1. John Boffa Chief Medical Officer Public Health Assoc Prof., NDRI A Comprehensive primary health care approach to ICE, alcohol and other drugs John Boffa Chief Medical Officer Public Health Assoc Prof., NDRI

2. 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

7. 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

8. Focus on illicit drugs puts Australia’s drinking problem on ice June 2015 The Conversation But 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.some form of methamphetamine11 or more standard drinks

9. 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.classified as alcohol-related

13. 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.

14. THE NEUROSCIENCES REVOLUTION OF THE LAST 20 YEARS HAS GIVEN US EXTENSIVE NEW INSIGHTS INTO THE PATHOPHYSIOLOGY OF ADDICTION

16. Science must replace ideology as the foundation for the treatment of drug addiction: AMT????

17. A KEY PRINCIPLE IN UNDERSTANDING ADDICTION Drug use is a voluntary, preventable behaviour….

18. but... addiction Drug addiction is not just “a lot of drug use”.

19. Drug Addiction Compulsive drug seeking and use, even knowing the negative health and social consequences

20. ADDICTED RAT “even knowing the negative consequences”

22. Exercise

23. The Rat Park Experiment

24. Virtually all drugs of abuse “hijack” the dopaminergic mesolimbic reward system in the brain Ventral tegmental area Nucleus accumbens Limbic system Orbitofrontal cortex

26. Le Foll, B. et al. CMAJ 2007;177:1373-1380 IN ADDITION, A NUMBER OF THE BRAIN’S OTHER CHEMICAL MESSENGER SYSTEMS ARE AFFECTED BY THESE DRUGS EACH DRUG Drug receptor

27. Drug addiction is a chronic relapsing brain disease

28. 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

29. Dopamine D2 Receptors are Lower in Addiction DA D2 Receptor Availability control addicted Ice & Cocaine Heroin Alcohol DA Reward Circuits DA Reward Circuits DA Drug Abuser Non-Drug Abuser

30. Patchy, reduced brain blood flow in heroin patient = less brain activity NORMALHEROIN

31. ALCOHOL METHAMPHETAMINE NORMAL

32. Drug users have increased brain responses to drug related images NORMALALCOHOLIC

34. NORMALADDICTED NORMAL

35. which do improve with continued cessation of drug use The addicted brain shows distinct changes which do improve with continued cessation of drug use NORMAL ACTIVE HEROIN USE 1 YEAR DRUG FREE

36. METHAMPHETAMINE

37. chronic relapsing illnesses The principles for treating drug addiction are the same as for treating other chronic relapsing illnesses such as asthma, diabetes, arthritis or multiple sclerosis.

38. Rapid induction of remission Supportive maintenance of remission Expectant observation Rapid, non judgmental re-treatment of relapse if or when necessary

39. Treating drug addiction is not like fixing a ruptured appendix or a broken bone ONE OPERATION WILL NOT CURE IT !!

40. A good treatment outcome is: A significant decrease in drug or alcohol use Long periods of abstinence with only occasional relapses

41. Drug addiction is a BRAIN BRAIN disease that is expressed in BEHAVIORAL BEHAVIORAL ways and which occurs in a SOCIAL SOCIAL context

42. Psychosocial Stream Medical Stream Social and cultural support Service delivery model: 3-stream approach with care coordination and case management

44. 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.

45. SOCIAL CONTEXT

52. Australian Early Development Index

54. % of children in Normal IQ Range (>84) by Age (longitudinal analysis) Martin, Ramey, & Ramey. 1990. American Journal of Public Health

55. CONGRESS CHILD CARE EARLY LEARNING STUDY Collette Tayler Isabel Brookes

57. 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.

58. Preliminary analysis – Language Development

59. 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

60. ` T H A N K Y O U