Drug addiction: Therapeutic problems in everyday clinical practice E. Mellos Psychiatrist – Psychotherapist Program “ATHENA”, Eginition Hospital, Department of Psychiatry

It is a commonly held belief that substance abuse is determined by biological, psychological, cultural and environmental factors and related with a number of consequences in a personal or social level Despite the fact that the problem of drugs in the EU member states has been stabilised in some respects, various other epidemiologic indicators acknowledge new and adverse challenges, relating to the problem

A) the new patterns of drug use B) the problem of co-morbidity C) the Internet pharmacies D) the specific groups of drug users

The drug situation in Europe - new patterns of drug use Heroin abuse is now relatively stable in many EU countries and the number of new users has fallen since the 1990s Injecting use seems to be decreased in some countries, although in others like the new EU members states it may still be increasing The number of drug-related deaths has shown a modest decline after many years on the rise. Drug-related deaths fell from 8,838 in 2000 to 8,306 in 2001 representing a small but significant 6% decrease

Cocaine use remains an issue of increased concern for many EU countries. Surveys show recent cocaine use (last 12 months) has risen to some extent among young people in Spain, UK, Denmark and Germany Cannabis remains the most commonly used illegal substance in Europe with roughly 20% of adults having tried it at least once in their lifetime Cannabis prevalence rates are higher for young people (15-34) ranging from 15 to 35%

Expect XTC in the last years new substances, such as 4-MTA, PMA, PMMA, Ketamine and GHB, are emerging Overall available data show that European trends in the recent use of ecstasy are still upwards, while trends for recent amphetamine use are more complicated in the majority of countries

B) Comorbidity According to the international literature almost half of the individuals with a substance abuse disorder suffer from another mental disorder Personality disorders have been found in 50-90% of drug dependent patients, affective and anxiety disorders in 20%-60% and psychotic disorders in 5-20%

Both drug treatment and psychiatric services regularly fail to detect individuals with co-morbidity, because the diagnosis is often particularly difficult to make Treatment of psychiatric comorbidity in drug users is regarded as complicated and unrewarding and the prognosis of treatment outcome is often poor and uncertain Treating clients with co-morbidity requires cooperation and coordination between services that are involved in their treatment, including health and social services

C) Internet pharmacies The amount of psychotropic substances have been increasing steadily over the past year and now constitute the vast majority of sales of such illicitly operating Internet pharmacies There is great concern over the fact that the lack of age restrictions with regard to potential customers for these drugs could become a major source for abused prescription medications among children and adolescents Internet sales include substances like opioids (codeine or even fentanyl), stimulants and benzodiazepines

D) Specific groups of drug users During the last decade there is an increased focus on the specific group of addictive population, such as minorities or refugees, prisoners, pregnant women or mothers with children These groups of addicts are usually under-represented in therapeutic treatment facilities and may require specialised interventions

Ethnic minorities or refugees could be reasonably considered one of the more vulnerable groups with respect to drug abuse Factors such as language and cultural barriers are often an obstacle to be granted access to services for people from these groups Preventive and treatment interventions specifically designed for ethnic minorities or refugees are still isolated in most European countries

According to the European epidemiological data the number of problem drug users range from 20-50% of the total prison population, in most member states For a number of addicts prison is merely a place where they continue to use drugs, while others start using drugs in prison or commence the injecting use

Women users consist a heterogeneous group with different characteristics and needs, most of which are not answered by the existing treatment modalities The increase in the rate of women drug users is much higher than the men’s in most countries Women still remain a minority in most drug addiction programmes, especially those who have children The need for the development of specific therapeutic programmes for women should not lead to the conclusion that all women are to be treated separately from men

Conclusions (I) During the last two decades, advances in both neurosciences and behavioral sciences have revolutionised our knowledge about the nature of drug addiction and what to do about it A great number of addicts are out of contact with therapeutic or care services and not adequately helped, the drop-out and relapse rates are quite high and eventually the outcome of treatment of drug dependence are not satisfactory

Conclusions (II) Due to the complexity of the addiction and the pervasive consequences treatment typically involve many components Effective treatment must cover the multiple needs of the individual, not just his/her drug use The current status for treatment is that it must include both counseling or psychotherapy and medications Associated services such as medical, educational, legal, financial and others are important components of comprehensive addition treatment

Conclusions (III) There has been a constant growth in all types of drug treatment since the mid 1990s Substitution treatment has become the most commonly available form of specialised treatment for opiate users Nevertheless, the demand still exceeds the supply in some countries Considering all the above, it could be inferred that therapeutic interventions should be both multiple and diversified. However, they would also require to complement each other and to initiate a continuous dialogue between them