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DOC-5-BERTHA MADRAS.Ppt-Usa INTER-AMERICAN DRUG ABUSE CONTROL COMMISSION C I C A D Secretariat for Multidimensional Security DRUGS SUMMIT EUROPEAN, LATIN AMERICAN AND OEA/Ser.L/XIV.4.1 CARIBBEAN MAYORS AND CITIES CICAD/DREU-LAC/doc.5/10 April 21 –23, 2010 5 May2010 Lugo, Spain Original: English INTERVENTION Bertha Madras, PhD Professor Psychobiology, School of Medicine Harvard University Drug Policy, Public Health andScience Bertha K. Madras, PhD (the Honorable) Professor of Psychobiology Department of Psychiatry Harvard Medical School [Former Deputy Director for Demand Reduction White House Office of National Drug Control Policy] Ref: Uhl and Grow, 2004 Drug use: shaped by culture, access, economics, perception, information Drug Policy Goals: Limit, reduce drug use, and associated consequences to individuals, society Policy Drivers: Society, public health, law, values, economics, but based on statistics, science Successful Policy: Uses statistics, articulates goals, quantifiable outcomes, measures, accountability, flexibility • Why do people take drugs? • How drugs affect the brain? • Adaptation, addiction? • Public policy from modern biology To have novel • feelings •sensations •experiences AND To share them To alleviate anxiety worries fears Self-medication hypothesis To alleviate sadness depression hopelessness Self-medication hypothesis UUserser Drug Environment Psychiatric symptoms Prior experience with drugs Trauma Risk-seeking behavior Genetic factors Poor school achievement Age and age of onset Embedded in volitional choices are involuntary components • Drug use during development may alter the course of brain development, making addiction more likely - A teenager uses the “Emotional” part of the brain (reduced sensitivity to risk, sensation-seeking, novelty-seeking) - An adult uses the “Reasoning” part of the brain (self-regulation, judgment, reasoning, problem-solving, impulse control) • Drug use during development reflects “risk-seeking, emotional decisions Age at first use and abuse/dependence as adult Elevated Risk for <14 18+ <14 18+ ce n Addiction to: e 15 nd Nicotine e p is e s d Alcohol / 10 gno se a u i Inhalants b d a 5 h t Stimulants i w Cocaine % 0 Alcohol Marijuana Opioids Hallucinogens Anxiolytics National Survey Drug Use and Health, NSDUH Sept 2008 • Drug effects • Host response to drugs • Potency, purity • Dose • Access • Delivery method: i.v., oral, inhale, insufflate • Cost Visible by brain imaging Genes, proteins Behavior Opioids produce Withdrawal from opioids produce Analgesia Excess pain Euphoria Dysphoria Tranquility Anxiety Pinpoint pupils Dilated pupils Intestinal slowness Cramps, diarrhea Relaxation Muscles aches All addictive drugs produce brain adaptation. Upon cessation, all drugs produce intense physical withdrawal signs (heroin, alcohol, sedativvee-h-hypnotics) or psychological withdrawal. Drugs promote craving –impulsive or compulsive drug –seeking. Source: NIDA ADOLESCENTS: are at high risk, warrant prevention, intervention programs DRUG REWARD: universally sensed by animal brains. ADDICTION: is a chronic, relapsing disease A DISEASE MODEL should motivate medical professionals to diagnose intervene, treat. ALL DRUGS: produce withdrawal which could benefit from medications assistance to prevent relapse. The Science • WHY CONSIDER ADDICTION A BRAIN DISEASE? Prevention • MAGNITUDE OF THE PROBLEM, STRATEGIES Intervention • IDENTIFY RISKY, PROBLEMATIC USE, ADDICTION Treatment Treatment • PRINCIPLES OF EFFECTIVE TREATMENT • ARTICULATE GOALS, OUTCOME MEASURES, Drug policy ACCOUNTABILITY National Survey on Drug Use and Health (NSDUH) ANNUAL Verbal screening data on drug use, age, drug, frequency of use (70,000 people) Monitoring the Future (MTF) ANNUAL Verbal screening data of drug use among 8th , 10th , and 12th graders (50,000 people) Treatment Episode Data Sets (TEDS) ANNUAL Data system of admissions to substance abuse treatment providers (approximately 1.6 million records each year) Drug Abuse Warning Network (DAWN) CONSTANT Drug-related visits to hospital emergency departments (EDs) Drug-related deaths investigated by medical examiners and coroners Past Year Dependent/Abusers, Ages 12 or Older (in Thousands) Dependence or abuse is based on the definition found in the 4th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Source: SAMHSA, 2007 National Survey on Drug Use and Health (September 2008). Bought from friend or relative Took from friend or relative w/o asking Bought drug dealer 71% obtained from friend Other source or relative Free from friend or relative From one doctor Source: SAMHSA, 2006National Survey on Drug Use and Health (September 2007). 4.6 % felt they needed treatment 93.6% and did not make an 93.6% effort 95.5% Did not feel they need 4.6% Did not feel they neededt reatment 1.8% felt they needed treatment treatment and did Did not seek treatment make an effort Source: SAMHSA, 2007 National Survey on Drug Use and Health (September 2008) 21 Million People Need, But Do Not Receive Treatment for Illicit Drug or Alcohol Use The Drinker’s pyramid Drinkers: 129 million; 51.6% Bingers: 58.1 million; 23.3% Heavy drinkers: 17.3 million; 6.9% Binge drinking • 5 or more drinks • same occasion • at least 1 day in past 30 days = 58.1 million Heavy use + 5 or more drinks • same occasion • 5 or more days in • past 30 days = 17.3 million = 75.4 million people Addictions in 2010 Source: Dr. M .Willenbring, NIAAA Medical and Psychiatric Conditions Occur More Frequently in DSM-IV Abuse/Dependent Patients Medical Occurances: Controls vs Abuse/Addiction Control n = 3,690 ions t Abuse/Addiction n = 747 ondi c 30 *** l a *** c i *** p <0.001 d 20 me *** h t i w *** 10 d *** e *** s no g 0 a i D % Headache Depression Hypertension Anxiety disLoordwerer back pain Injuries/Overdose Patient records from Dec ‘97-Apr ’98 Adapted from Mertens JR et al, Arch Intern Med 163: 2511-2517, 2003 • Reduce drug use • Change perception that drug use is acceptable • Change perception that drug use is harmless • Prevent progression to addiction Source: UN Office on Drugs and Crime, 2008 Report • 25% decrease in youth drug use since 2002 • > 860,000 fewer users Source: Monitoring the Future (MTF) Elements of Effective Drug Policy • SBIRT • Is SBIRT effective? • Is SBIRT cost-effective? • How to Implement SBIRT Screening (S) Brief Intervention (BI) . Brief Treatment (BT) Referral to Treatment (RT) Screening, Brief Intervention (SBIRT) 1 2 Substance abuse leads to Excessive drinking, illicit drug use, and prescription drug misuse are significant medical, social, and prescription drug misuse are often undiagnosed by medical legal, financial consequences. professionals. TTrreaeattmmeenntt GGAPAP WWhhyy SSBBIIRRT?T? 3 A brief intervention itself is inherently valuable, and positive 4 screens may not require referral Early, brief to specialty treatment. to specialty treatment. interventions are clinically effective and cost-efficient. SBIRT Core Components Screen Brief Brief Intervention questionnaire Low Yields a score: Feedback of score Identify, quantify Raise awareness of risks substance Motivates and establishes abuse, goals Strategies for change. Associated Moderate problems Brief Treatment Enhanced level of intervention-cognitive behavioral, medications, Severe more than one session Referral to TX Referral of those with Adapted from Tom Stegbauer, DHHS, 2008 more serious or Source: SAMHSA. A Guide to Substance Abuse Services for PrimaryCare Clinicians TIP Series No. complicated mental or 24 (1997) http://whqlibdoc.who.int/HQ/2001/WHO_MSD_MSB_01.6b.pdf substance use http://www.coloradoguidelines.org/pdf/guidelines/sbirt/SBIRT%20Resources%20-%208-6-08.pdf conditions • Alcohol, Tobacco • Illicit drugs • Federal SBIRT Data • WHO multi-national trial Screening, Brief Interventions for Alcohol Have Major Impact on Morbidity and Mortality Study Results -conclusions Reference Trauma patients 48% fewer re-injury (18 months) Gentilello et al, 1999 50% less likely to re-hospitalize Hospital ER screening Reduced DUI arrests Schermer et al, 2006 1 DUI arrest prevented for 9 screens Physician offices 20% fewer motor vehicle crashes over 48 month follow-up Fleming et al, 2002 Meta-analysis Interventions reduced mortality Cuijpers et al, 2004 Meta-analysis Treatment reduced alcohol, drug use Burke et al, 2003 Positive social outcomes: substance-related work or academic impairment, physical symptoms (e.g., memory loss, injuries) or legal problems (e.g., driving under the influence) Meta-analysis Interventions can provide effective public health approach to Whitlock et al, 2004 reducing risky use. Meta-analysis Pharmacotherapy as much as triples these rates Fiore et al, 2000 43 studies Tobacco: http://www.ahrq.gov/clinic/uspstf/uspstbac.htm Alcohol: http://www.ahrq.gov/clinic/uspstf/uspsdrin.htm SBIRT Screening Results Total screened (n) = 459,599 Screening Screened positive (n) + 104,505 Negative Screen 77.3 % Positive screen 22.7 % Positive Reinforcement Moderate Use Moderate/High Use Abuse/Dependence Brief Intervention Brief Treatment Referral to Treatment 70 % 14 % 16 % Source: Madras et al. Drug and Alcohol Dependence 99: 280-295, 2009 Outcomes for positive screens in need of intervention? Reductions in Substance Use from intake to 6 month follow-up es -up c w 80 n o Intake l a l t s 6 Month follow-up fo ub 60 th s ic f i mon c 6 e 40 t p *** a s *** nd ng i a 20 t r e k *** po *** a *** e *** nt R i 0 t % a Heroin Cocaine Marijuana Other Drugs Heavy Alcohol Methamphetamine Source: Madras et al. Drug and Alcohol Dependence
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