood
NIAAA National Epidemiologic Survey on Alcohol
and Related Conditions, 2003
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Stigma and discrimination To punish To
permit Denial Not to share suffering To
ignore responsibility To attenuate sense of
guilt
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- fragile - sensible - suffering persons
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Addiction Medicine Closing the Gap between
Science and Practice June 2012
Most of those providing addiction care are not
medical professionals Misunderstandings about
the nature of addiction among
professionals Disconnection of addiction
medicine from mainstream medical practice
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Am J Addict. Co-occurring disorders policy and
practice in Germany. Hintz and Mann, 2006
Many practitioners continue to hold negative
opinions about drug addicted patients "Substance
Use Disorders patients are only weak-minded
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Drug addiction is often the result of an
unwholesome social atmosphere in which those who
are most exposed to the danger of drug abuse
live Resolution III, 1972 (amendments to 1961
Convention)
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A social atmosphere detrimental to physical,
mental and moral well-being
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Adverse childhood experiences
Household dysfunction
Emotional neglect
Abuse
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J Clin. Psychiatry, 67 Suppl 718-23. Adolescent
substance abuse and psychiatric
comorbidities. Deas, 2006 Psychiatric disorders
in adolescents often predate the substance use
disorder. Once the substance use disorder
develops, the psychiatric disorder may be
further exacerbated
More than 40
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Drugs to cope with Extreme poverty Exploitation
Social exclusion Hunger Work overload Exposure
to violence Displacement Abuse Early childhood
trauma
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Circuits Involved In Drug Abuse and Addiction
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Reward / salience
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Control
Control
Drive
Neutral drugs
Saliency
Drive
Memory
Memory
Addicted brain
Adapted from Volkow et al., J Clin Invest
111(10)1444-1451, 2003.
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Drug dependence
Compulsive behavior motivational system
hijacked by drugs strong instrumental memories
linking actions to drug-seeking persistent
stimulus-response habits neutral environmental
stimuli associated with drug highs through
pavlovian conditioning
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usurpation of emotional memory
Cocaine addicts brain is not activated anymore by
monetary reward
Milton and Everitt, 2012
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unseen (backward-masked) cocaine cues of 33
milliseconds duration in male cocaine patients
Childress et al., PLoS ONE 2008
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Nature Reviews Neuroscience AOP, 12 October
2011 Alfred J. Robison and Eric J. Nestler
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Cocaine mechanism of action epigenetic changes
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Are drugs dangerous only for the brain?
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Are drugs dangerous only for the brain?
Cocaine users at risk of silent heart
attacks
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Lancet Adverse health effects of non-medical
cannabis use. The health effects most likely to
occur and to affect a large number of cannabis
users
increased risk of motor vehicle crashes
a dependence syndrome
impaired respiratory function
cardiovascular disease
adverse effects on adolescent psychosocial
development and mental health
Hall and Degenhardt, 2009, 2014
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Ecstasy
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The pathogenesis of a complex health problem
Genetic predisposition temperament
Stress during pregnancy
Disrupted attachment
Neglect and abuse
Lack of bonding to family
Substance Use Disorders
Lack of engagement in school
Social exclusion frustration
Coping with work overload
Early onset psychopathology
Coping with hunger
Coping with stress
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Temperament and personality traits at risk
genetic vulnerability
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Temperament and personality traits at risk
genetic vulnerability
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European Journal of Pharmacology, 2004 Prenatal
stress affects 3,4-methylenedioxy methamphetamine
pharmacokinetics and drug induced motor
alterations in adolescents female
rats Morley-Fletcher S., Puopolo M., Gentili
S., Gerra G., Macchia T. and Laviola G.
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J Consult Clin Psychol. 2009 Feb77(1)1-11. Paren
ting moderates a genetic vulnerability factor in
longitudinal increases in youths' substance use.
5-HTTLPR status SS linked with increases in
substance use over time the association was
greatly reduced by involved-supportive parenting
Brody et al., 2009
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American Journal of Medical Genetics Part B
(Neuropsychiatric Genetics) 141B17
(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
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PARENTS CARE PERCEPTION
PBI SCORE
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10 less risk
20 less risk
90 less risk
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RISK OF DRUG DEPENDENCE IN THE ADULT
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short version (S) of the 5-HTTLPR
agreeable autonomy
secure attachment
insecure attachment
hostile autonomy
Zimmermann et al., 2009
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Childhood neglect Altered response to
emotions HPA axis
dysfunction
Addiction Severity
Gerra et al., 2013
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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
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Isolation and Social Status Can Change
Neurobiology
Becomes Dominant No longer stressed
Brain DA D2 Receptors
Individually Housed
Group Housed
Becomes Subordinate Stress remains
Morgan, D. et al. Nature Neuroscience, 5
169-174, 2002.
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Epigenetic mechanisms in vulnerability
Profiling of childhood adversity-associated DNA
methylation changes in alcoholic patients and
healthy controls.
Childhood adversities could induce methylation
alterations in the promoter regions of specific
genes and changes in gene transcription with
increased risk for substance use disorders
(Zhang et al., 2013)
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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
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Vulnerability conditions for substance use
disorders
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44 of households with a member living abroad are
caring for at least one child left behind.
This proportion is higher in rural than in
urban areas 47 respectively. Moldova, UNICEF
2009
- Maternal deprivation - A grandparents society -
Social exclusion
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What is the response to complex health disorders?
An articulated and comprehensive treatment
response
Drug use disorders are treatable
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to acceptance, - treatment - recovery -
rehabilitation
Moving from social exclusion and loneliness
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Moving from a sanction-oriented approach ...
to a health-oriented approach
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Moving from criminal justice approach to health
care and social protection
The Convention indicates that States Parties may
provide measures for treatment, education,
aftercare, rehabilitation or social
reintegration as an alternative to conviction or
punishment. The Conventions do not require
conviction and punishment for possession,
purchase or cultivation for personal use. Art.
3, para. 4. (d) of the 1988 Convention
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Forced treatment unnecessary
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Building a therapeutic alliance Offering a menu
of services Integrate pharmacological and
psychosocial interventions Establish clear
rules Discuss the prognosis
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• intoxication / withdrawal
• Naloxone
• Clonidine
• Lofexidine
• Beta-blockers
• Anti-arrhythmic
• Anti-hypertensive
• Re- hydration

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2) compulsive behaviour control CBT and
medications extinction of conditioned
behaviour reduce craving prevent
relapse identify and avoid trigger stimuli
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3) psychiatric comorbidity treatment mental
health disorders diagnosis medications
psychotherapy
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4) family dysfunction management family
engaged family therapy restore
interpersonal relationships support
innovative solutions
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5) reduce sense of guilt/ stigma explain
scientific evidence underline the role of
the disease consider vulnerability
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6) social cohesion / engagement
intensive caregiving community/school
support work-place / employer attitude
services not isolated
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7) dismantle misleading views / believes
drugs are manageable drugs as a way of
life drugs improving relationships
drugs improving creativity drugs enhancing
productivity
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8) recognize that authenticity is better than
an artificial status induced by drugs you
can be loved with limits and problems you
can love yourself as you are you are unique
and not standard
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9) self-transcendence ideals
political believes dreams / future
perspectives faiths
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10) recognize impotence in front of drugs in
front of things to be changed
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Detoxification naltrexone
Pharmacotherapy for stimulants users
Mental health care
Counselling
Health care
Measures to prevent HIV and Hepatitis
Dentist
One stop shop
Psychotherapy CBT
Antiretroviral therapy
Buprenorphine maintenance
Family therapy
Social assistance
Vocational skills and reintegration
Methadone maintenance
Outreach and home visiting
Follow up in prison
Overdose prevention
Self-help groups AA - NA
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TREATMENT OF DRUG USE DISORDERS
Detoxification protocols Short term
pharmacological treatment of withdrawal and
intoxication Long term pharmacological
interventions -
agonists -
antagonists -
anti-withdrawal
- anti-craving -
anti-reward
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TREATMENT OF DRUG USE DISORDERS
Non-pharmacological treatment modalities
- brief intervention
- individual
psychotherapy - group
psychotherapy - family
psychotherapy -
cognitive-behavioural interventions
- therapeutic community -
motivational interviewing and motivational
enhancement -
contingency management
- self-help groups
- job skills education Treatment of
co-occurring substance use and mental health
disorders Treatment of co-occurring HIV/AIDS
Hepatitis TBC cardiovascular liver diseases
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opioid medications for addiction treatment
wrongly considered as state drugs instead of
street drugs
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The differences
Kinetic Drug liking/reinforcing effects Effects
on HPA axis Effects on the immune system
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CNS Drugs 27, Issue 10, pp 851-861 Extended-Releas
e Intramuscular Naltrexone (VIVITROL) A Review
of Its Use in the Prevention of Relapse to Opioid
Dependence in Detoxified Patients Syed and
Keating, 2013
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Abstinence negative urines
24 months
Naltrexone
Placebo
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Promising medication for stimulants dependence
treatment Topiramate Adderall Methylphenidate Mod
afinil Baclofen Buprenorphine/naltrexone SRNI
antidepressants
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No differences in socio-demographic conditions
between heroin addicts and patients in treatment
Paola Sacerdote, Silvia Franchi Gilberto Gerra
Vincenzo Leccese Alberto E. Panerai Lorenzo
Somaini
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E-mail gilberto.gerra_at_unodc.org
Twitter _at_gilbertogerra