John Boffa Chief Medical Officer Public Health Assoc Prof., NDRI A Comprehensive primary health care...

A Comprehensive primary health care approach to ICE, alcohol and other

drugs

John BoffaJohn BoffaChief Medical Officer Public HealthChief Medical Officer Public Health

Assoc Prof., NDRIAssoc Prof., NDRI

Introduction

1. The Epidemiology of metamphetamines in the NT

2. ICE and Alcohol – the need for a combined approach

3. The neuroscience of Addiction

4. The 3 streams of care in effective treatment

5. The social determinants of addiction and Early Childhood

ICE and Alcohol

Methamphetamine, including ICE, dependence is currently a very big problem for a small number of people and their families.

Alcohol dependence is a very big problem for a large number of people and their families and of much greater harm to the community as a whole

There is a common approach to both treatment and primary prevention so we need to address both together

Focus on illicit drugs puts Australia’s drinking problem on ice

June 2015 The ConversationBut another – largely unremarked on – negative outcome of the strong focus on ice is that it takes the spotlight away from the harms of excessive alcohol use, which is actually a bigger problem in Australia. A reported 2.1% of Australians have used some form of methamphetamine in the last 12 months while 15.6% of people aged 12 or older have consumed 11 or more standard drinks on a single drinking occasion in the same period.

Focus on illicit drugs puts Australia’s drinking problem on ice

June 2015 The Conversation

Of the 1,565 solved homicides in Australia between 2000 and 2006, 729 (47%) were classified as alcohol-related. Both people had consumed alcohol in 60% of these cases, only the offender in 21%, and only the victim in 19%. Of the homicides involving an intimate partner relationship, between 2000 and 2006, 44% were related to alcohol.

Figure 1 Wholesale PAC Supply – Tennant Creek

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

2007 2008 2009 2010 2011 2012 2013 2014

PA

C (

Lit

re)

Total Total Wine Total Spirits Total Beer Cider

Many people still see drug & alcohol

addiction as a moral problem to be

handled through the criminal justice

system rather than through a health lens.

THE NEUROSCIENCES REVOLUTION OF THE NEUROSCIENCES REVOLUTION OF

THE LAST 20 YEARS HAS GIVEN US THE LAST 20 YEARS HAS GIVEN US

EXTENSIVE NEW INSIGHTS INTO THE EXTENSIVE NEW INSIGHTS INTO THE

PATHOPHYSIOLOGY OF ADDICTIONPATHOPHYSIOLOGY OF ADDICTION

Science must replace ideology as the

foundation for the treatment of drug

addiction: AMT????

A KEY PRINCIPLE IN

UNDERSTANDING

ADDICTION

Drug use is a voluntary, preventable behaviour….

but...

Drug addictionaddiction is not just

“a lot of drug use”.

Drug Addiction

Compulsive drug seeking and use, even knowing the negative health and social

consequences

ADDICTED RAT

“even knowing the negative

consequences”

Exercise

The Rat Park Experiment

Virtually all drugs of abuse

“hijack” the dopaminergic

mesolimbic reward system in

the brain

• Ventral tegmental area• Nucleus accumbens• Limbic system• Orbitofrontal cortex

Le Foll, B. et al. CMAJ 2007;177:1373-1380

IN ADDITION, A NUMBER OF THE BRAIN’S IN ADDITION, A NUMBER OF THE BRAIN’S OTHER CHEMICAL MESSENGER SYSTEMS OTHER CHEMICAL MESSENGER SYSTEMS

ARE AFFECTED BY THESE DRUGSARE AFFECTED BY THESE DRUGS

EACH DRUG

Drug recept

or

Drug addiction is a Drug addiction is a chronic relapsing chronic relapsing

brainbrain disease disease

Drug addiction is a Drug addiction is a chronic relapsing chronic relapsing

brainbrain disease disease

The addicted brain is distinctly, biologically different from the non-addicted brain, including:

• Receptor function and availability

• Metabolic activity

• Responsiveness to environmental cues

• Gene expression

Dopamine D2 Receptors are Lower in Addiction

DA

D2

Rec

epto

r A

vaila

bili

ty

control addicted

Ice & Cocaine

Heroin

Alcohol

DA

DA

DA

DA DA DA

DA

Reward Circuits

DA DA DA DA

DA

Reward Circuits

DA

DA

DA

DA DA

DA

Drug Abuser

Non-Drug Abuser

Patchy, reduced brain blood flow in heroin patient = less brain

activity

NORMAL HEROIN

ALCOHOLALCOHOL

METHAMPHETAMINEMETHAMPHETAMINE

NORMAL

NORMAL

Drug users have increased brain responses to drug related images

NORMALALCOHOLIC

NORMAL ADDICTEDNORMAL

The addicted brain shows distinct changes which do improve with which do improve with

continued cessation of drug usecontinued cessation of drug use

NORMALNORMAL ACTIVE ACTIVE HEROIN USEHEROIN USE

1 YEAR 1 YEAR DRUG FREEDRUG FREE

METHAMPHETAMINEMETHAMPHETAMINE

The principles for treating

drug addiction are the

same as for treating other

chronic relapsing illnesseschronic relapsing illnesses

such as asthma, diabetes,

arthritis or multiple

sclerosis.

The principles for treating

drug addiction are the

same as for treating other

chronic relapsing illnesseschronic relapsing illnesses

such as asthma, diabetes,

arthritis or multiple

sclerosis.

• Rapid induction of remission

• Supportive maintenance of

remission

• Expectant observation

• Rapid, non judgmental re-treatment of relapse if or when necessary

Treating drug addiction is not like fixing a

ruptured appendix or a broken bone

ONE OPERATION

WILL NOT CURE IT !!

A good treatment outcome is: A good treatment outcome is:

• A significant decrease in drug or alcohol use

• Long periods of abstinence with only occasional relapses

Drug addiction is aBRAINBRAIN disease that is expressed in BEHAVIORALBEHAVIORAL ways and which occurs in a SOCIALSOCIAL context

Service delivery model: 3-stream approach with care coordination and case management

Extended Abstinence is Predictive of Sustained Recovery

It takes a year of abstinence

before less than half relapse

Dennis et al, Eval Rev, 2007

After 5 years – if you are sober, you probably will stay that way.

SOCIAL CONTEXTSOCIAL CONTEXT

Australian Early Development Index

% of children in Normal IQ Range (>84) % of children in Normal IQ Range (>84) by Ageby Age (longitudinal analysis) (longitudinal analysis)

Martin, Ramey, & Ramey. 1990. American Journal of Public Health

CONGRESS CHILD CARE EARLY LEARNING STUDY

Collette Tayler

Isabel Brookes

Preliminary analysis – Language Development

• Preliminary analysis of completed follow-up language assessments show an average language development gain of 7 months in a 3.5 month period.

Preliminary analysis – Language Development

Conclusions

1. ICE is a problem which is not out of control, is very treatable and is nowhere near the problem of alcohol

2. There is a common way of treating ICE, Alcohol and other drugs and this works

3. The social context of drug addictions is key to understanding the differential effects of drugs on different population

4. Early Childhood programs are key to the primary prevention of addictions

`THANK

YOU