Michael W. on Global Addiction Treatment and the Abstinence Model — Part 1 — Mike

Wait a second, I'm waiting until I get up his slides. And he is the medical director at Bradford Health Services in Alabama and he's going to talk to us about cultural influences in addiction treatment. I appreciate the opportunity to start out the 2015 CME program, it's a big privilege and honor. I'm going to talk today about cultural influences in addiction and addiction treatment and actually I'm excited to do that here because there's some tie to IDAA. After I got sober, by the way, I'm Mike. I'm an alcoholic and addict. I had heard for a number of years I'd need to go to IDaa. And, you know, busy other things happened. Didn't make it for the first few years. And then in 2003, I went and was in Mobile. And I was just fascinated by the meeting, really enjoyed it, and have been a regular attendee since then. There was another meeting about 10 years ago I started hearing about. And it was ISAM, the International Society of Addiction Medicine. How many people have had the opportunity to go to that? Anybody been able to go through it yet? And, you know, I hear these great stories about it, and the same kind of thing was I'd really like to be able to go to some time, put it on my bucket list. Well, last year it was in Japan. I'll be honest with you because this is an honest program. I didn't even look at the itinerary. I just wanted to go into Japan. Okay? And so I went with a friend of mine. We went to Tokyo first. We were there for about five days. And then the conference was about an hour and a half above in Yokohama. And I went up there just thinking, well, you know, this will be icing on the cake. Hopefully I'll get a little bit out of it. It was one of the most fascinating conferences I've ever been to in my life. To see the global scope of addiction, what other people are doing with it, what are some of the differences. And, you Know, again, we've seen a lot of growth in addiction medicine in the states over the last 10 years. And it was just nice to see that there are other countries, unfortunately, that are having to deal with addictions like we do. but also there's a lot of treatment and education about that. So, that's what I'd really like to be able to share today is to talk about some of those presentations and some of the things that are going on globally with addiction and addiction treatment. So, I'm just going to flap through this real quickly, and we'll get to the topic. So, the objectives are to identify global trends and challenges in treating substance use disorders, Discuss some of the controversies between different countries in treating substance use disorders, and there's some pretty unique ones that are out there definitely. We don't have those problems just in the United States. And then to highlight the key advances being made throughout the world to improve access and treatment for patients with substance use disorders. So what I did is I went through the talks and picked up some of ones that I thought We're most interesting, and this kind of highlights the different countries. We're going to kind of go around the globe, hopefully in about 45 minutes. What I'd like to do is start off sort of a geography type of thing and talk about the countries just a little bit as far as population size, ethnic breakdown, and religious background to show how some countries are very similar. A lot of differences, of course, in a lot of these countries, yet they all have one common denominator, and that's problems with addiction. So we'll start off with Australia, the down-under country. And you can see there it's the sixth largest country as far as in size, a population of 23.7 million, most European ancestry, a fairly nice GDP of 46,000. And when you look at religion background, about 60% Christian, and then the next highest one was nonreligious of 22%. They had a presentation, something that relates a lot here to the States, is about, well, first off, they have universal health care that's been in place since 1975. So a lot of places, they had the fourth highest life expectancy in the world, and not surprisingly, they're the highest rate of skin cancer in the World. So they had a representation regarding opiate treatment and sustained naltrexone preparation use. And just like we have in the States and especially people that deal with trying to treat opiate addiction through abstinence. We have a big issue here in the States with people, once you get them detoxed early on, we have a lot of issues with overdoses and deaths. And they have the same thing in Australia. Now, they have a program in Western Australia that's state-driven, so this is provided by the government. And what they do is they had a study looking at trying to prevent these overdose deaths, and they looked at so that some of the studies showed that long-acting naltrexone implants can reduce the chance of overdose deaths in the first 120 days post-implantation. So they did this where they had bring the patients in and again, they note that there's that 7 to 10 day period between detox and naltrection use which represents a high time of overdose and they did a protocol, what they do is and I think some people in the states do this, they put them into treatment they do a very brief detox and they just throw them into withdrawal they go ahead and put the naltrexone in, look, you know, gosh if you're going to feel bad, we hate that, but feeling bad is worse than being dead and they go head and keep them in and then they get that naltrezone in very early which tends to be a problem sometimes in some of the programs that I've worked at is getting them in there before they discharge and they said using this method that there's been no over death overdose deaths in their program in the 16 years in their outpatient program so again something that we've been looking at the states and they've been doing in Australia trying to decrease mortality and people who are getting off of opiates next nation is just above north here with Canada you can see some of the demographics there it's a second largest country with 35.75 million people again and 77% white, 14% Asian, GDP similar to Australia, and actually the religious breakdown pretty similar to Australia too, 67% Christian and 24% non-religious. They had an interesting study. Let me do the interesting facts first. Rakes number one in number of adults having tertiary education, so if a Canadian is telling you that they're smarter than us, they're probably right. But they had a study where they looked at sort of the demographics between opiate substitution treatment? Looking at it, is there a difference between people in Canada that are on methadone versus buprenorphine? And I guess they were looking as to would there be more criminal element in people that are On methadones. And they did a study of 103 opiate-addicted patients. 75% were on methidone, 25% were on suboxone. 43.3% of these had known criminal history. Of those, about a third were convicted in third-cent jailing time, 10% were involved in a violent crime. But what they found out as far as the breakdown between the patients on methadone and suboxone was there wasn't really much difference as far as the criminal history went. They were very similar whether they were on methudone. No difference in criminal history between patients on suboxones versus methadones. And the only difference actually in the whole study between the people on subaxone and methadon was regarding urine drug screens that the methadone patients tended to have a higher frequency of positive test for cocaine. So that was the issue they had there that they presented at the conference. China, that was one of the countries I was kind of surprised that they were actually at the international conference. I've been to a conference in China previously, and the only thing they talked about with addiction was with Internet, gambling, and work. They really didn't talk about substance dependency at all. As we know, it's a very large country. GDP is significantly lower than we saw in Australia and Canada. And here we have a big change in religion as far as mostly looking at Buddhism and Confucianism. So what they looked at here on the interesting facts was 16 of the world's 20 most polluted cities are in China. I was in that conference in Beijing, and it was really kind of depressing how polluted that area was. And there's a number of books, some very interesting talk about opium wars between the British and French and China, so they have a big opiate history back there. One of the things that was interesting here, I know in the States when we're treating addiction a lot of times that's the first time someone will come in to get any kind of medical treatment, I mean, that's the first time you might link them up to be tested. And so they noticed this in China, and so they did a 10-year study of people who were in methadone clinics and do HIV testing to see what the percentage of HIV would be in patients that were addicted to opiates in China and then if they were positive to link them into treatment for HIV. So very progressive, I think, in my opinion, for China. We know that opiate-dependent patients are vulnerable to HIV infections, especially when they're using intravenously. We also know that early identification of cases and linkage to appropriate care is a public health challenge. And since 2014, urinary HIV testing has been offered to patients in methadone clinics in Hong Kong. And so they've done a lot of these tests. They ended up doing over, I think, 90,000 tests were done between 2004 and 2013. This covered up to 91% of the patients in the methadone clinics annually. Seventy-five new cases were detected during that time. Sixty-three percent of the new cases were followed up by the HIV clinic, and HIV prevalence among methadome-treated patients increased moderately from 0.2% in 2004 to 0.68% in 2013. So again, just like we're trying to do here in the States you're looking at ways that these infectious disease and with treating addiction to make sure that we treat the whole patient next we go to England much smaller country than China you see the ethnicity there again the GDP is very similar to Australia in Canada and religious background breakdown is very similar also to Australia and Canada they had some of the interesting The fact, of course, is that the National Health Service provides the majority of health care in the country. That's sort of the ones I think about when we think about national health services have been around for a long time, although England's not the oldest for that. They looked at a study with psychiatric comorbidity relating to mortality and opiate addicts to see if there was anything that would predispose patients to higher risk for death in psychiatric issues. and, you know, they have a very wide registry that they can pull from because of the National Health Service. They identified 220,000 patients in the London area. Of those, 4837 were opiate-dependent patients, and they had 176 deaths. And so what were some of the things they found as far as relating to mortality? The two things theyfound were comorbid personality disorders and alcohol use disorders in these patients were found to increase mortality. Alcohol use disorders were associated with a two-time increased risk of fatal overdose and a seven-time increase for liver-related deaths in our patients that have opiate issues. I think it's one of the things we talk about very frequently in the States is making sure people understand the risk of drinking if they have an addiction to opiates, and they saw this in England also. They also saw an increased death rate with comorbid personality disorders, although they did not go specifically into what the personality disorders were. If they said exactly what were some of the issues I don't really remember at this time but they just noted that they did have and all these deaths were related to liver related deaths, not necessarily overdose. Now, this was one of the most, I think one of the most interesting things at the talk where there were probably four or five talks on disulfiram, antabuse. And there were some very, I would say, very strong opinions about the use of antabase. And England was one of those ones that really believed in abuse. They felt like it was very underutilized and that it was probably the most effective thing to use in the treatment of alcoholism as far as a medication treatment. And they did a study where they presented some data from England where they felt supervised. Disulfiram was more effective than other relapse-preventing medications. They felt that its mode of action was deference, not aversion, and that's a big difference. I'll talk about another country that was very opposed to the use of disulfiram, and that is what one of their problems was. And they felt like it both facilitated it reinforced the cognitive behavioral process of exposure and relapse prevention. England's not the only one I'll talk about. Again, it's something that I don't know how many people out here now are still using disulfiram very regularly. So maybe something, after you see the talk, maybe something you need to look back because people across the world are still saying that it can be effective even though it's been out there a long time and not used as much as some of the other things are. and so they didn't have any ethical objections to the use of doxulfiram in their patients. What about France? Go across the pond there, the English Channel to France and you see the breakdown there. Again, GDP capital is fairly similar to some of the other countries we talked to and also the religious breakdown. down. It's not surprisingly rated as the number one tourist destination in the world and recognized by the World Health Organization for having one of the best overall health care systems in the word. There were a lot of talks at this. The United States is not the only one that's having significant issues with prescription opiates, and they had a study that they presented about some people that are having issues with opiats, not just prescription opiates. They did a cross-sectional study of individuals who were in treatment centers in France. This one had 144 patients, 77% were males, average age was 39 years old. And you can see the most common reason people were in treatement in France for opiats were heroin. But they had other things that people were at. They were starting to see more frequency of individuals in treatment for things other than heroin. And that tends to be the new trend in a lot of the countries. And look at the commonly abused drugs include buprenorphine, codeine, methadone, and morphine. And the number one drug of choice treatment is bupropen. So it was interesting to know, and I'm not a bupaphen basher, but a lot times people were coming out with bupraphen and said, well, you know, it's safe. It cannot be abused. There are a number of countries that made presentations, not that they didn't use it, but that they had people in treatment, just like we do here in the States, for abusing buprenorphine. So I thought that was very interesting to see they're seeing the same kind of issues we are. Germany, staying in England, again you can see some of the data there, very similar to some ofthe other developed countries that we're talking about in this field. They also, the interesting thing is they have the world's oldest universal health system. I did not know that. I thought it was England. Nobel Prize has been awarded to 104 Germans, and they have the highest third number of international migrants worldwide, and that's a thing that is actually making some challenges in Germany as far as some of the other countries in Europe as far As some of changes that are seen with addiction and about the ability to get treatment for those patients. now before I got sober I always thought I wish I would have gone to Germany before I got sober because I know they like to drink a lot and so it wasn't surprising that in Germany they had a presentation relating to can alcohol dependent patients reduce their alcohol consumption if you're in recovery or in treatment with me the answer is no but abstinence has been the predominant treatment goal in alcoholism, and we've heard this before from our people here in the United States. Is that the reason we only reach a small percentage of our patients? Because a lot of them won't come into treatment if the only thing that we're going to talk about is abstinence. A large U.S. study showed that 42% of patients won't initiate treatment because of that. They're unwilling to quit alcohol completely. And so they talked about the European Medicinist agency published guidelines in 2010 where the reduction of alcohol consumption and now called dependent patients is an accepted goal and that's part of the practice there in Germany then as they're looking at risk reduction you know we've had things here like drink wise rational recovery things like that and so you're going to see some presentations there's another one too that we're looking you know treatment goals maybe they should be set a little bit differently and a lot of this kind of ties to to the DSM-5. There's another talk talking about alcohol use disorders on the spectrum and maybe with mild alcohol use disorder, looking at reduction not necessarily total abstinence as an acceptable treatment modality. Well India had a couple presentations there, very large country, very poor country. You can see first country we've had that majority of the religion is Hindu so much much different as far as a religious background. They were another one that surprisingly did a talk on disulfiram and the use of disulfaram in India, and they felt that it was very effective in their patients. They said it had been approved there for alcoholism since 1951, and there did a study comparing it to acamprosate, naltrexone, topramax, and blacophon. They looked at various studies with over 200 patients on disulfiram, and what they found is they felt it had greater efficacy, just like they talked about in England. They felt it reduced relapse rates, increased time to first drink, increased days of abstinence, and they felt that it was underutilized in the treatment of alcohol use disorders. So I found that very interesting that a couple of countries there, England and India both, were looking at something that's been out for a long time and saying at least in their population, maybe you're looking also again at cultural things and also expense. And this is something that can be readily available fairly inexpensive that they feel can be very effective for their patients if they are unable to get the length of treatment or the other modalities that may be available in more developed nations. Okay, Indonesia, I guess it surprised me fourth most populous country in the world and the other thing it's interesting about is they have 300 distinct native ethnic groups with 745 different languages and dialogues so that was I thought very surprising, boy that'd be hard to you know treat patients there if you didn't understand the language. Again a very relatively poor country and a very high percentage of Muslims in Indonesia. One of the things probably driven their treatment as far as looking at addiction is the issues with HIV and AIDS, which has been a significant issue increasing over the last 20 years. That's challenged by that they have limited mental health services, and this was supposed to be changed. That's actually Germany, so I got put on, so sorry about that. But they were looking at psychiatric trainees towards addiction. And this was one of the things, again, that surprised me in Indonesia that in people that are training to be psychiatrists in Indonesia, addiction is part of the curriculum and training that they have them look at. And they interviewed 35 trainees to see what their perception toward addiction was. Now, the good news is that they did think addiction was a disease, but they felt that it was a very poor prognosis that it would not easily treat it. And because of that, less than 50% wanted to work with addiction patients. They felt that it would be unrewarding. And furthermore, they felt that only 30% of them agreed that they were ready to manage addiction patients when they graduate. And so one of the things that came out of this meeting and different things is how we're trying to improve on a global experience of training people to be adequately available to treat individuals who have substance use disorders, not only in the United States but across the country. And that was one of the big issues. And Indonesia is trying to find, with their limited mental health services, individuals who are available and felt comfortable treating with individuals who had substance issues. Well, the next country in the Middle East, Iran. Again, this was one that sort of surprised me, that Iran would be at the International Society of Addiction Medicine talking about addiction issues. You can see some of their demographics right there. again, a country that's a majority of Muslims. Of course, we know they have the largest gas reserves in the world, but also I did not know this, that they've had again, just like Indonesia, a lot of issues with IV drug use and HIV. And this is again something that's driving them to look at more effective treatments for addiction because of the medical morbidity that they find in Iran. They actually have a national HIV treatment system that includes free needle exchange, which again was kind of surprising to me in a country like Iran. Now they talked about methadone maintenance treatment in Iran, and this is some of the things that we talked about France with buprenorphine, but a number of countries, again, the main field with individuals who have opiate addictions is risk reduction. It's not absence. It's getting people on methadrone. It'S keeping them on methidone. That's the whole goal, and that's what the thing of this study was, was looking at how can they get people on methadone and keep them on methadones so that they can hopefully decrease the morbidity. This was a 2007 study to determine predictors of retention in treatment at methadon clinics. They followed seven outpatient treatment facilities in four cities, and the main thing they found here was that the dropout rates were very, very high. They only had about 22 percent that were still in the programs at the end of six months, and they identified things that we would expect, that we probably see the same thing here in states as far as retention rates are affected by you know the city social support distance to the clinics and the individuals desire to continue to use drugs now the next thing when they talked about I guess if they couldn't get people into treatment but you know some kind of risk reduction or other areas and it seems like the majority of people in Iran that had substance use disorders were males well you start talking about fertility issues and males you'll get their attention i can tell you that right now and so infertility is one of the most social serious social problems in iran and so these presenters did a study on kerak which is a high purity street level heroin and what they found out was that they studied it on sperm fertility in adult mice and found out that it showed multiple effects on sperm that resulted and decreased fertility. So I guess this is trying to look at a different way maybe to engage that male population that's using heroin in Iran to maybe get into treatment or get onto methadone because it's going to affect their fertility. How about the next country is Italy. You see the breakdown there fairly similar to some of the European nations we've talked about. They've had universal health systems. Organized crime is reported to represent 7% of Italy's GDP. I thought that was rather interesting. They were talking about medications and the treatment of alcohol use disorders that deal with the gabinergic system. And what was interesting, the individual that presented this, I could tell, and I'll tell you why when we get later down the slide, that he didn't know a lot about addicts. Because we got down, he was talking about sodium oxybate, which is GHB and baclofent in the management of alcohol abuse disorders. and both studies have shown that they're effective in treating symptoms of alcohol withdrawal. Both have showed effectiveness in reducing alcohol cravings and alcohol intake. Baclofen, they found out in one study, it was pretty significant too, that it really had a profound effect in individuals who had alcohol use disorders and liver cirrhosis. Why that is, I'm not sure, but it was just interesting that the study was pretty impressive. Now this is the part where the guy was, you could tell he wasn't in recovery He didn't know much about addicts because he said, you know, sometimes the patients will abuse that. And I thought that was kind of funny. So you kind of need to watch out about that. But they were using it in this area of Italy and felt that if the appropriate patients were picked out that just were primary alcohol use disorders, that they had some successful outcomes with it. And they also talked about if they had somebody on back for a long period of time, they need to make sure that they tapered it off because they would have physical withdrawal symptoms. Well, as I said previously, the conference was in Japan, so there were a lot of presentations in Japan at this meeting, a lot OF different things in there. We've got a number of those. Basically, they have an insurance system that's set up fairly similarly to the United States, but they did a thing, again, of current conditions of prescription drug abuse in Japan. It's a growing problem in Japan, just like it is in other countries. The difference is that their big thing is not opiates, it's sedative hypnotics. Sedative hypnotic seem to be the big problem in Japanese. And most are supplied by prescriptions from psychiatrists, so they're not necessarily getting off the Internet or off the street. They get them from prescriptions. and they're commonly used in suicide attempts. And so this is one of the big things in Japan was about the co-occurring disorders of alcohol use disorders and depression and suicide and that they were going to be more diligent on working on making sure sedative hypnotics are appropriately prescribed. How about pharmacotherapy for alcoholism in Japan? For the last several decades, they've only used Sinamid, which I've never used or really heard about before. similar to disulfiram. It's an aversive drug, but you have to give it three times a day and it causes more problems with the liver than Anabuse does. But for a number of decades that had been what had been used specifically in Japan. They did a large study of 471 in patients, 357 out patients, and they combined this time they were looking at acamprosate and disulfiram for treatment and seeing which one was better. They said that disulfaram continued to be the major treatment for the outpatient when the person was an outpatient, but in their studies, they felt that acamproside was very well tolerated, and in Japan, that was the first drug of choice for people who had alcohol use disorders in Japan. This is where they talked about diagnostic criteria trying to define, I thought this was interesting just to compare it to what we see here in the United States how some of those things go together and they looked at a number of patients that were hospitalized in Japan they looked up they looked into six of the ICD-10 criteria for alcohol dependence and they found that three were really strongly correlated with each other strong desire, cravings, difficulty controlling use and progressive neglect of alternative interest and that the withdrawal and physiological tolerance weren't as closely related, and I know that's something I see very similar especially in early stage alcohol use disorders is those are the things that more correlated. And this comes on later and that was the same thing that they saw in the patients in Japan that had alcohol use disorders. And they didn't see necessarily any relationship between the number of criteria that would be clicked off and abnormal lab values including GGT and MCV. So what about profiles of alcoholics in Japan? These were 260 male alcoholic patients in a local center. They had to do some questionnaires while they were getting treatment, and they found five distinct alcoholic clusters, pre-contemplation, ambivalence, derived, involved, and participation. That's just similar to the United States that will have changed that we always talk about and try to identify where the patient is, try to move them along. So they saw the same thing in Japan when they looked at these clusters and how people were motivated or not motivated to get better. They found elderly alcoholics have lower levels of motivation. I think that's very similar sometimes in patients that I see. Down at Bradford, older alcoholics have been drinking for a longer part of time, a lot less motivation, harder to treat. And also interesting, and they said that alcoholics on welfare in Japan are more likely to die of their problems. I'm not sure what that means, but it was just kind of an interesting fact there. What about the treatment system for alcohol use disorders in Japan? And they talked about because the treatment's not only influenced by culture, the policy of medical systems, and clinical characteristics of the patients. In Japan, people with alcohol use disorder, they go off for treatment at two to three months. So similar to some of the extended care programs or health care programs here that treat addiction issues, they do much longer-term treatment in Japan than they do here in the States for alcohol use disorders. They did say that Japanese patients tend to develop alcohol use disorder later in life, and they have a much lower incidence of comorbid antisocial personality disorders in polydrug addiction compared to Western countries and cities. They have a different self-help group that's based on AA, and that would be a whole other topic, but it's just kind of interesting. In that one, you're not anonymous. You actually list your name down, and actually you pay to be a member of the group. So kind of an interesting type thing there. And then they do a lot of additional treatments Also now we're seeing a lot in the States with Buddhism, meditation, mindfulness, things like that. They've already incorporated that in their treatment with alcohol use disorders and have been doing that for quite some time. As I said earlier, some of the big concerns in Japan is that they have a higher rate of suicide with individuals especially who have addiction issues. So they wanted to look at certain things that might increase the risk for somebody to commit suicide so they could hopefully address that and decrease their suicide rates. Fifty-four hospitals, 853 patients. They're followed for six months after discharge. About 16% experience suicidal ideation. Nine percent attempted suicide. Associated with suicide attempts, these were the things they found out Pretty straightforward, I think. The lifetime of depression, if they had any issues of violence during intoxication, and, of course, if they'd had more and more hospitalizations with alcohol use disorders, then they ended up having more problems with depression and also possibly committing suicide. What about predictors of inpatient treatment for alcoholism? They study 54 hospitals. at least 25 patients from each hospital. They were followed again for six months after discharge, mostly male, 853 patients. Forty percent remained absent, so a pretty good absence rate for six months out after treatment. And positive predictive factors were male patients who lived with someone or were married and patients who completed the program. So again, some of the things that we see very commonly in the United States also are positive predictive factors in Japan after people are getting treatment, no different in ethnicity or culture there. Another study talking about acamprosate, again a double-blend randomized trial, 327 patients, 34 medical institutions, and you can see right here, I'm just gonna get down to the bottom line, is the basic thing is, again, this was the second study that they presented is that they felt in the Japan, in the Japanese, that acamprosate was the best medication to use as far as assisting individuals in staying sober from alcohol. This one right here, I don't have any... They did a randomized trial of this medication, and I'll probably butcher the pronunciation. Afinprodil, has anybody else heard of that? I hadn't either, so... Well, that makes me feel a little bit better than nobody else has heard about it. It's some kind of NMDA works through that system, and so it's supposed to reduce the rate to relapse. So this is something that we'll just have to see down the road if coming out of Japan, if it comes to the United States, or we'll hear more about it, but this was probably one of the few talks I heard about where there was something sort of a cutting edge that I had never heard of the medication before. We'll just have to see if anything else comes out regarding that. Talked about disulfiram, they also studied, so they're doing studies with that, and acamprosate randomly assigned to four groups. The reason I put this one in here was because it was more pharmacogenetics where they looked at four groups, so you either got disulfaram or you got placebo, And then one group got the disulfiram, and some adjunctive therapy consisted of mailed letters. The other people didn't. And the only difference—they didn't find any difference whether they got the disulfaram or not—but they looked at this different genetic marker, the inactive aldehyde dehydranase, and they found that individuals that had an inactive aldehydrehydranase had a much higher level of abstinence. So there's some studies out there, really. They're starting to look at the pharmacogenetics and saying, well, medications, you might need to look more specifically at the pharmacogenetics, and they may be more appropriate in certain patients if you can do a genetic background, and of course we're talking about it in the future, and be able to identify patients which may be better with certain medications than others. Malatias, we're going back over to the southeast now. You can see there the GDP. And again, we're talking about a country that's mostly Islamic and Buddhist. They have the second largest telecommunication network in Southeast Asia, and they also have the largest railroad station in Southeast Africa, so a well-developed country. There were two countries that made presentations. Malaysia was the one about a real change in the addiction pattern, and this was with amphetamine-type stimulants causing significant problems in their country. It has increased markedly in recent years, and in 2011 methamphetamine overtook morphine as the number two abused drug in Malaysia. And with that they saw a lot of complications because they're seeing it increasingly locally produced with increased amounts being seized. I can tell you in Alabama, after they made some of those changes with putting the pseudofedrine behind the pharmacy counters, we stopped seeing trailers continuing to blow up on their own. It seemed like people were always trying to produce methamphetamine and weren't doing good jobs of it. And it seemed like every week there would be some kind of trailer that was on fire or blew up in some rural part of Alabama. So anyway, they've noticed that same kind of thing with these substances. And as we know, you know, in the States we see the same thing. This is a type of substance that's used that seems to be associated with increased sexual activity and the complications that can cause. They see the some kind of complications of this type of thing with paranoia, cardiovascular, neurological issues and also high incidence of blood-borne virus transmission including hep C and HIV. And the trendings were because again in this country as in the United States, they're not sure what to do with it. Opiates are, in a certain way, relatively easy. They can get them into a clinic, put them on methadone or Suboxone or whatever. They're just not sure because they don't have that medication management type of thing that they fall back on, and it's really causing significant issues there. Norway is, of course, going back up to Europe now. It was interesting that 77% said they were members of the church in Norway, but only 20% said religion occupied an important part of their lives. You go to church but don't think much about it. They're a very large, in fact, they have the highest human development index in the world, and I don't know what all the specifics are to calculate that, but I take it that's good. But what they were really proud of, and I remember the woman who made this presentation, is that they said that they had the first full specialty in addiction medicine in the world. It was started in January of this year, so it was going to be a five-year program with three and a half years in addiction management training, including detox, hospital, outpatient treatment, and things, as I would say, down here. And so that's something that hopefully we'll continue to see spread to other areas of the world is where people come in and you know rather than have to do it you know in a psychiatry residence or do it on top of doing another residency they'd come in just do a primary addiction medicine residency so I thought that was very good for the Norwegians Peru was one of few of the countries that were there from South America they have big issues in areas that are economically deprived as far as addiction and substance problems and they're also the world's leading producer of coca and cocaine producers so that probably is very problematic they didn't do a presentation on cocaine though they did a presentation on lifetime prevalence of alcohol use disorders in Peru. You can see here they interviewed about 4,000 adults, did face-to-face interviews, looked at the lifetime prevalence and the biggest thing here I thought was there was a real you know the males look fairly similar to what we see here in the States but the females were very very low much lower than we see her in the states so they haven't developed that kind of issue, they did notice some variations depending on the cities. Romania, so we're going back into Europe now, there's a demographics regarding Romania right there. They have a universal health system as most European countries do. What was interesting, the transmittable diseases like TB, syphilis and viral hepatitis are much more of an issue in Romania than in Western Europe. And this was the other country. So I talked about Malaysia, a totally different area of the world. Now you come into Romania, and they're having the same problem with these amphetamine-type substances. Since 2009, these legal highs, which are mainly amphetamines-type stimulants, have produced major changes in epidemiology and the morbidity of IV drug users in Romania. For the last five years, they've had a stable population of problematic drug users in Romania. But what's changed is there's been a shift from 96% opiate users to 49% amphetamine-type stimulant users. And with that change, what they have noticed, just like they noticed in Malaysia, is they're having, due to increased frequency of daily injections and a cut in the needle exchange program in Romania, the following have occurred. A 10-time increase in new HIV cases and doubling of morbidity and mortality among IV drug users in Romania just due to that change. So that's something they're really struggling with in Romania as they are in Malaysia with this type of substance. Slavic Republic staying in the Eastern European area this was interesting, I would never guess this, that they rank among the top alcohol consuming countries in the world and they did talk about this, that Slavic journalists tend to avoid coverage of drug problems and practice self-censorship so probably like the United States luckily I think this is one area we've made a lot of progress in the states as being more open on that and not having this self-censorship. They have had issues also with intravenous drug abuse, and they are looking at that, comparing it with infectious rates of HCV. What was interesting about this was that the route of menestation, they had 100 patients each using either opiates or methamphetamine. They looked at the rates of JCV infection, And 65% of the heroin users in this country had HCV, and they had a very high, 93% of those people use IV, that use heroin. But they had much lower rate methamphetamine, only 12%, and that correlated because for whatever reason, in the Slovak Republic, most of the people that use methamphetamine don't use an IV. And so they don't have as much problem from a public health issue as far as HCV and their methamphetamine users in the Slovak Republic. And that's just kind of talking about that, about they just have a lower injection rate. But both are much higher than the generic population. So again, individuals, if we can reduce that morbidity on that, that would be very important. South Korea, one of the most ethnically homogeneous societies in the world, known as the single-race society. Kind of an interesting fact there for South Korea. They have a very high population density in South Korea, and also they have the highest rate of suicide in the industrial world. They've had issues with prescription drug abuse too, so it's not only us in France and Italy and other places. Also in Asia and Japan, they've had the same kind of issues. Again, their big issue, just like Japan, tends to be with benzodiazepines. I thought they had reported issues with propofol abuse of several celebrities, so I guess they must have followed the Michael Jackson thing over there in South Korea too. But that was one of the things they talked about. And they talked About a very high percentage of people in South Korea have prescriptions for benzodiazepines. There, diazepam was the most frequently prescribed, not for anxiety or depression, but mostly for GI problems. and they noticed that people on benzodiazepines also had a higher risk for hip fractures, which you've noticed the same thing in the States. They also looked at pharma genetics. I talked about that in Japan with the disulfiram. They did a similar study with naltrexone, a fairly small study, but they looked at different genotypes, and I'm going to try to rush through because I'm running a little bit behind, but the main thing is that they noticed certain people with a certain genotype responded much better to naltrexone than those who didn't. And they said, well, considering that Asians are much more frequently to have this type of genetic makeup, that they may respond more favorably for treating alcohol disorders than Caucasians would. It will be interesting to see if that pans out as they do larger studies. They talked also, just like Germany did, about controlled drinking as a strategy for alcohol use disorders, very similar to the thing. I'm not going to go through that in detail, but what was interesting, they had one person from South Korea present this, and then almost like the next day, they had another person present it like it was like a point-counterpoint, where the next person said, well, you know, abstinence should be the goal of alcohol dependence. So just like we've had a large growth here in the United States about addiction disorders and treatment and have a lot of disagreements. They have the same kind of things in other countries, too, where some people are saying you need to look at risk reduction, trying to do controlled drinking as a part of treatment, and yet there are other people in the same country that are saying no, that doesn't work. Abstinence needs to be the reason that tends to be the best treatment choice for alcohol use disorders. Spain, I'm sorry, I'm running a little bit behind this is a little bit longer than I thought it would be, but national health system. Just to let you know, again, another country that has problems with prescription opiates, and the reason I wanted to put this slide up was because the issue had to deal with they're also seeing people, most common thing is heroin, but they're starting to see people come into treatment for abusing other opiats, including buprenorphine, just like we've seen here in the States. okay now Switzerland was an interesting country because Switzerland is very liberal in their treating of addictions and so there had an interesting study of course the Red Cross was founded here highest world life expectancy and of course they make great chocolate so they're the largest consumers of chocolate in the world that wouldn't be surprising what is surprising is that they are totally about harm reduction. And some of the people probably already know this, is that They Have Heroin Clinics in Switzerland. You come into the clinic if you're addicted to heroin and get prescription heroin as a treatment. You come in twice a day. They currently have 1,500 patients in 23 cities that are on heroin. They come for two injections daily. average stay in the clinic is 2.5 years and the thing that they want to do is eventually they say is that 61 percent of them leave because they're tired of coming into the clinic getting injections twice a day being tied to that as they'll go leave to try methadone or to try abstinence they have other opiate reduction modalities also that include methadome which is the largest one Subutex or buprenorphine, morphine and that's it. Now the Swiss were on the other side. It was interesting when you watch the England people present about disulfiram and then you had the Swiss I thought they were going to get in a fight because I'm telling you they were very much in disagreement with the English about the use of antabuse. Actually they outlawed it in 2007. They They said it shouldn't be used. It's unethical. And what was interesting when they did this, this is sort of a political thing, because when they interviewed most of the doctors, they said, well, they shouldn't do that. We don't have any problems with using antabuse. And 75% believed that it could be useful despite it being taken off of the country's formula. And the reason behind it was really it had nothing to do with science as much as it did the way that the people that felt that the way it treated patients, that it was aversive, that it Was cruel to patients and it shouldn't be used. So whichever way you want to follow on that, it's just kind of interesting. There's some significant disagreements that we have in the States about how you should treat opiate addiction. I was just surprised that globally there are people still arguing about antabuse. So I know I've got to get going here. I'm just going to switch right toward them. Tanzania the only program that was there that from Africa and the big issue again we've seen in some of the other countries is dealing with HIV and AIDS and they have a significant issue with HIV infection and substance abusers and something that they are addressing and realize that they've got to do better as far as looking at treatment of these substance use disorders to decrease the chances of having HIV in their population. We look at the infection rates, and again you're seeing it a lot higher than you would see in the general population with things that are definitely transmitted. We see higher rates in the United States with people that have substance use disorders. They see those all over the world. Thailand had the same issues. One of the big things about Thailand is we know 10% of the tourist dollars are They're spent on the sex trade. Prescription drug abuse is the same thing there that we have in provinces and other countries. Here, medications are normally obtained on the black market via the Internet. Also, they do get them from indiscriminate prescribing like we see here in the States. But the highest abuse rate tends to be the cold remedies. So again, like we used to see with the methamphetamine, that tends to being the bigger thing. And if you think of Thailand with a sex trade, it makes kind of sense, while those are the big ones. Don't really see the things with Lortab or the things that we see here mostly with the state, see a little bit of codeine calc medicine, but it tends to be more around methamphetamine and benzodiazepines. United Arab Emirates in the Middle East, as we know. What's interesting about this country is that flogging and stoning are still legal punishments. Now, this to me was very interesting is that they actually, I thought they were just flogger stone drug addicts. I didn't think they'd have any treatment for them, but they actually have a treatment center in the United Arab Emirates for people that have substance use disorders. They actually opened a center in 2002 and expanded it in 2010 and went from 12 beds to 120 beds put in electronic medical records for the patients so that they're in treatment and treatment increased it's kind of like if you build it they will come increase from 433 to 2009 to 1633 in 2014 so pretty interesting that in a country that I would not think would tolerate addiction disorders not only did you know they actually recognize it as an illness and have treatment for it and they mostly have polysubstance dependence including opiates and prescription drugs and with this thing they've seen a decrease in their relapse rates with more formalized treatment I'm just gonna I'm sorry I'm running over into justice time so the United States only thing I want to say about it hopefully these slides we can make available but the big thing they talked about naltrexone they had a study about naltrexone about it being effective in the criminal justice system you know I started off with Australia so a couple studies there again looking more for the treatment of opiate use disorders with naltrexone and seen success in different countries the other areas that they talked about were cannabis and I will tell you there's a lot of controversy on cannabis both a lot of people think in different countries that the United States is too aggressive on cannabis and that we're we're tied up with it that it shouldn't be that much concern about marijuana use with a lot of the countries so I'll go ahead and stop there and sorry ran over and be glad to answer any questions thank you We may have time for one or two questions since we got started a couple of minutes late. Please, if you have a question, go to one of the microphones so we can get you on the tape. I have a questions. So I'm a neurosurgeon. I practiced in the U.S. for years and now I'm practicing in Cambodia at a government hospital. And what I've been surprised is the amount of post-op pain, how it's controlled in developing countries. For instance, after major spine surgery, we rarely use any opioid analgesics. We surveyed the patients, and they're not really unhappy with the value of pain control. And then I did some research, and in the USA, we consume 80% of world's opioid analzesics, but we only make up 4% of the population. The question for me is, is prescribing patterns for doctors an agenda item for the ASAM doctors? I think that's been quoted quite a bit about how overuse of opiates has become a big issue in the States. And that was one of the things they talked about in certain countries that even were noticing some issues with opiats, they weren't necessarily prescribed by doctors. and so it does tend to be a cultural thing there looking at ways to treat pain other than and hopefully there's been more education and with the epidemic that's come out with problems with prescription opiates that people are looking at more effective other ways that there are other ways to treatment other than opiats, especially chronic pain. Okay, thank you very much. Thank you. Thank you very very much