HRD programs

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HRD programs

• Emran M Razaghi, MD, MPH

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Definitions

• Psychoactive substance
• when taken in or administered into one's system
• affects mental processes, e.g. cognition or
  affect
• does not necessarily imply dependence-producing

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Definitions

• Abuse
• a maladaptive pattern of use
• continued use despite knowledge of having a
  persistent or recurrent social, occupational,
  psychological or physical problem
• use in situations in which it is physically
  hazardous
• non-medical or unsanctioned patterns of use

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Normality

• As
• Health
• Average
• Utopia
• Process

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A disease?

• DSM-IV definitions
• Substance use
• Substance abuse
• Substance dependence

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Definitions

• Dependence syndrome
• a cluster of physiological, behavioral, and
  cognitive phenomena
• use of a substance takes on a much higher
  priority
• the desire (often strong) to take the
  psychoactive drugs
• after a period of abstinence, a more rapid
  reappearance of other features of the syndrome
  occurs

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Definitions

• Harmful use (ICD-10)
• a pattern of psychoactive substance use
• causing damage to health
• physical (e.g. hepatitis following injection of
  drugs)
• mental (e.g. depressive episodes secondary to
  heavy alcohol intake)
• commonly with adverse social consequences

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Definitions

• Hazardous use
• a pattern of substance use
• with increased the risk of harmful consequences
  for the user
• with patterns of use that are of public health
  significance despite the absence of any current
  disorder in the individual user

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Epidemiology

• The global burden
• 2 billion alcohol users, 1.3 billion smokers and
  185 million drug users
• tobacco, alcohol and illicit drugs contributed
  12.4 of all deaths worldwide in the year 2000
• total years of life lost 8.9
• proportion of DALY on males in the developed
  countries 33.4 of all DALYs

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Epidemiology
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Epidemiology
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Epidemiology
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Epidemiology
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What people think (WHO)

• Drug dependence is simply a failure of will or of
  strength of character

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What people think (WHO)

• People who have drug dependence can easily move
  back to occasional use

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What people think (WHO)

• It's not worthwhile to invest in treatment for
  individuals who have drug dependence - it is a
  waste of public funds

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What people think (WHO)

• There is already enough research for policy
  making on drug and alcohol related problems,
  there is no need for more

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What people think (WHO)

• All that is needed to cure dependence is
  treatment centers - once you are in, you are cured

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Prevention
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Prevention
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Prevention

• Regulation of the physical and economic
  availability of alcohol
• Lowering the age of availability, decreasing its
  cost, or increasing the number of outlets
  increase its consumption
• Increasing the cost quite effective in reducing
  problems associated with alcohol

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Prevention

• Regulation of the physical and economic
  availability of illicit psychoactive substances
• Affect the shape of the market, the purity of the
  substances available and their price
• No permanent effect on eradication of drugs

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Prevention

• Mass media
• In-effective in reducing different types of
  psychoactive substance use
• Community-based interventions
• Changes observed in such areas as acceptance of
  health orientated policies and increased
  knowledge
• For such changes tobe sustained requires that
  they be institutionalized

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Prevention

• School-based interventions
• produce change if
• provided at a developmentally appropriate time
• provided during the period students experience
  initial exposure to psychoactive substances
• local prevalence data used
• complementary general health/life skills added
• psychoactive substance use education is best
  integrated within a well-founded health
  curriculum
• programs with primarily following abstinence goal
  fail to produce behavioral effects

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Treatment

• Philosophies
• Social control
• Abstinence
• Harm reduction

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Treatment

• DSM-IV course specifiers
• Early full remission
• Early partial remission
• Sustained full remission
• Sustained partial remission
• On agonist therapy
• In a controlled environment

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Treatment

• Short term objectives
• Keep the patient in treatment
• Eliminate illegal use
• Eliminate asocial behavior

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Treatment

• Long term objectives
• Acquire resistance skills
• Acquire social skills
• Acquire capacity for maturity

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Drug Control Strategies
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Enforcement Examples

• Minimum sentencing for Marijuana users
• Drug Free School Zones
• Employment Drug Testing
• Sport Drug Testing
• Country Boarder Enforcement
• The War on Drugs

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What Is Harm Reduction?

• Refers to an emphasis on reducing the negative
  consequences of using a substance rather than on
  reducing the quantity or frequency of its
  consumption.
• Programs may encourage lighter consumption, but
  the focus is on reducing the harmful consequences
  that may ensue from substance abuse.

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Harm Reduction Examples

• Needle Exchange Programs (NEP)
• Dance Safe
• Safe Crack Kits

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Lets debate

• What do you think is a more effective deterrent
  harm reduction programs or enforcement?
• What programs do you know that make drug use more
  safe, if any?
• Do you agree with the drug laws that are in
  place, why or why not?
• Do you find value in programs that make drug use
  safe?
• Do you or your close friends use drugs?

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Harm reduction or harm maintenance?

• What people are saying?

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Rationale for harm reduction

• Humanitarian rationale
• Public health rationale
• Human rights rationale

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Risk environment for IDUs

• The law
• Management of the law enforcement
• KAP of frontline officers
• KAP of HRD service providers
• Attitudes and experiences of IDUs

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Ecological approach

• How
• Social factors
• Political factors
• economic factors
• Features of the physical environment
• Personal characteristics
• determine health.

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HRD in the 21st century

• Coverage
• Innovation
• Sustainability
• The role of social capital

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HRD, deciding for scale up?

• Recognize national HIV problem
• Recognize need for harm reduction
• Plan implementation
• Ensure sustainability

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CQI
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Rationale for harm reduction

• Humanitarian rationale
• Public health rationale
• Human rights rationale

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Thank you!