Addictions: Sharing International Responsibilities in a Changing World

Addictions: Sharing International Responsibilities in a Changing World

Programme Abstracts

Under the auspices of Azienda Ospedaliera “Ospedali Riuniti di Trieste” Friuli-Venezia Giulia Region Municipality of Trieste Trieste Association of Medical Doctors and Surgeons University of Trieste

Local Organizing Commitee Maria Grazia Cogliati – Giuseppe Dell’Acqua - Salvatore Ticali – Claudio Poropat – Anna Peris – Fabio Fonda – Fabio Samani – Bernardo Spazzapan Roberta Balestra – Antonina Contino – Claudia Milievich – Daniela Vidoni – Cesarino Zago

Scientific Secretariat Prof. Flavio Poldrugo University of Trieste School of Medicine Community Health Agency, Trieste Departments of Mental Health and Addictions Office for Research and Innovative Projects on Alcohol, Other Addictions and Mental Health Piazzale Luigi Canestrini, 4 – 34126 Trieste (Italy) Tel. Italy + 040 350010 or Italy + 040 571077 Fax Italy + 040 350010 or Italy + 040 370950 e-mail: [email protected]

Organizing Secretariat the office Via San Nicolo` 14 – 34121 Trieste (Italy) Tel. Italy + 040 368 343 – Fax Italy + 040 368 808 e-mail: [email protected] website: www.theoffice.it/ISAM

2001 ISAM Meeting

ISAM Board of Directors President Dr. Nady el-Guebaly

Canada

Vice Presidents Dr. Jorge Gleser Dr. Flavio Poldrugo Dr. G. Douglas Talbott

Israel Italy USA

Treasurer

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Dr. Joaquim Margalho Carrilho

Portugal

Dr. Saul Alvarado Dr. Gudbjorn Bjornsson Dr. Colin Brewer Prof. Cai Zhi-Ji Dr. Maria Delgado-Pich Dr. Joao Carlos Dias da Silva Dr. Marc Galanter Prof. Michael Krausz Dr. Peter E. Mezciems Dr. Davinder Mohan Dr. Wayne Moran Dr. David Smith

Panama Iceland UK China Argentina Brazil USA Germany Canada India Hong Kong USA

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Room Oceania (A+B) - ISAM BOARD Meeting

17.30 – 19.00

Room Oceania (A+B) - Subjects with dual diagnosis

16:45 - 18:15

Room Oceania (A+B) Treatment of addictions (pharmacological issues)

Room Oceania (A+B) Conclusions

12:00-13:30

13:30-14:00

Room Oceania (C) Recent development in naltrexone treatment

10.30 – 11.15 Room Vulcania 2 Detention versus alternative measures 11.15 – 12.00 Room Vulcania 2 Smoking

Room Oceania (A+B) Treatment of addictions (psychological and epidemiological issues)

10:30 - 12:00

Room Oceania (C) Treatment of addictions (medical issues)

Room Oceania (A+B) - AEP-ISAM symposium. Alcohol-related problems: a challenge for the insurance companies

09.00 – 10.30

FRIDAY 14 SEPTEMBER 2001 08.00 – 09.00 Room Oceania (A+B) - Business Meeting

Poster session (main hall)

Room Marconi (2nd floor) Workshop on validity of U.S. placement criteria for drug abuse treatment

Room Oceania (A+B) - Campral symposium. Progress in alcoholism management acamprosate first line in research and treatment

Room Vulcania 2 Workshop on working with drug affected teenagers – key strategies for intervention

14:30 - 16:30

Room Oceania (C) Symposium on the course of adolescent drug and alcohol abuse: trajectories of use and patterns of change

13.00 – 13.30

Room Oceania (A+B) mpaired health professionals and the role of the general practitioners (with the Plinius maior society contribution)

Room Oceania (A+B) - Public health organization and international aspects (part II)

11.35 – 13.00

10.00 – 11.25

THURSDAY 13 SEPTEMBER 2001 08.00 – 10.00 ISAM Committees Meetings

Room Oceania (A+B) - Public health organization and international aspects (part I)

Room Oceania (A+B) - Global Charter

16:00 – 17:30

Room Oceania (A+B) - ISAM BOARD Meeting

14:30 – 16:00

09.00 – 13.00

WEDNESDAY 12 SEPTEMBER 2001 09.00 – 18.00 Registration

PROGRAMME

WEDNESDAY 12 SEPTEMBER 2001 9.00 – 13.00 14.00 – 18.00

Registration

09.00 – 13.00

Room Oceania (A+B) ISAM BOARD Meeting

14.30-16.00

Room Oceania (A+B) PUBLIC HEALTH ORGANIZATION AND INTERNATIONAL ASPECTS (PART I) Chairman: G. Dell’Acqua (Trieste – Italy)

N. el-Guebaly (Calgary, Alberta – Canada) Addiction Medicine: towars a global perspective D. Vereen (Washington, DC – USA) Substance Abuse Policy: a science-based approach G. Benagiano (Rome – Italy) The Italian approach to addictions G. Dell'Acqua (Trieste – Italy) Mental health, drugs: a community approach G. Nicoletti (Rome – Italy) Public health organization for addictions 16.00-17.30

Room Oceania (A+B) GLOBAL CHARTER Chairman: F. Poldrugo (Trieste – Italy)

The Geneva partnership on alcohol – a tool for alcohol policy formulation J. Orley (Washington, DC – USA), S. Naclerio (Miami, FL – USA), S. Genovese (Rome – Italy) 17.30 – 19.00

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Room Oceania (A+B) ISAM BOARD Meeting

THURSDAY 13 SEPTEMBER 2001 08.00 – 10.00

ISAM Committees Meetings

10.00 - 11.25

Room Oceania (A+B) PUBLIC HEALTH ORGANIZATION AND INTERNATIONAL ASPECTS (PART II) Chairman: N. el-Guebaly (Calgary, Alberta – Canada)

Australian moves towards formal recognition of addiction medicine as a specialty J. Bell, P.S. Haber, K. Curry (Sydney, NSW – Australia) Substance abuse in Israel: patterns, attitudes, policies and treatment strategies J. Gleser, D. Elisha, M. Reiter (Jerusalem - Israel) Needs assessment in drug education: the view of staff in the Iranian school T. Doostgharin (Teheran - Iran) Belgrade multisystemic model in alcoholism: 40 years’ evolution of clinical experience and research projects B. Gacic (Belgrade – Yugoslavia) The war on drugs and criminal justice system Y. E. Razvodovsky (Grodno - Belarus) Dependencies, the need for an integrated, intersectorial approach A. Berlin (Paris – France), L. Chabot (Montreal, Quebec – Canada) 11.25 – 11.35

Coffee Break

11:35-13:00

Ro om Oceania (A+B) IMPAIRED HEALTH PROFESSIONALS AND THE ROLE OF THE GENERAL PRACTITIONERS (WITH THE PLINIUS MAIOR SOCIETY CONTRIBUTION) Chairman: F. Poldrugo (Trieste – Italy)

J. Barrias (Porto - Portugal) Some aspects on alcohol consumption in an environmental perspective N. el-Guebaly (Calgary, Alberta – Canada) Physician education in substance-related disorders: challenges and opportunities B. Monheit, L. McCall, L. Waters (Melbourne, VIC – Australia) An Interactive drug and alcohol training course for general pactitioners O. Lesch (Wien – Austria) Barriers to the General Practitioners management of alcohol-related problems: coherence of alcohol treatment networks in Austria

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D. H. Angres, K. Bettinardi-Angres (Drowners Grove, IL - USA) Diagnosis and treatment of chemically dependent physicians J. D. Beasley, M. Delgado-Pich (Cordoba – Argentina) Diagnosing and managing chemical dependency. Addictionend.com.project G. Douglas Talbott (Atlanta, GA –USA), P. E. Mezciems (Guelph, ON – Canada) Physician impairment – alcohol and drug addiction – a global problem 11:35-13:00

Room Oceania (C) SYMPOSIUM ON THE COURSE OF ADOLESCENT DRUG AND ALCOHOL ABUSE: TRAJECTORIES OF USE AND PATTERNS OF CHANGE Chairman: H. B. Waldron (Albuquerque, NM – USA)

Multiple pathways to adolescent drug use and abuse: differential implications for prevention H. Hops, B. Davis, F. Lee (Eugene, OR – USA) Latent classes of familial alcoholism and depression: relations to neuropsychological functioning in late adolescence and adulthood M. E. Bates, V. L. Johnson, S. Buyske (New Brunswick, NJ – USA) Immediate and longer-term treatment oucomes for adolescent drug and alcohol abuse H. B. Waldron, C. W. Turner, J. L. Brody, T. R. Peterson (Albuquerque, NM – USA) Profiles of change in drug use during and after treatment for substance abusing adolescents C.W. Turner, H. B. Waldron, J. L. Brody, T. R. Peterson, T. Ozechowsky (Albuquerque, NM – USA) Course of adolescent alcohol use disorders across 3 year after treatment C. S. Martin, T. Chung (Pittsburgh, PA – USA) 11:35-13:00

Room Vulcania 2 WORKSHOP ON WORKING WITH DRUG AFFECTED TEENAGERS KEY STRATEGIES FOR INTERVENTION Chairpersons: B. Lampropoulos, P. S. Haber (Sydney, NSW – Australia)

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11.35-13.00

Room Marconi (2nd floor) WORKSHOP ON VALIDITY OF U.S. PLACEMENT CRITERIA FOR DRUG ABUSE TREATMENT

11:35-12.15

E. Sharon, D.R. Gastfriend (Boston, MA – USA) “Rationale, methodology and validity of replication studies using the ASAM Criteria"

12.15-12.40

S. Pirard, Estee Sharon (Liege – Belgium), David R Gastfriend (Boston, MA – USA) Role of comorbid psychiatric and substance use disorders, gender and drug of choice issues in placement criteria"

12.40-13.00

Discussion

13.00 – 13.30

POSTER SESSION (main hall) Chairmen: M. Galanter (New York, NY - USA), J. Gleser (Jerusalem, Israel)

Craving by imagery cue reactivity in opiate dependence following detoxification U. Goswami, D. Behera, U. Khastgir (New Delhi – India) The differences between heroin addicts with and without comorbidity M. Lovrečič (Koper – Slovenia), M. Z. Dernovšek, R. Tavčar (Ljubljana-Polje – Slovenia), B. Lovrečič (Koper – Slovenia) Smoking and alcohol use in a group of suspended school students B. Lampropoulos, C. Clarke, A. Bauman, M. Kohn, K. Williams, S. Roman (Sydney, NSW – Australia) Alcohol and aggression A. Belluscio, B. Mauri, F. Berretta, F.D’Arista, D. Fiorentino, A. Freda, S. Giaccio, M. Ceccanti (Rome – Italy) Naltrexone (NTX) therapy for the control of craving in alcoholics: results in family history-positive subjects M. Ceccanti, M. L. Attilia, G. Sebastiani, F. Berretta, G. Coriale, L. Silli, M.F. Ioni, F. Ulanio, G. Balducci (Rome – Italy) Assessment of readiness to change questionnaire (RTCQ) test in an Italian population of alcoholics. Preliminary report M. Ceccanti, F. D’Arista, F. Lucidi, F. Berretta, S. Giaccio, B. Mauri, D. Fiorentino, M. L. Attilia, G. Balducci (Rome – Italy) Characteristic of drug-abusers in the early treatment J. Galić, S. Jelić, S. Šalamon, K. Butorac, L. Sabljić, A. Rogar, A. S. Hotujac (Zagreb – Croatia) Psychosocial issues in female opioid dependence – an Indian scenario U. Khastgir, U. Goswami, U. Kumar, D. Behera (New Delhi – India) Mode of previous heroin use and methadone dose in maintenance L. Okhrulica, M. Rakova, D. Klempova (Bratislava – Slovak Republic) Alcohol-related neuromuscular damage in young patients G. Tamaro, R. Simeone, S. Renier, G. B. Modonutti (Trieste – Italy)

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14:30-16:30

Room Oceania (A+B) CAMPRAL SYMPOSIUM PROGRESS IN ALCOHOLISM MANAGEMENT ACAMPROSATE FIRST LINE IN RESEARCH AND TREATMENT Chairmen: P. De Witte (Louvain - Belgium), K. Mann (Mannheim,- Germany)

M. Prendergast (Lexington, KY – USA) Acamprosate: modulator of NMDA receptor R. Luthringer (Rouffach – France) Acamprosate effects measured by cerebral mapping B. Mason (Miami, FL – USA) Effects of acamprosate on alcohool and drug use in the American clinical study I. Pelc (Brussels – Belgium) Results of the Capriso study F. Poldrugo (Trieste – Italy), P. Lehert (Mons – Belgium) Acamprosate and quality of life A. Palmer (Basel – Switzerland) Overview of acamprosate cost effectiveness studies 16.30-16.45

Coffee Break

16:45-18:15

Room Oceania (A+B) SUBJECTS WITH DUAL DIAGNOSIS Chairman: B. Spazzapan (Gorizia – Italy)

Psychiatric comorbidity of substance dependance - T. M. S.A. Gawad (Cairo - Egypt) The implementation of the Joint Services Development Unit (JSDU) for the management of psychiatric and substance using conditions. The development of an integrated model of clinical care and professional development in Western Australia S. Ryan (Claremont, WA – Australia) Pain reduction with opioid elimination - E. Covington (Cleveland, OH – USA) Organ transplantation – the role of addiction medicine - M. M. Kotz (Cleveland, OH – USA) Addiction comorbidity in pathological gambling - B. Spazzapan, P. Lenassi (Gorizia, Italy) Pathological gambling: a stepped care model of interventions N. el-Guebaly (Calgary, Alberta – Canada) 20.00

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Gala Dinner – Caffé degli Specchi (Piazza Unita d’Italia)

FRIDAY 14 SEPTEMBER 2001 08.00 – 09.00

Room Oceania (A+B) Business Meeting

09.00 – 10.30

Room Oceania (A+B) AEP-ISAM SYMPOSIUM. ALCOHOL-RELATED PROBLEMS: A CHALLENGE FOR THE INSURANCE COMPANIES Chairman: K. Mann (Mannheim - Germany)

D. Escher (Milan – Italy) The insurers’ initiative to reduce alcohol abuse J. Allen (Bethesda, MA – USA) The role of biomarkers of heavy drinking in health care management A. Palmer (Basel – Switzerland) Cost and benefit of intervention for alcohol-related problems B. Boisset (Paris – France) Medical consequences of alcohol: a treatment program devised by an insurance company 10.30-12.00

Room Oceania (A+B) TREATMENT OF ADDICTIONS (PSYCHOLOGICAL AND EPIDEMIOLOGICAL ISSUES) Chairperson: M. C. Delgado-Pich (Cordoba – Argentina)

Women and the twelve steps M. C. Delgado-Pich, C. Bergoglio, D. Gigena (Cordoba – Argentina) Alcoholism and drug problems in industry D. E. Smith (San Francisco, CA – USA) Incidence estimates of substance use disorders in a cohort study D. Mohan, H. Sethi, A. Chopra (New Dehli – India) The substance abuse subtle screening inventory (SASSI) use in research of addicted families M. Rus-Makovec, K. Sernec, Z. Čebašek-Travnik, S.V. Rus (Ljubljana – Slovenia) New statistical considerations to improve Quality of Life instruments: finding AIQoI9, a short, specific and sensitive subset of MOS-SF36, specific to alcoholism P. Lehert (Mons – Belgium), F. Poldrugo (Trieste – Italy) Imagery cue reactivity in opiate addicts: individual variables and differential response U. Goswami, D. Behera, U. Khastgir (New Delhi – India)

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10:30-11:15

Room Vulcania 2 DETENTION VERSUS ALTERNATIVE MEASURES Chairperson: A. Baez Moquete (Trieste – Italy)

Law enforcement officers survey on drug control policy Y. Razvodovsky (Grodno - Belarus) Public attitudes towards drug control policies Y. Razvodovsky (Grodno - Belarus) Drug addiction and jail. The role of the network between community services Alternative measures to detention A. Baez Moquete, G. Rossi (Trieste, Italy) 11:15-12:00

Room Vulcania 2 SMOKING Chairman: A. Munoz (Las Condes, Santiago – Chile)

The predictive determinants of smoking cessation programs in Egypt M. Hashem Bahri, A. S. Al-Akabawi, M. SH. Omar, A. B. Farghaly (Cairo – Egypt) Addressing nicotine dependence in addiction treatment M.. C. Delgado-Pich, D. Gigena, C. Bergoglio (Cordoba – Argentina), A. Munoz (Las Condes, Santiago – Chile) Effectiveness of interventions for helping people stop smoking in the Trieste area. A 2 year survey G. L. Montina, F. Pivotti, C. Poropat, E. Cariello, P. Todaro, M. L. Onor, F. Poldrugo (Trieste – Italy) 10:30-12:00

Room Oceania (C) TREATMENT OF ADDICTIONS (MEDICAL ISSUES) Chairman: A. Kastelič (Ljubljana - SLOVENIA)

Current trends in addiction epidemiology, research & treatment D. E. Smith (San Francisco, CA – USA) The direct ethanol metabolite ethyl clucuronide is a specific marker of recent alcohol consumption F. Wurst (Basel –Switzerland), A. Alt (Ulm – Germany), S. Seidl (Erlangen – Germany), B. Sperker (Greifswald – Germany), B.H. Lauterburg (Bern – Switzerland), D. Ladewig, F. Müller-Spahn (Basel – Switzerland) , J. Metzger (Stuttgart - Germany)

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The introduction of Acudetox into the Italian public drug and alcohol treatment services D. Blow, G. Picozzi, G. Rotolo (Rome – Italy) Heroin use during pregnancy: the impact of prenatal care and different therapeutic regimens on perinatal outcomes G. Salamina, C. Tibaldi, C. Pasqualini (Turin – Italy) Ecstasy-induced neurotoxicity A. O. Brundusino (Pavia – Italy) 12:00-13:30

Room Oceania (A+B) TREATMENT OF ADDICTIONS (PHARMACOLOGICAL ISSUES) Chairman: F. Vocci (Bethesda, MA – USA)

From rapid opiate detoxification to rapid antagonist induction: changing concepts and techniques in treatment with oral and implanted Naltrexone C. Brewer (London – UK) Medical prescription of heroin to chronic treatment-resistant heroin addicts: a state of the art trial in a sceptic international environment W. van den Brink, V. M. Hendriks, P. Blanken, J. M. van Ree (Utrecht – The Netherlands) Medications development for the treatment of cocaine dependence at NIDA A. Elkashef, F. Vocci (Bethesda, MA – USA) Comparison of rapid opiate detoxification and Naltrexone therapy with methadone maintenance in the treatment of opiate dependence: a randomised controlled trial J. B. Saunders, R. Jones, B. R. Lawford, R. Young, J. Connor, E. Painter, A. Dean, L. Keen (Herston, QLD – Australia) Tramadol abuse and dependence: an addiction medicine perspective G. Skipper (Montgomery, AL – USA), D. Smith (San Francisco, CA – USA), J. Tracy, L. Gordon, P. Mansky (Rancho Mirage, CA – USA) Medications for the treatment of opiate dependence: current therapies and new developments F. Vocci (Bethesda, MA – USA)

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12:00-13:30

Room Oceania (C) RECENT DEVELOPMENT IN NALTREXONE TREATMENT Chairman: D. E. Smith (San Fiancisco, CA – USA)

Pharmacological extinction of alcohol abuse and other addictions D. Sinclair, H. Alho (Helsinki – Finland) A cost-effective protocol for Naltrexone treatment of alcoholism H. Alho, J. D. Sinclair (Helsinki – Finland) The use of long-acting Naltredxone in the treatment of opioid addiction and alcoholism D. E. Smith (San Francisco, CA – USA) Nalmefene in the treatment of heavy drinkers R. Mäkelä (Helsinki – Finland), A. Kallio, S. Karhuvaara (Espoo - Finland)

13:30-14:00

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Room Oceania (A+B) Conclusions

LANGUAGE The conference language is English.

GENERAL INFO

CONFERENCE VENUE Congress Centre - Stazione Marittima - Molo Bersaglieri 3 – Trieste (Italy) Tel: Italy + 040 304 988 (during the conference only).

INSURANCE Participants are advised to purchase comprehensive travel insurance coverage. The Organizing Committee and/or the office shall not be held liable for loss or damage to property belonging to conference participants, or for personal injuries sustained during or as a result of the conference or during the tours arranged by the office. REGISTRATION FEES (After 31 May 2001) ISAM member Lire 945,000 (USD 450) Participant Lire 1,155,000 (USD 550) Accompanying person Lire 325,500 (USD 155) ISAM member Trieste Meeting + Ljubljana Satellite Symposium Lire 1,050,000 (USD 500) Non-ISAM member Trieste Meeting + Ljubljana Satellite Symposium Lire 1,260,000 (USD600) Conference registration fees cover participation in the sessions, conference material (name badge, conference kit and final programme and abstracts), lunches, invitations to social events, coffee breaks. Registration fees for accompanying persons cover 1 half day tour of Trieste on Thursday 13 September, the invitation to the Gala Dinner (Thursday evening) and the visit of Aquileia and Grado (Friday 14 September). TOURS Thursday 13 September 2001 (9.00 – 13.00) Guided tour of Trieste including the visit of the Miramare Castle. Departure at 9.00 from the main entrance of the Congress Centre. The cost is Lire 63,000 (USD 30) per person. Friday 14 September 2001 (14.30 – 22.30) Guided tour of the ancient Roman town of Aquileia (visit of the Basilica and the Roman Museum) and the beautifull Venetian town of Grado. Its sandy shores are well known and appreciated all over Europe. Dinner included. Departure at 14.30 from the main entrance of the Congress Centre. The cost is Lire 126,000 (USD 60) per person.

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ADDICTION MEDICINE: TOWARDS A GLOBAL PERSPECTIVE Nady el-Guebaly, MD University of Calgary, Addiction Centre – Foothills Hospital, Calgary Alberta, Canada Based on the experience of the International Society of Addiction Medicine (ISAM) over the last 4 years, a number of challenges are emerging as we develop a global network in addiction medicine: 1.

The need for standard terminology.

2.

The need for complementary empirically-based social policies beyond ideologies whether in “the war on drugs” or in “harm reduction”.

3.

The need to account for and harness cultural sensitivities.

4.

A reframing of our thinking on particularly stigmatized addictions such as intravenous use and HIV.

5.

The need for enhancing the knowledge, skills and attitudes of physicians as well as other health professionals, and maintaining their competence.

6.

A need for dialogue with industries and with the business community.

7.

he need for active sharing of meaningful research information.

The promising role of ISAM in undertaking to address the above will be highlighted.

THE ITALIAN APPROACH TO ADDICTIONS G. Benagiano, P.G. Zuccaro Istituto Superiore di Sanità and First Institute of Obstetrics and Gynecology, University "la Sapienza", Rome, Italy In listing goals to be achieved by the year 2015 the World health organization included fighting drug addictions and specified that this objective is to be achieved through the integration of socila and health policies and interventions. Italy has fully endorsed this approach which calls for a redefinition of principles and models of social organization and structures, in order to offer better services to individuals, bearing in mind global personal needs, as identified by an in depth analysis of the various situations. For this reason, Italy is attempting to set up collective interventions, properly targeted to individual requirement that also take into consideration non medical aspects, such as social class, lifestyle, religion, interpersonal relations, marginalization and migration. These interventions must be channeled through families and schools. The major feature of the italian approach to fighting drug addictions is the clear separation between personal use and trafficking of illegal drugs. Whereas the fight against national and international dealers has been intensified, a more benign approach is being implemented towards drug abusers, in an attempt to help - rather than prosecute - them and, in this way, try to limit the self inflicted damage. The overall objective of italian interventions is to achieve a better protection of the health of drug abusers with a variety of measures including decriminalization of personal drug use, while trying to protect them from the pressure brought by the criminal activities of dealers. In this way Italy wishes to distinguish itself from those countries where use and trafficking are basically treated in the same manner; the underlying philosophy is that an illegal drug abuser is a sick individual and not necessarily a person dangerous per se for the community and society at large. Italy also endorses the six objectives set by the European Union at its Helsinki summit in december 1999. In conclusion, while Italy wishes to pursue the goal of at least decrease addiction among its citizens, it hopes to do so by treating, rather than prosecuting the individual abuser.

THE GENEVA PARTNERSHIP ON ALCOHOL – A TOOL FOR ALCOHOL POLICY FORMULATION Dr John Orley, Consultant, International Center for Alcohol Policies, 1519 New Hampshire Avenue, NW, Washington, DC 20036, USA; Mr. Steven Naclerio, Bacardi-Martini, Inc., 2100 Biscayne Boulevard, Miami, FL 33137, USA; Mr. Stefano Genovese, Osservatorio Permanente sui Giovani e l’Alcool, Viale di Val Fiorita, 90, 00144 Rome, Italy. The Geneva Partnership on Alcohol: Towards a Global Charter provides a new and ambitious agenda for the development of alcohol policies, at the global, national and local level. Developed as a collaborative effort by international experts from public health, research, industry, government, and others with a stake in alcohol policy, it provides a comprehensive approach to developing partnerships for policy formulation. The panel will discuss the process by which the Geneva Partnership was developed and will outline its content and the particular areas on which it focuses. Discussion will also focus on ways in which the document addresses the reduction of the risk of alcohol abuse and health damage and the need for policies covering such issues. Some of the areas included in the document are: a) controlling access to alcohol, b) regulating advertising, c) ensuring that information and education is available widely on the effects of alcohol on behaviour, d) enforcing laws and regulations on such matters as drinking and driving, e) encouraging people to drink alcohol in responsible ways by promoting drinking environments that encourage moderate consumption, with servers and sellers trained to promote only responsible drinking, f) detecting problem drinkers as early as possible and helping them and g) ensuring the quality and purity of alcoholic drinks. The Geneva Partnership represents a balance between individual rights and responsibilities and those of society as a whole. It looks at the role of the state, as well as that of private enterprise in encouraging a safe drinking environment; it makes proposals to ensure that beverage alcohol is consumed and sold responsibly; it makes clear that consumers, producers and sellers alike have a stake in reducing the abuse of alcohol and problems potentially associated with it. This document was developed as a co-operative process involving the public health and scientific communities, the beverage alcohol industry, governments and the non-governmental sector. Co-operation between these same players is required in the development of alcohol policies and the Charter provides an appropriate building block in the process.

AUSTRALIAN MOVES TOWARDS FORMAL RECOGNITION OF ADDICTION MEDICINE AS A SPECIALTY J Bell°, PS Haber* and K Curry °Medical Head, Drug Health Service, Canterbury Hospital, Sydney, Australia *Medical Head, Drug Health Service, Royal Prince Alfred Hospital, Sydney, Australia Director, Langton Centre, South Eastern Sydney Area Health Service, Sydney, Australia There is currently no training or certification scheme in Australia for practitioners in addiction medicine. Development of such a system has 3 objectives: (1) to define standards of practice (2) to create a career path to attract and retain practitioners to work in the field and receive specialist rates of remuneration (3) to contribute to undergraduate and post-graduate generalist medical education. Australian specialists receive their credentials through medical Colleges but the likely number of specialists in Addiction Medicine is insufficient to support an independent College. Negotiations are being held to enable the training and certification to occur within the Royal Australasian College of Physicians. A series of working groups has identified core competencies in addiction medicine, and a training syllabus is being developed. Core training experience will include ambulatory and residential detoxification, general hospital consultation-liaison, methadone and other pharmacotherapies, hospital-based internal medicine (notably gastroenterology and neurology), public health aspects of drug and alcohol use and psychiatry. Other recommended training experience should include pain medicine, clinical pharmacology, emergency medicine, and clinical research. As with other specialty training (such as psychiatry and internal medicine) the total duration of training will be 6 years. Assessment will be continuous, with written and clinical (viva) examinations, and structured assessments including written case histories, a clinical log book, and significant contribution to a clinical research study. The program will be finalised in November 2001, and recruitment to training posts should begin during 2002. The skills of selected established practitioners will be recognised by a "grandfather clause". A program of continuing education is under concurrent development.

SUBSTANCE ABUSE IN ISRAEL: PATTERNS, ATTITUDES, POLICIES AND TREATMENT STRATEGIES Jorge Gleser MD, David Elisha Ph.D., MBA, and Michael Reiter Ph.D. Dept. for the Treatment of Substance Abuse. Ministry of Health, Israel This paper reviews the highlights of historical events in Israel in order to provide a framework for understanding trends and patterns of substance abuse problem in the country throughout its brief history. An attempt will be made to identify the patterns of substance abuse in each period, the prevailing community attitudes toward the problem, the governmental response, the treatment approaches and the status of the service system. Since the establishment of the State of Israel in 1948, the country has experienced significant political and social changes as well as a rapid cultural transformation. These events may be attributed primarily to the fact that Israel has absorbed millions of immigrants during its turbulent history and that its population grew ten fold from 600,000 in its first year of statehood (1948) to 6 million in 2000. The absorption of millions of Jewish immigrants has been mostly quite successful. Yet, many of them experienced cultural shock as well as serious social and economic problems due to relocation. The result was the emergence of distressed neighborhoods characterized by economic stagnation and social ills typically associated with anomie and disintegration. These communities became problem centers for high rates of school dropout and juvenile delinquency, unemployment, criminality and an emerging culture of substance abuse. The 1967 Six-Day brought in its wake significant developments in the political and sociological sphere. The Israeli society as a whole moved away from the pioneering and socialist spirit toward a more liberal, permissive and materialistic society. The influx of American and European young volunteers introduced many Israelis to the drug culture while the opening of borders in 1967 and after the Lebanon war in 1982, made drugs more accessible as smugglers had easier time importing large quantities of cannabis and high-grade heroin into the country. These significant changes in cultural an socio-political reality had the combined effect of increasing substantially recreational use of alcoholic beverages and illicit drugs including hallucinogens imported from the USA and Western Europe . New waves of immigrants reached Israel again in the late seventies and the nineties, mostly from the former Soviet Union. Mostly they were productive and well adjusted individuals but some came to Israel with problems such as delinquency, mental illness, chronic alcoholism and/or opioid addiction, typically taken intravenously. Although small in absolute numbers, the newly arrived drug addicts and alcoholics joined an existing drugsubculture of Israeli youngsters creating a strain on the substance abuse treatment centers necessitating an expansion of the existing services as well as changes in policies and intervention strategies. The significant growth in services for substance abuse in Israel (not without a number of shortcomings) shows the increasing concern for the problem of addiction. Most substance abusers who seek treatment today are admitted promptly or within one month of their request, nevertheless attention must be given to sudden political and social changes and to the expansion and renewal of the policies, services and technologies. NEEDS ASSESSMENT IN DRUG EDUCATION: THE VIEW OF STAFF IN THE IRANIAN SCHOOL Taghi Doostgharin senior lecturer at Alameh T University, Also visiting research fellow to the department of social and policy sciences of Bath University, UK This paper examines staffs’ views of drug education in Iranian schools as indicated by the findings of a survey of schools at the national level. Staffs in schools overwhelmingly expressed the need for drug education. However, they were divided over the need for beginning of teaching pupils specifically about illegal drugs. Respondents were generally optimistic about the potential positive impact of drug education on young people’s drug use. However, the majority of them stated that school should not be seen as the sole source of drug education for young people. The community, in particular parents need to be included in overall strategies for drug education. Staff responding to this survey showed that many of them had no clear idea about drug education. They wanted good in-service support, including training and support for schools in the planing and delivery of drug education. In additions they wanted some publications that could be easily understood and used in the classroom. It appeared that a unique drug education at the national curriculum should not be considered. Based on the different areas of the country and the frequency of the drug problem in each area different kind of drug education approach should be undertaken.

BELGRADE MULTISYSTEMIC MODEL IN ALCHOLISM: 40 YEARS’ EVOLUTION OF CLINICAL EXPERIENCE AND RESEARCH PROJECTS Branko Gacic, MD, PhD University Clinical Centre, Belgrade, Yugoslavia Since foundation of the Institute for Mental Health in Belgrade, Yugoslavia in 1962 there was a long tradition of continuous clinical and research work in alcoholism in which the author participated constantly. Evolution on Belgrade Multisystemic Model in Alcoholism is described chronologically – as the interrelationship between clinic and research. The author presents an overview of the major, mainly international research projects – vitally interconnected with development of clinical theory and practice: from traditional, biomedical, individually oriented model (abstinence rate 28%) via group, socially oriented (abstinence 36%) to ecosystemic, biopsychosocially oriented model (abstinence 70 – 80% and better life quality). Current approach, initiated by the author in 1973 and constantly developed up to now, is illustrated by schematic diagram of its development during past four decades. In conclusion, the most important results are summerized and discussed. Belgrade Model combines multisystemic and postmodern approaches that open new perspectives in work with alcohol and other substance – related problems, in new times of constantly changing world.

THE WAR ON DRUGS AND CRIMINAL JUSTICE SYSTEM Y.E. Razvodovsky Grodno State Medical University, Department of Psychiatry, Drug-Related Problems Research Group, Belarus In this report the role of criminal justice system in solving illegal drug-related problems in Belarus is discussed. National drug control policy presupposes both non-control and drug control measures. The prevailing character of today’s policy reflects a punitive approach to control. According to legislation use of drug is not a crime, at the same time possession of it is illegal and presuppose punishment of imprisonment for up to 3 years. 70 per cent of those convicted for drug-related crimes were imprisonment according this article of the law. This fact once more proves that repressive measures are taken against drug addicts, but not against drug dealers. The confusion has not been resolved yet. What is the aim of the repressive policy towards drug addicts? To isolate them from the society? To punish them for their disease? To frighten potential drug users? Obviously, in such a way the state admits its inconsistency in helping the sick people. In our opinion, while approaching drug-related crimes, it is necessary to differentiate between possession of drug for personal use, and connected with narcobusiness on the one hand and committed by drug addicts on the other. Sharp growth in the number of drug addicts in recent years, on the one hand and growth in the activity of law enforcement institutions on the other has lead to such a situation in which criminal justice system has to deal with still growing number of drug addicts. In this situation the role of it in solving drug-related problems becomes very important. As our date manifest imprisonment of drug addicts to increase of their criminality and isolation from the society. Most of drug addicts after released from prison continue taking drugs. Therefore, in order to break the cycle of drug abuse and its consequences all drug addicts inmates must have access to effective drug treatment programs. There exist a necessity to accelerate the expansion of programs that offer alternatives to imprisonment for nonviolent drug law offenders. Sending convicted drug addicts to special treatment establishments of prison type can be considered as an alternative to imprisonment. Such establishments exist in the system of the Ministry of Internal affairs and their purpose is to provide compulsory treatment for drug addicts. Another alternative is to send convicted drug addicts in special labor establishment of open type, where they are supervised by criminal justice system.

DEPENDENCIES, THE NEED FOR AN INTEGRATED, INTERSECTORIAL APPROACH Alexandre Berlin* Ph.D. and Luc Chabot** M.Ed. Honorary Director, European Commission, 121 Avenue d’Italie Paris 75013, France, ** CEO, World Forum Montreal 2002, 801 Sherbrooke East Suite 901 Montreal (Quebec), Canada H2L 1K7 In recent years drugs and dependencies have become major health, social and economic issues, hampering often development. However these issues are handled in international fora most frequently through vertical sectoral approaches. There is a growing need for an integrated intersectoral approach at the global level. The World Forum, on Drugs, Dependencies and Society – Impact and Responses to be held in Montreal 23-27 September 2002 is attempting such an approach. The Forum will consider the human, social and economic impact of substance abuse and other dependencies at all levels of society. It will cover both illicit drugs (including synthetic ones), and licit drugs (alcohol and tobacco), as well as compulsive gambling. It is aimed at providing a non-confrontational platform for interactions between approaches, disciplines, domains of activities and individuals (professional from various sectors – researchers, educators, clinicians, government health workers – public policy officials and decision makers at all levels of society, voluntary agencies staff, associations leaders, and people everywhere concerned by drugs and dependencies). The Forum has several goals. It will encourage the use and sharing of structured information as well as ideas; providing examples of best responses to the challenge of addictions drawn from world-wide experience, increase public awareness towards dependencies issues leading to increased priority at policy/political level. It will also facilitate the establishment of a truly integrated and balanced approach towards drugs and dependencies. The Forum will achieve these targets by focussing on the human, social, environmental and economic costs of drugs and dependencies, by stressing an integrated approach and by devoting special attention to youth, the world of work as well as AIDS/HIV and other transmissible diseases. The current status of the Forum including its preliminary programme will be presented and views from the participants will be solicited. ISAM has agreed to be one of the main co-sponsors of this event and to take charge of the organization of a session devoted to the medical treatment of substance abuse.

PHYSICIAN EDUCATION IN SUBSTANCE-RELATED DISORDERS: CHALLENGES AND OPPORTUNITIES Nady el-Guebaly, MD University of Calgary, Addiction Centre – Foothills Hospital, Calgary Alberta, Canada A systematic review of the literature elicits components of an optimal educational strategy including acquisition of knowledge, a desired attitudinal shift (often the most difficult to achieve) and behavioral skills. Both passive and interactive learning reinforced at regular intervals and supported by national and international interest groups appear to offer the best promise for sustaining positive behavioral change by physicians. Drawn from the Canadian experience, programs aimed at improving physician awareness about alcohol will be briefly described. A new educational initiative is built upon society's wish to make harm reduction measures such as methadone maintenance or buprenorphine prescriptions more accessible. An introductory course in addiction principles, sponsored by licensing authorities, is mandated as prerequisite for physicians volunteering to manage individuals with opiate addiction. Resulting opportunities and limitations will conclude the presentation.

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*B. Monheit, *L McCall, **L Waters * Monash University Department of General Practice, Melbourne, Australia ** Southern Metropolitan Addiction Consultancy Clinic, Melbourne, Australia In Australia most General Medical Practitioners have been reluctant to take on drug and alcohol work as part of their primary care work. However, the community, government and patients see doctors as being the main provider of credible advice and medical treatment for addiction. The introduction of new pharmacotherapies such as naltrexone, buprenorphine and acamprosate in Australia over the past three years have made GPs aware of a greater role they could play in the treatment of addiction. To assist those GPs who have developed an interest in this area we have developed a seven session drug and alcohol course. It is run by and is designed for GPs and utilises case discussions, an interactive format as well as background reading material and written exercises. Sessions are focused on the following key topics: Doctor’s own attitudes, current theories of addiction, history taking and case management, pharmacotherapies, motivational interviewing and dual diagnosis management. The course has been supported financially by government, and together with encouragement by the leaders of the profession, doctors are slowly taking up this work. To provide drug and alcohol training to doctors who live in more remote towns we have started to utilise teleconferencing facilities to link different GP groups. Two large TV screens are utilised at each learning site to provide instant interaction between all participants and with the lecturer. After initial hesitation and technical problems, participants now feel comfortable with this medium. Evaluation of the course shows great satisfaction with the content and format. Follow up of participants revealed increased confidence and a reported increase in drug and alcohol work performed by the GPs.

BARRIERS TO THE GENERAL PRACTITIONERS MANAGMENT OF ALCOHOL-RELATED PROBLEMS: COHERENCE OF ALCOHOL TREATMENT NETWORKS IN AUSTRIA OM Lesch1,2, H Walter1, I Hertling1, H Lind1, K Ramskogler1 1

Department of Psychiatry, University Hospital of Vienna; 2Anton Proksch Institut Kalksburg, Vienna

Since 1953 withdrawal and addiction treatment is paid by the Austrian state, social insurance. Therefore a well established basis for out-and in patient therapy could be developed in all counties of Austria. Stepping out from the treatment modalities of the Anton Proksch Institute for Addiction and Treatment a network of different treatment facilities is now available all over Austria. At hand of the facilities of API , upper Austria and Burgenland the treatment network for prevention, inpatient - , outpatient treatment and aftercare will be presented. General practitioners hold a key role in all therapeutic stages and are thereby well integrated in the addiction long - term treatment. As long – term treatment is basic to this concept, we are able to follow – up our patients for years. This led to a long term study which resulted in the establishment of subgroups of alcoholism illness course. These subgroups enable us to offer our patients an individual, “ tailer-made “ , therapy. Especially in Type I and IV the general practitioners work is central to treatment, which will be shown in this presentation. The four types are nowadays easy to diagnose ( assessment by computer ) and comfortably to handle, helping to target the basic disturbance underlying the development to addiction.

DIAGNOSIS AND TREATMENT OF CHEMICALLY DEPENDENT PHYSICIANS Daniel H. Angres, M.D. and Kathy Bettinardi-Angres, MS, RN Rush Behavioral Health Physicians have at least an equal or perhaps greater risk of becoming chemically dependent than the general population. Estimated lifetime prevalence of chemical dependency for physicians have been suggested from anywhere between 12 to 20 percent of the physician population. Physicians have particular risk factors that contribute to the disease of chemical dependency. They also have a higher degree of accountability in their profession. This particular presentation will outline what is involved in making the diagnosis of chemical dependency in the often highly defended physician with this disease. The presentation will also go into detail in regards the specific risk factors that contribute to physicians becoming chemically dependent and having potential impairment in the workplace. There will also be an emphasis on specialized treatment for chemically dependent physicians. The details involved with specialized treatment for chemically dependent physicians will be highlighted. Also outcome studies indicating overall abstinence rates as well as looking at prognostic indicators will be detailed. The extensive aftercare-monitoring program with utilization of state medical society’s assistance programs will also be discussed. Kathy Angres, MS, RN, will discuss family involvement, critical to chemical dependency treatment in general and physicians in particular. The risk for physicians becoming chemically dependent is a worldwide phenomenon. When appropriately diagnosed and treated, particularly in a specialized fashion, the addicted physician has as a rule excellent outcome. The above presentation will utilize clinical observations and research described in the book, Healing the Healer, The Addicted Physician , by Daniel H. Angres, M.D., G. W. Talbott, M.D., and Kathy Angres, MS, RN. DIAGNOSING AND MANAGING CHEMICAL DEPENDENCY / ADDICTIONEND.COM. PROJECT Joseph D. Beasley, MD, MPH., DTM&H.,(Lond.). Maria C. Delgado-Pich, MD, CASAC. The Mother and Child Corporation..116 Broadway, Suite 4. Amityville, NY 11701. U.S.A In the U.S.A. Alcohol and Drug Abuse/Dependency is the most frequent diagnosed illness in clinical practice. Clinicians know the importance of diagnosis as the first step or doorway to treatment. Over the years this doorway has been open, but frequently passed by many when attempts are made to search for the cause and effects factors that present the patient with a variety of clinical symptoms. At times there are casual assumptions or impressions about alcohol/drug abuse which become evident and are referred to in a generalized manner. Many times, alcohol/drug abuse becomes a secondary diagnosis that is lost or put aside while other clinical symptoms are treated. Frequently the patient is referred for further diagnosis and treatment of the alcohol/drug problem. The “Diagnostic and Statistical Manual of Mental Disorders” (DSM) or the “International Classification of Diseases” (ICD) have traditionally been the sources for listed diagnoses of substance abuse and dependence. These references are not always readily helpful to clinicians who are looking for simple descriptive language to describe the patient’s clinical syndrome of alcohol/drug abuse or dependence. Neither do they always help pull together the patient’s history in order to help formulate the diagnosis. Consequently, treatment for alcohol an drug problems are left to a later time and place. This is a presentation about the book “Diagnosing and Managing Chemical Dependency”, Fourth Edition, along with the companion website “Addictionend.com” is designed for professionals but adapted by glossary for use as an educational tool to help the professionals educate their staff and patients under their supervision. Both publications are a concise, practical and step by step guide for the diagnosis, treatment and prevention for alcoholism and other drug abuse/addictions. Areas covered include definitions, pharmacology and pathogenesis; clinical signs and diagnosis; treatment; addiction in pregnancy; and recovery support systems. This ready reference source and format has been demonstrated to be extremely helpful to thousands of clinicians. The precise but simplified language is of great help in providing the necessary diagnosis and treatment for the patient at the earliest possible stage. This is a non-profit interactive project. We need and invite your help to improve the effort.

PHYSICIAN IMPAIRMENT ALCOHOL AND DRUG ADDICTION – A GLOBAL PROBLEM G. Douglas Talbott, M.D., Medical Director, Talbott Recovery Campus, E. Mezciem, M.D., Homewood Health Centre , Guelf, Ontario, Canada Alcohol and drug addiction in physicians is a global problem with an incidence of 10% in Europe and the Americas. The factors leading to these addictions in physicians are presented. Indentification continues to be a major problem. The six major elements of early and verified identification are detailed. Intervention is a necessity with the denial of physicians and the conspiracy of silence within the medical community. Successful intervention leads to a multidisciplinary assessment where treatment options are presented. Criteria are detailed and dictate whether inpatient, outpatient, or intensive residential outpatient will be recommended. Treatment elements critical to successful treatment are catalogued and analyzed for both inpatient and outpatient programs. High recovery rates in programs designed and structured for physiciansare presented. Elements of the impaired physicians program that have global applications are outlined and characterized with a data base of over 1,500 impaired physicians that were assessed and treated at the Talbott Recovery Campus. Impairment in physicians with illnesses and behaviors other than alcohol or drug are outlined.

MULTIPLE PATHWAYS TO ADOLESCENT DRUG USE AND ABUSE DIFFERENTIAL IMPLICATIONS FOR PREVENTION Hyman Hops, Ph.D., Betsy Davis, Ph.D., and Fuzhong Lee, Ph.D. Oregon Research Institute Despite continued efforts to reduce and/or prevent alcohol and drug use among children and adolescents through media and school prevention efforts, and despite an apparent declining trend during the 1980s in the USA, the last few years have witnessed an increase in the prevalence of drug use, particularly the illicit ones. These data suggest that prevention and/or intervention strategies may have to be examined from a different conceptual framework than has been done for traditional programs. We need to focus on more distal variables that predict substance use acquisition since by early adolescence, the child may be well along a drug use/abuse trajectory and the possible effectiveness of intervention procedures may be limited. Second, while males usually have higher rates of drug use compared to females early in adolescence, the evidence for the possible antecedents that differ by gender that could inform prevention strategies have been largely ignored. Third, it is likely that the developmental patterns leading to the onset of substance use and potential for abuse are not similar for all children. Evidence suggests at least two different trajectories leading to early onset, i.e., prior to age 15, and late onset, during late adolescence or young adulthood. The purpose of this presentation is to illustrate differential trajectories leading to alcohol and other drug use that could provide critical information for the development of prevention and intervention activities, using the results from two different longitudinal studies that span the range from elementary school to young adulthood. The first study examined a normative group of elementary school students during grades two to five who were followed up during grades nine and ten in high school. Extensive data was collected at each time point with heavy emphasis on multiple methods and informants. The results showed differential predictors by gender over a fiveyear period. The second study used five waves of a 19-year longitudinal study whose primary goal was the identification of peer and family predictors of adolescent and young adult drug use and abuse. Using data for 6th graders, from the time of the first annual study assessments to the eighth year, we applied piecewise growth mixture modeling to multiwave panel data spanning the period from early adolescence, late adolescence, and into young adulthood resulting in two distinct latent developmental trajectory classes. Class 1, with a high initial status of alcohol use at Grade 6, showed an upward increase in trajectory only during high school whereas Class 2, with a low initial status of alcohol use at Grade 6, showed a linear increase in middle school with a second growth spurt at high-school entry and continuity in growth throughout the high school years. The results also found differential predictors of these two latent classes. The results will be discussed in terms of improving prevention and intervention efforts designed to reduce or eliminate problematic substance use among children and adolescents.

LATENT CLASSES OF FAMILIAL ALCOHOLISM AND DEPRESSION: RELATIONS TO NEUROPSYCHOLOGICAL FUNCTIONING IN LATE ADOLESCENCE AND ADULTHOOD Marsha E. Bates, Ph.D., V.L. Johnson, Ph.D., & S. Buyske, Ph.D. Rutgers University Familial alcoholism (FHA+) has been associated with increased vulnerability to neuropsychological impairments, however, the literature is equivocal and FHA+ youth do not appear to be uniformly at risk. Considered within the framework of brain reserve theory (Satz, 1993), subtle changes in neurosubstrate present in FHA+ offspring would be most likely to manifest in neuropsychological impairment in the context of other risk factors that lower the threshold for impairment. We suggest that increasing age and familial histories of other psychiatric disturbances such as depression may diminish brain reserve and thus increase liability for neuropsychological deficit in FHA+ offspring. Further, a longitudinal follow up of adolescents may be necessary to detect a developmental unfolding in vulnerability. This study examined differences in neuropsychological abilities between familial history groups during late adolescence and again 7 years later using data from the Rutgers Health and Human Development Project (N = 1271). Our family history classification system took into account alcohol use disorders and depression on the part of parents as well as substance use disorders and depression on the part of siblings of participants. Family risk groups were classified using latent class analysis to extract latent variables that represented unique profiles of observed alcohol, substance use, and depression diagnoses for first degree relatives of participants. The BIC statistic indicated significant improvements in model fit up to 3 classes. Class 1, the Low Risk Comparison Class (63% of the total sample), was characterized by no or a low probability of alcohol and depression diagnoses in first degree relatives. Class 2, the Limited Parental Risk Class (22% ), was characterized by a heightened probability of depressed mothers, somewhat elevated probability of alcoholic or depressed fathers, but low probabilities of an alcoholic mother or affected siblings. The High Risk Class 3 (15%) was very heavily weighted with sibling diagnoses and with multiple parental diagnoses. Controlling for age cohort and sex, an omnibus MANOVA to test for differences between latent classes in performance on the eleven neuropsychological tests indicated that there were no a significant differences between classes during late adolescence. However, a parallel MANOVA conducted on neuropsychological test scores 7 years later, revealed significant differences between family risk classes. Post hoc analyses showed that the High Risk Class performed significantly more poorly than the other two risk classes in verbal ability, abstraction, cognitive flexibility, and symbol coding. Effect sizes were in the small to moderate range. Although the High Risk Class comprised a larger number of participants with alcohol use disorders and major depression than did the Low and Limited Risk Classes, these disorders did not mediate nor moderate familial risk effects on neuropsychological functioning. The results suggested that youth with heavy loadings of first degree relatives including siblings with alcohol and substance use disorders and depression have heightened neurocognitive vulnerability, but that neuropsychological deficits may not become evident until adulthood.

IMMEDIATE AND LONGER-TERM TREATMENT OUTCOMES FOR ADOLESCENT DRUG AND ALCOHOL ABUSE Holly Barrett Waldron, Ph.D., Charles W. Turner, Ph.D., Janet L. Brody, Ph.D., and Thomas R. Peterson, M.S. The University of New Mexico Center for Family and Adolescent Research Research evaluating approaches for engaging and intervening with substance-abusing adolescents and examining treatment outcomes across time have been rare. This presentation will focus on findings from three treatment outcome studies, each conducted with a different clinical sample of youth referred for substance abuse treatment. The first study examined the efficacy of the Community Reinforcement and Family Training (CRAFT) method of unilateral family therapy to engage treatment-refusing youth into treatment. The intervention was designed to enlist parents (n=44) as change agents to increase adolescents’ engagement in treatment and thereby ultimately impact substance abuse. Parents successfully engaged 71% of youth into treatment and showed significant improvements in depression, anxiety, self-esteem, and medical and physical symptoms. The second study examined the efficacy of interventions for youth engaged in treatment. Adolescents (n=114), aged 13-18 years, were randomly assigned to one of the four intervention conditions: individual cognitive-behavioral therapy (CBT), Functional Family Therapy (FFT), an integrative treatment

including both FFT and CBT, or an education/ skills group comparison condition. Treatment outcomes were examined 4-months, 7-months, and 18-months after the initiation of therapy for the four treatments conditions for two outcome measures: percent days of use and percent of youths achieving minimal use. Each intervention demonstrated some efficacy, although differences occurred for outcome measured, speed of change, and maintenance of change. From pretreatment to 4 months, significantly fewer days of use were found for the family alone and combined interventions. Significantly more youth had achieved minimal use levels in the family and combined conditions and in CBT. From pretreatment to 7 months, reductions in percent days use were significant for the combined and group interventions and changes in minimal use levels were significant for the family, combined, and group interventions. Similar outcomes were obtained at the 18-month follow-up. Extending this study, another efficacy trial was conducted using similar treatments for adolescent problem drinking. Preliminary outcomes for 48 youth and their families replicate our previous findings, demonstrating significant pre- to post-treatment reductions in alcohol use. Taken together, the three studies provide empirical evidence for the efficacy of psychosocial treatments for adolescent substance abuse. The implications of the differential patterns of change over time for improving treatments and matching clients to treatment will be discussed.

PROFILES OF CHANGE IN DRUG USE DURING AND AFTER TREATMENT FOR SUBSTANCE ABUSING ADOLESCENTS Charles W. Turner, Ph.D., Holly B. Waldron, Ph.D., Janet L. Brody, Ph.D., Thomas R. Peterson, M.S., and Timothy Ozechowski, Ph.D. The University of New Mexico Center for Family and Adolescent Research Adolescent substance use problems have stimulated increased research attention in recent years. This study evaluated patterns of change during and after treatment for youths receiving cognitive-behavioral and family therapy interventions for their substance use disorders. Adolescents were randomly assigned to one of the four intervention conditions: individual cognitive-behavioral therapy (CBT), Functional Family Therapy (FFT), an integrative treatment including both FFT and CBT, or an education/ skills group comparison condition. The sample included 114 youth, ages 13-17, and their parents, with 75% male adolescents, and 39% AngloAmerican, 43% Hispanic-American, 8% Native American, and 10% of other or mixed ethnicity adolescents participating. Treatment outcomes were examined 4-months, 7-months, and 18-months after the initiation of therapy for the four treatments conditions. Outcomes were percent days of marijuana use and percent of youths achieving minimal use. Each intervention demonstrated some efficacy, although differences occurred for outcome measured, speed of change, and maintenance of change. The present analysis examined profiles of change during and after treatment. The dependent variables were the percent days use of marijuana for each youth at the four measurement periods. We used k-means cluster analysis procedures to identify 6 profiles of change across the measurement periods. The findings from these profile analyses suggest that family interventions produced more rapid improvement in problem behaviors and better resistance to relapse. The clinical significance of these findings in relationship to those adolescents who have been able to achieve and maintain abstinence will be presented. Implications for improving treatments for adolescent substance use disorders will also be discussed.

COURSE OF ADOLESCENT ALCOHOL USE DISORDERS ACROSS 3 YEARS AFTER TREATMENT Christopher S. Martin, Ph.D., and Tammy Chung, Ph.D. Western Psychiatric Institute and Clinic Little research has prospectively characterized the medium and longer-term course of adolescent alcohol use disorders (AUDs). We examined the course of AUDs over three years in adolescents recruited from a variety of addictions treatment programs. Adolescents age 14-18 were assessed 2-6 weeks after beginning an index episode of treatment, and participated in 1-year (n=334) and 3-year (n=172) follow-up assessments. The sample was 60% male and 81% Caucasian, and had a mean age at baseline of 16.6 years (SD=1.3). Alcohol diagnoses

were made with a modified SCID, and substance use was measured with several questionnaires and a structured interview. The data show a substantial decrease in alcohol use and problems over time in the majority of treated adolescents. At baseline, 42% of the sample had DSM-IV alcohol dependence and 29% alcohol abuse; most of the other subjects reported heavy drinking and alcohol problems. Adolescents with dependence were about equally likely to show a full remission of symptoms or remain dependent at 1-year and 3-years; relatively few were in partial remission status. Alcohol abusers tended to remit to no diagnosis or remain abusers, although 15% and 24% became dependent during the two follow-up intervals. Adolescents without a DSM-IV AUD tended to remain in this category, but during the two follow-up intervals, 12% and 17% became abusers, and 6% and 3% became dependent. Male gender and Conduct Disorder predicted AUD symptoms at the follow-ups. The data also indicate that adolescents whose AUD symptoms remitted were more likely to report non-problem drinking than abstinence. The quantity and frequency of alcohol use during the first year of follow-up in the non-problem drinkers (averaging 3.0 drinks 4.2 times/month) was significantly lower than those with continuing AUD diagnoses or symptoms (averaging 8.8 drinks 8.5 times/month). Non-problem drinkers also showed increases in social functioning and decreases in drug use. Among non-problem drinkers at 1-year, 57% retained this status through the 3-year assessment, 10% became abstinent and 33% returned to problem use. Nonproblem drinking at 3-years occurred in 26% of those who were problem drinkers at 1-year, and 50% of those who were abstinent at 1 year. The results suggest a great deal of variability in the course of adolescent AUDs, and suggest new ways to conceptualize treatment outcomes among teens.

WORKING WITH DRUG AFFECTED TEENAGERS – KEY STRATEGIES FOR INTERVENTION Lampropoulos B, Paediatrican, Department of Adolescent Medicine, The Children's Hopsital at Westmead and Westmead Hospitals, Haber PS, Medical Director Drug and Alcohol Services, Royal Prince Alfred Hospital Substance abuse and resultant morbidity and mortality are a growing problem amongst teenagers globally. There is evidence that substance abuse is becoming more common amongst teenagers and commencing at an earlier age. Drug affected teenagers are particularly difficult to connect with medical and drug treatment services. Specialised services for substance using teenagers are not available everywhere. Thus generalist clinicians and adult oriented drug and alcohol services are often called upon to play a role in the care of patients who are in their early teens. The purpose of this interactive workshop is to explore strategies and techniques that allow the development of therapeutic relationships with drug affected teenagers. These range from systemic issues (such as the setting) to specific skills which allow engagement in an individual consultation (such as confidentialty, use of the HEADSS assessment, motivational skills). We will look at understanding why these strategies and techniques are important and how to put them into practice through the use of illustrative cases.

VALIDITY OF U.S. PLACEMENT CRITERIA FOR DRUG ABUSE TREATMENT David R. Gastfriend, M.D.(1), Estee Sharon, Psy.D.(1), Sandrine Pirard, M.D.(2) (1) Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, U.S.A. (2) Department of Psychiatry, University of Liege, Belgium Addictions treatment worldwide may potentially benefit from standardized criteria for determining how a patient should be matched to a particular setting of care. The American Society of Addiction Medicine (ASAM) published its Patient Placement Criteria in 1991, revised these in 1996, and again in 2001. Although now endorsed by over 20 US states, the US Veterans Administration and the US Department of Defense, the ASAM Criteria have only recently undergone prospective testing. Two naturalistic studies and one random controlled trial in three distinct samples have now tested whether the ASAM Criteria are feasible and valid. Results are promising, indicating that the ASAM Criteria: 1) can achieve a quite satisfactory inter-rater reliability; 2) do differentiate patients into levels of care; 3) may not be easily accepted by patients without system supports, and 4) may predict clinical, functional and utilization improvements in outcome. A key benefit of this research is the

use of computer technology to achieve a comprehensive implementation of a complex, hierarchical decision tree. These three studies indicate the potential advantage of a single software implementation for use in multisite studies and across multiple populations. This finding has implications for research and treatment in international settings as well. Sponsored by U.S. National Institute on Drug Abuse Grants R01-DA08781 and K24-DA00427 to Dr. Gastfriend and Belgian Government grant "Fonds National de la Recherche Scientifique, FNRS" and Belgian American Education Fund grants to Dr. Pirard

PSYCHIATRIC COMORBIDITY OF SUBSTANCE DEPENDANCE Dr. Tarek M.S.A.Gawad Dept. of Psychiatry - Faculty of Medicine, Cairo University, Egypt An Egyptian study of 60 substance dependant inpatients were recruited from private and public mental hospitals in Cairo. The aim of the study was to assess the impact of psychiatric comorbidity on the severity of substance dependance. According to the results of the structured clinical interview for DSM III R - patient edition ( SCID-P ), patients were divided into two groups i.e. the Comorbid group and the Noncomorbid group. The distribution of psychiatric diagnoses revealed that antisocial personality disorder was the commonest comorbid diagnosis (31.4%) followed by major depressive disorder (14.2%). Other psychiatric diagnoses were marginally represented. The Addiction Severity Index (ASI) , which is a semi-structured clinical interview assessing the severity of substance dependance by exploring six major areas of functioning, was applied to the whole sample. The result of the ASI showed no statistically significant difference between the two group.

THE IMPLEMENTATION OF THE JOINT SERVICES DEVELOPMENT UNIT (JSDU) FOR THE MANAGEMENT OF PSYCHIATRIC AND SUBSTANCE USING CONDITIONS THE DEVELOPMENT OF AN INTEGRATED MODEL OF CLINICAL CARE AND PROFESSIONAL DEVELOPMENT IN WESTERN AUSTRALIA Serena Ryan Joint Services Development Unit (JSDU), Graylands Hospital, Claremont, Australia The association between mental illness and drug and alcohol use is well documented. There have been numerous studies that indicate a significant number of people with mental illness are also dually diagnosed with a substance abuse disorder. Whilst research methodologies have varied, the data indicates that up to 40% of people with a mental illness also have a substance abuse disorder. A local survey found that approximately 35% of inpatients had a medium or high dependency on alcohol1. Within Western Australia there has unfortunately been a tendency for consumers to seek mental health support from mental health professionals and substance abuse support from drug and alcohol professionals. This has resulted in fragmentation of care for consumers. Consumers with dual diagnosis are either intense users of mental health services (particularly inpatient facilities) and drug and alcohol service or they slip through the gaps. Philosophy of the JSDU The overall operating philosophy of the JSDU is that persons with co-occurring mental health and drug dependence disorders are best served by holistic, individually tailored, and integrated interventions. Such interventions are best provided in the least restrictive manner and are most effective if they are based on a high quality helping alliance. It is considered that, wherever possible, individuals with co-occurring conditions are best managed within a single agency. However, increasing severity of mental health disorders may necessitate a move to parallel agency input. In order to ensure that customers benefit from joint agency input such interventions will need to be carefully coordinated and case managed. Given the desirability of single agency interventions staff in both the mental health and drug sectors will need to be sufficiently skilled to be able to provide interventions that address both aspects of consumers’ presentations. It is stressed that the effectiveness of interventions for ‘co-morbidity’ are dependent on the quality of the helping alliances that are established. The enhancement of clinicians’ abilities to establish and maintain high quality therapeutic relationships will be a central focus of JSDU activity. Demonstration sites It is envisaged that JSDU will provide an intensive clinical education and consultancy service to a number of pre-selected demonstration sites. In the first instance these sites will include a tertiary inpatient unit, both government and non-government alcohol and drug agencies, a community mental health/drug service and a rural and remote mental health service. JSDU will provide the demonstration sites with clinical consultancy using a multi-disciplinary team approach, coupled with individually tailored professional development, training and education directed to agency needs, policy and practice development and, if appropriate, telepsychiatry and teleconference support. A consultancy and case management telephone ‘hotline’ will also be established. The aim of these interventions is to create a sustainable enhancement of service provision for ‘co-morbid’ consumers. It is envisaged that demonstration projects will benefit directly by being able to better manage such clients. In return, JSDU will, by working in a collaborative consultancy role with a variety of different agencies, gain improved understanding of the challenges presented by ‘co-morbid’ clients and will develop experience in how best practice is most effectively achieved. The process of the implementation of these demonstration sites will be presented and the evaluation process will be outlined.

1

Bartu, A. (1993) Alcohol and other drug use of patients prior to admissions to a psychiatric hospital. WAA&DA – January.

PAIN REDUCTION WITH OPIOiD ELIMINATION Edward Covington, M. D. The Cleveland Clinic Foundation, 9500 Euclid Avenue Desk C 21, Cleveland OH 44195 USA In addictive disorders that patients have the illusion of an improved quality of life from use of a substance that has markedly demonstrated their quality of life diminished. The last decade has seen a reversal of the traditional clinical beliefs that chronic opioid therapy (COT) was inadvisable in nonmalignant pain. Numerous articles report that there is sustained pain reduction with chronic opioid therapy. Opioids have clearly been shown to be very safe in long term use, even at high doses. However, the question of efficacy remains. Studies of intrathecal opioids suggest that very high levels of patient satisfaction and retrospective reports of substantial benefit may occur despite minimal change in pain level and function. This raises the question of the extent to which the purported benefits of long-term opioid therapy represent an indifference to pain and dysfunction rather than an amelioration of them. Case studies will be presented of patients who believed they were benefiting from chronic opioid therapy, but after opioid elimination concluded that their pain and function were actually worse on opiods and their cognition improved with opioid weaning. They commonly described “getting myself back” after elimination of opiods. Physiological considerations and treatment implications will be described.

ORGAN TRANSPLANTATION – THE ROLE OF ADDICTION MEDICINE Margaret M. Kotz, D. O. The Cleveland Clinic Foundation, 9500 Euclid Avenue Desk P 57, Cleveland OH 44195 USA Allocation of organs for transplant has created medical, ethical, and economic concerns at a time when availability of organs is extremely limited . Although transplantation may be life-saving for those with many diseases, it is not available to everyone. Patients’ use of alcohol and other drugs is a controversial issue in the transplant community. While compliance with medical requirements is important for all transplant recipients, it requires special attention in those whose organ failure resulted from substance use. This is because relapse into abuse of mind-altering drugs both increases the likelihood of medical noncompliance and exposes the graft organ to a toxic substance. Local, regional and national regulations have affected organ allocation. The Ohio Solid Organ Transplant Consortium was formed to ensure equitable access to donor organs without regard to financial or other considerations. At The Cleveland Clinic, a tertiary care facility in Ohio, a chemical dependence transplant team was formed in response to criteria established by the OSOTC for transplant patients with addictive disorders. The assessment, treatment and monitoring of patients with comorbid organ failure and addictive disorder require specific expertise. A prominent role for specialists in addiction medicine on the transplant team has resulted. This presentation will describe the responsibilities of the chemical dependence transplant team, the scope of the referral process, and the team’s appropriate roles vis a vis patients, families and transplant professionals.

ADDICTION COMORBIDITY IN PATHOLOGICAL GAMBLING Bernardo Spazzapan - Patrizia Lenassi Addiction Unit - Gorizia - Italy Pathological gambling (PG) is a problem of public health of increasing importance. The psychopathology of PG and the international classifications show common pathways with the Obsessive-compulsive spectrum in the group of Impulse control disorders. The comorbidity with other addictions is high. This depends on similarpsychobiological and personality traits. In young people PG may be included in the area of sensation seeking and/or risk seeking behaviours. A bio-psycho-social therapeutical approach is the most useful as in other addictions.

PATHOLOGICAL GAMBLING: A STEPPED CARE MODEL OF INTERVENTIONS Nady el-Guebaly, MD Professor of Psychiatry, University of Calgary, Addiction Centre – Foothills Hospital, Calgary Alberta, Canada David Hodgins, PhD, Associate Professor of Psychiatry, University of Calgary This presentation is divided into two portions: 1.

An overview of our research on a sample of ‘naturally recovered’ pathological gamblers (N=106) and their change strategies. These strategies formed the basis for the development of a workbook “Becoming a Winner”, tested through a random assignment of pathological gamblers (N=102) into three conditions: (a) a waiting list control; (b) the workbook sent through the mail and (c) the workbook plus a motivational telephone interview. Gamblers reported reading the manual and following the strategies with significant reduction in gambling at 12 months. Additional motivational interviewing was also helpful.

2.

An overview of the literature conducted to identify the empirical evidence underpinning the management of pathological gambling. A range of pharmacological and psychological treatments is available for clinicians but the field so far musters only 5 randomized controlled trials on psychological approaches, and 2 ‘hopefuls’. The second tier of some 20 studies describes outcome related to GA attendance, couple therapy and comprehensive inpatient treatment. There is one open label trial of medication, 2 pending and one evaluation of prevention program.

THE INSURERS’ INITATIVE TO REDUCE ALCOHOL ABUSE Dario Escher Direttore Generale, ASSIBA S.p.A., Milan, Italy The Insurers may fight off the subsequent alcohol abuse by applying more expensive tariffs or more strict selection criteria to people prone to high alcohol consumption. Insurers may promote – as precautionary measure - campaigns against alcohol abuse. Measures taken up in Belgium, France and Norway are described this report. Finally this report inquires into a peculiar initiative taken by an Austrian firm as regards to its employees.

THE ROLE OF BIOMARKERS OF HEAVY DRINKING IN HEALTH CARE MANAGEMENT John P. Allen, PhD, MPA Scientific Consultant to the National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA. Research on biomarkers of heavy drinking has become quite extensive, with over 1200 references now available on the topic. Despite this large corpus of scientific information, the translation of findings to applied clinical utilization has been limited. The proposed presentation attempts to partially bridge the research-practice gap by describing several currently available tests with particular emphasis on their capabilities as well as their sources of false positive and false negative errors. This is followed by discussion of how markers can be used in medical practice for alcohol problem screening, facilitating differential diagnosis, motivating patient change, monitoring relapse status, and evaluating new medications for alcoholism treatment. Research dealing with the relationship of biomarker findings and medical care issues (e.g. predicting future health care costs and assessing patient risk factors for determination of insurability) is then summarized. Finally, the presentation will offer recommendations for use of biomarkers in a variety of health care and insurance contexts.

MEDICAL CONSEQUENCES OF ALCOHOL: A TREATMENT PROGRAM DEVISED BY AN INSURANCE COMPANY Dr B. Boisset Mutuelle Générale de l’Education Nationale, France L’auteur présente le dispositif alcoologique mis en place par la Mutuelle Générale de l’Education Nationale (M.G.E.N.) depuis plus de 15 ans. Installé en région parisienne sur plusieurs sites, il est destiné aux soins de patients alcoolodépendants venant de la France entière. Le département d’alcoologie repose sur l’action d’une petite équipe pluridisciplinaire qui a développé un important travail en réseau. L’approche théorique qui a présidé au montage des différents protocoles s’appuie sur le cognitivisme et la phénoménologie. Certains résultats, (du moyen terme 2 ans, au long terme 15 ans) montrent l’intérêt d’un tel dispositif trans – institutionnel. De récentes directives européennes contraignent la M.G.E.N. à d’importants remaniements qu’elle va réaliser sans renoncer à ses actions de soins et de prévention.

LAW ENFORCEMENT OFFICERS SURVEY ON DRUG CONTROL POLICY Y. E. Razvodovsky Grodno State Medical University, Department of Psychiatry, Drug-Related Problems Research Group, Belarus Today there is many debates concerning establishing control over illegal drug: how, in what balance, by whom and in what measures should drugs be controlled. Opinion of those, who puts drug control measures into practice, may be of interest in this respect. Applying the methods of structured interview, including questions relating to drug control policy measures, we surveyed law enforcement officers. The results of the interview showed that the majority of the respondents have negative attitude to the idea of legalization of both soft and hard drugs. At the same time, most of them considered, that use and possession of drugs in small amounts should not be a reason for imprisonment – only administrative punishment would do. Repressive measures should be taken against drug dealers, but not users. As far as the former is concerned, their punishment should be reinforced. The results of the survey manifest predominance of the point of view, according to which drug addicts are sick people and they need treatment, but not punishment. Prolonged compulsory treatment in special establishments of closed type that exist in the system of the Ministry of Internal Affairs is considered to be optimal variant of the policy aimed at drug addicts. The majority of those interviewed think that imprisonment of drug addicts can only be a means of isolating them from the society, but it has nothing to with treatment. According to those respondents, only 1-5 per cent abstains from using drug after being discharged. A lot of drug addicts continue drug taking in prison. At the same time half of the interviewed consider imprisonment of drug addicts to be a good preventive measure. It means, fear of punishment is a preventive factor for potential drug users. Most of those interviewed state that keeping in prison d.a. together with criminal population might cause numerous problems. Thus, the majority of the respondents admit the restricted possibility of punitive approach to solving drug-related problems. There prevails the point of view according to which effective drug control policy should integrate law enforcement measures and measures of ‘medical model’.

PUBLIC ATTITUDES TOWARDS DRUG CONTROL POLICIES Y. Razvodovsky State Medical University, Department of Psychiatry, Drug-Related Problems Group, Belarus The prevailing character of today’s drug control policy reflects a punitive approach to control. Survey carried aut in this field reflect public support of this policy. The goal of any drug policy is to reduce harm. Today there is many debates about legalization of drugs. Legalization proposals are often presented under the guise of harm reduction. As far the experiens show, when drugs are legalized, they are used more widely and the total cost of their use go up if compared with the costs of drugs which are still under prohibition. And vice versa: restricted availability and high prices can help to hold down the number of first-time users and reduce the human, social and economic costs of drug abuse. It is known that policy-making apparatus is influenced by public opinion. In this paper the results of the survey of public attitudes towards drug control policy are discussed. 562 citizens of Belarus of different sex and ages took part in the survey. Methods of structured interview was applied. The results are as follows: 76 per cent of respondents think that legalizing of drugs is a bad idea. 71 per cent of those interviewed consider that law should punish drug taking. 91 per cent agree that it is necessary to make the punishment for sailing drugs more strict. 90 per cent of people, participating in the survey consider that drug addicts should be treated but not punished. As far as alcohol is concerned, 36 per cent agreed to the idea of increasing prices for alcohol and at the same time 14 per cent expressed their negative attitude to this. 20 per cent of those interviewed think that alcohol should be prohibited. Thus, there is substantial support for policies, which increases the price and reduces the availability of alcohol. The results of the survey manifest negative attitude of the society to the idea of legalization of drugs and sanctioning of repressive measures towards drugdealers and drug-users. At the same time, the majority of population considers drug addicts to be sick people. It means, they support the ‘medical model’. DRUG ADDICTION AND JAIL. THE ROLE OF THE NETWORK BETWEEN COMMUNITY SERVICES. ALTERNATIVE MEASURES TO DETENTION Dr. Ariadna Baez Moquete, MD. Giovanna Rossi, Social Assistant Drug addiction Community Service, Department on Addiction, Trieste, Italy Italy is provided , in the within of the European countries, of one of the most effective networks of services for the prevention, treatment and rehabilitation programs of the drug addicts. A network formed by public health and social services, therapeutic communities and private social services who had learned, in the course of the years,to construct solid synergies and to offer different ways of personalized cure, rehabilitation and attention to the specificity of the persons. Sanitary services for drug addictions (SER.T) are present in the penitentiaries Institutes since 1990 to aim to guarantee the continuity of the therapeutic relationships wih the drug addicts subjects imprisoned. More over, in base to article 135 of the Unified Text of Laws in narcotic matter (T.U. n° 309) Penitentiary Amministration has institued and organized a serviced of support called “Sanitary office for the drug addictions, alcohol addiction and support to the prisoners affected from HIV” in which they operate medical doctors, psychologist and professional nurses. The priority objectives of the collaboration in action between the services for the drug addictions (SER.T) and this sanitary garrison are: • The continuation of the therapeutic programs in action in the outside. • To guarantee eventual participations on detoxification programs by substitute therapy with methadone or sintomatic drugs. • To program support’s interventions to the drug addicts during the period of their detention. Article 8/1 of legislative decree n. 230/1999 previews that, from 1 january 2000 the sanitary functions in the field of prevention and attention to the drug addicts prisoners and inmates are transferred to the National Health Service. As far as the penal aspect, exists one tightened collaboration between the services for the drug addictions (SER.T) and the Adult Social Centers of the Ministry of Justice (CSSA) in order to structure therapeutic programms in support of the drug addicts with definitive sentences,imprisoned or free,to the aim to obtain the concession of one alternative measure of the detention as previewed by the Law: Art. 94 T.U. 309/90, domicile detention ( Art. 47 ter), semifreedom (Art. 92, comma 3) and more over in order to activate the useful resources of the community for the social reintegration of the drug addicts subjects.

THE PREDICTIVE DETERMINANTS OF SMOKING CESSATION PROGRAMS IN EGYPT M. Hashem Bahri*; Al-Akabawi, A.S.* Omar, M.SH.** And Farghaly, A.B* *Psychiatry Department, Faculty of Medicine, Al-Azhar University ** National Cancer Institute, Cairo University, Egypt. Tobacco consumption is one of the most serious drug abuse problems in the world. People in the developing countries now a day consume between 1/3 to 1/2 of the world tobacco. Aim of the work: to analyze the psychological and behavioral aspects of Egyptian smokers associated with participation attrition and successful out come in smoking cessation programs. Methodology: 300 Egyptian smokers attending the antismoking center, Cairo were subjected to: personal interview; physical and psychological examination, chest X-ray, ECG, pulmonary function test (FEV1), blood sugar and cholesterol. Each participant will then eligible to Join the smoking cessation program for 2 weeks which depends mainly on behavioral, cognitive therapy, the electric nerve stimulation therapy and heath education program. Follow up after 3 months to assess the success of the program. Results and conclusion: the ratio between the quitters and continuers is 37% : 63%. The most important predictive determinants affecting the outcome in smoking cessation programs are: smoker's age (21-40 years), single, students, high level of education, living in urban area, beginning smoking over 17 years, a previous cessation experience, less number of smoked cigarettes, short duration, pleasurable feeling when smoke, no psychiatric problems, health problems especially if FEV1 is impaired. Continuers have stress personality disorders and drug dependence. ADDRESSING NICOTINE DEPENDENCE IN ADDICTION TREATMENT Maria C. Delgado-Pich, MD, Dario Gigena, MD and Carolina Bergoglio, MD Gaia Nova, Institute for Addiction Studies and Treatment, Gay Lussac 6590, Córdoba 5147, Argentina This paper describes an approach for addressing nicotine dependence in an outpatient facility for addiction treatment. Statistics show that Argentina has a serious problem with tobacco smoking. 35% of the adult population (17y.o. and older) and 50% of adolescents (12 y.o.-17 y.o.) are regular smokers. It is noted that 35% of healthcare professionals are nicotine dependent. The consequences of smoking are 40.000 deaths yearly, 32% cardiac related problems and 18% cancer; lung cancer is the primary type ( in women smokers supersedes breast cancer).Estimates indicate that by the year 2020 nicotine addiction could be the primary cause of death for Argentineans. A prevention program is especially important for individuals with regular alcohol/drug use. 70% (to 80%) of individuals with drug/alcohol disorders and 90% of dual disorders patients are nicotine dependent. Therefore a comprehensive Smoking Cessation Program is advisable for patients and their families. The program requires an individualized plan that addresses level of motivation, circumstances and needs. Various psychotherapeutic, pharmacological and relapse prevention approaches are offered in a three month / three phase program. Phase I- Preparation, Phase II- Action, and Phase III- Maintenance. Assessment and treatment planning are required at each phase. 40%-50% of the chemically dependent and dual-disorder patients who sought treatment for their nicotine dependence were able to stop smoking, and remained nicotine free during the first year of treatment. Further considerations about relapse events and continuos encouragement on being chemical free are discussed.

EFFECTIVENESS OF INTERVENTIONS FOR HELPING PEOPLE STOP SMOKING IN THE TRIESTE AREA. A 2 YEARS SURVEY Montina G.L.*, Pivotti F.**, Poropat C.***; Cariello E.°, Todaro P.°°, Onor M.L.^, Poldrugo, F.§ * Dipartimento di Prevenzione – ASS n° 1 – Trieste, ** Centro Cardiovascolare – ASS n° 1 – Trieste, *** Centro Prevenzione e Cura del Tabagismo – ASS n° 1 – Trieste, °Associazione Hyperion – Trieste °°Lega Vita e Salute, ^ Clinica Psichiatrica – Università di Trieste, § Dipartimenti di Salute Mentale e Droghe – Università di Trieste Background. Smoking cessation is often a difficult task, due mainly to psychological addiction. It has been shown that the provision of advice and counseling to small groups of smokers is effective in 10 to 25% of cases at 1 year follow-up.

Aim of the study. To evaluate the effectiveness of counseling group sessions in the Trieste area. Material and methods. 117 subjects (63 males and54 females, mean age 45.51SD12.36) who attended an intensive smoking cessation course held by 1 of the 3 associations active in Trieste (Lega Italiana per la Lotta contro i Tumori – LILT, Lega Vita e Salute – LVS ed Associazione Hyperion – AH) were studied. The three associations have different strategies: LILT courses: held by trained personnel (doctors,teachers), are homogeneous throughout Italy, and consist of 10 meetings of 90’ each over 2-3 months. AH courses:groups of 20 smokers attend a preliminary 4-day course followed by a more individualized series of 10 meetings. Medical and pharmacologic support may be provided as well. LVS courses: held by specifically trained personnel for groups of 40-50 people, who participate a “full immersion” treatment consisting of 5-consecutive-day meetings of 3 hours each, followed by 8-10 sessions dedicated to smaller groups (15-20 people). All the protocols included questionnaries investigating the degree of addiction (Fagestrom) and the motivations to smoke (“Why do I smoke?”). Results. The mean Fagestrom score was 6.43 and the most frequently reported motivation was “recreation” (73%). 64% of smokers had quitted at the end of the courses. After 2 years, 90 out of 117 subjects (76.92%) could be followed up by telephone interviews. During this period 75% of quitters relapsed (the majority – 67% - within 3 months after havig stopped smoking), and 25% was still abstinent. Conclusions. The results of the present study are in agreement with those reported in literature. The high percentage of relapses within few months after quitting, and the analysis of the questionnaires filled up during the courses, emphasize the importance of an ongoing psychological support during the early phase of abstinence.

WOMEN AND THE TWELVE STEPS Maria C. Delgado-Pich,MD, Carolina Bergoglio,MD, Dario Gigena,MD Gaia Nova, Institute for Addiction Studies and Treatment, Gay Lussac 6590, Cordoba 5147, Argentina. It has become recognized that in the population of regular drinkers/drug users who meet the criteria for “Abuse” or “Dependence”, women have some specific individual and environmental risk factors. The same barriers have an effect on how women might approach and incorporate or turn away from “the 12 Steps”. In treatment programs there are factors of fear, guilt, shame and opposition by the family and friends which act as barriers; also, inadequate training and awareness by healthcare professionals and a lack of women sensitive treatment services. Over the past several years we have seen an increased acceptance and efforts in the professional community about women specific issues and attempts to develop andcreate treatment programs that overcome some of the barriers. This presentation attempts to highlight components of women-oriented treatment and support groups for women. From the treatment model, a progression to looking at the 12 Steps in a women oriented manner is utilized to better enhance the recovery process.

ALCOHOLISM AND DRUG PROBLEMS IN INDUSTRY David E. Smith, M.D. Haight Ashbury Free Clinics, Inc. With the advent of the Drug Free Workplace Act in the United States in 1986, there has been a major focus on drug abuse and industry. The Drug Free Workplace Act covers all United States industries that receive any form of public funding, and includes a requirement for supervisory training, as well as employee drug education treatment and random drug testing. Evidence that developed from this drug free work place initiative indicates that 66% of substance abusers in the United States are employed. Since health insurance in the United States is a key to chemical dependency treatment, the random drug testing has served as a basis for early intervention and treatment for employed individuals. ASAM initiated Medical Review Officer training in the United States has been a very important force for medical training in this important area, as the Drug Free Workplace Act has demonstrated a significant decrease in workplace accidents and health care claims. With the globalization of the world economy, Medical Review Officer training and the expanded role of the addiction medicine physician in this area of drug abuse and industry will be an important international concern for ISAM members.

INCIDENCE ESTIMATES OF SUBSTANCE USE DISORDERS IN A COHORT FROM INDIA D.Mohan1 , H.Sethi 2 and A.Chopra 3, 1. Professor and Head 2. Research Officer 3. Research Officer Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi – 110029 Background There is no study reported in the Indian settings that provides estimates about incidence of substance use disorders in the general population settings. Objective To determine the incidence of substance use disorders by survey - resurvey. Design Cross-sectional survey carried out at two points of time after a interval of one year. Setting Representative sample from general population of urban megapolis, Delhi . Participants 5414 males having matched data at two points of time. Instrument Precoded , structured, based on DSM III R operationalised criteria for use of tobacco, alcohol cannabis and opioids ( past one month) . Results In the total cohort of 5414 individuals , 3515 were non users (any drug) at both points of time. The incidence rates for any drug use, tobacco , alcohol was 5.9% ,4.9% and 4.2 percent respectively. The incidence of tobacco among non users and alcohol users was 4.7% and 9.6% ( OR=2.1, CI= 1.3-3.6) whereas the incidence of alcohol among non users and tobacco users was 2.3% and 11.8% (OR= 5.76, CI= 4.3-7.7). Logistic regression predicted tobacco use at time I as an important variable for the start of alcohol use at time II (OR= 5.77, CI=4.3 to 7.7). Incidence of alcohol use was highest in the age group 41- 50 years. The Incidence of tobacco use among those upto the age of 20 years was 1.7 percent, and showed an almost consistent rate of around 4.0 percent in all the subsequent age groups. Conclusions Substance use disorders with high prevalence and incidence rates in this general population suggests the need for a balanced and integrated approach to its treatment? THE SUBSTANCE ABUSE SUBTLE SCREENING INVENTORY (SASSI) USE IN RESEARCH OF ADDICTED FAMILIES Rus-Makovec Maja, PhD, MD, Sernec Karin, MSs, MD, _eba_ek-Travnik Zdenka, PhD, MD; University Psychiatric Hospital Ljubljana, Center for Mental Health, Poljanski nasip 58, SI – 1000 Ljubljana, Slovenia, Rus. S. Velko, PhD, Department of Psychology at Philosophic Faculty, Askerceva 4, SI 1000 Ljubljana, Slovenia Background: The present research is a study on identification of psychosocial factors of parents with drug addicted children. It is also meant to test a new instrument in Slovenia named »The Substance Abuse Subtle Screening Inventory« (SASSI). SASSI covers a lot of different subscores, which identify possible negation of substance use problems and also covers direct and indirect signs of addiction (FVA – Face Valid Alcohol, FVOD – Face Valid Other Drugs, SYM – Symptoms, OAT – Obvious Attributes, SAT – Subtle Attributes, DEF – Defensivenes, SAM – Supplemental Addiction Measures, FAM – Family vs. Controls, COR – Correctional, RAP – Random Answering Pattern) (1). Methods: The sample consisted of 90 parents and 54 adolescents aged 14-19 years. The experimental group consisted of 44 parents and 27 drug – dependent adolescents, the control group of 46 parents and 27 non – drug – dependent adolescents. The data where obtained by a self-administered questionnaire covering all the relevant psychosocial adolescent and parent issues: social – demographic data; important life events; data about parents’ vulnerability; anamnestic data about primary family of the parents; data about self reported mental, physical and financial status and family climate; data about depression (Zung); data about self-esteem (Rosenberg); use of psychoactive substances (self – report questions, AUDIT, SASSI). Results: With the regard to literature data we were expected the high rate of parental alcoholism would be found in experimental group. The results showed that there were no signifficant differences found between parents from the experimental group and the control group considering the probability of PAS addiction in the parents, except in the SASSI subscores OAT and DEF of fathers. The results showed that the parents who were willing to be included in the experimental group were more “healthy” in the field of addiction (only 17 % of parents of addicted adolescents returned the questionnaire). Several signifficant correlations were found between the parental SASSI subscores and adolescent dependent variables which are relevant for adolescent psychological status (self-esteem, the level of depression, adolescent selfevaluation of physical and mental health). The SASSI instrument has proved to be very useful for the research on addiction, both in screening and in study of family interactions. (1) Miller FG, Roberts J, Brooks MK, Lazowski LE. The SASSI Institute. SASSI-3 user's guide. Baugh Enterprisses, Inc., Bloomington, Indiana 47401; 1997.

NEW STATISTICAL CONSIDERATIONS TO IMPROVE QUALITY OF LIFE INSTRUMENTS: FINDING ALQOL9, A SHORT, SPECIFIC AND SENSITIVE SUBSET OF MOS-SF36, SPECIFIC TO ALCOHOLISM Ph. Lehert, Dr,Eg,PhD, Faculty of Medicine, University of Melbourne, Australia, and Faculty of Economics, FUCAM, Mons , Belgium F.Poldrougo, MD, Faculty of Medicine, Department of Psychiatry, University of Trieste, Italy Quality of Life (QoL) became recently an important concern in clinical management. In Alcoholism, few research was devoted to this topic. MOS-SF36, a generic Health Related QoL Instrument was employed,and studies concluded into adequate metric characteristics. However, not based on specific symptoms of alcoholism, SF36 sensitivity was found low, and conversely, were unusefully redundant. It was conjectured that a short form concentrating on specific aspect of alcoholism might be expected to increase sensitivity, specificity, parsimony and simplicity of the instrument. The data were collected in 6 representative studies in Austria, Belgium, Germany, Portugal, United Kingdom, Switzerland. SF36 was administered at baseline, M3 and M6 and a pharmacological agent, acamprosate, was used to assess the sensitivity to change. Through a Mutiple Criterion Decision Making optimization procedure, we isolated 9 items from the original items of SF36 Instrument, that constituted the AlQol9 questionaire. This paper describes in detail this optimisation, and outlines the metric characteristics of this short scale. Finally, a causal model was derived through Structural Equation Modelling SEM technique, to test the invariance of the proposed scale to country specificities. A clinical interpretation is still needed at this stage, however, on the basis of these findings, AlQoL9 can be considered as a fully validated QoL instrument in alcoholism.

IMAGERY CUE REACTIVITY IN OPIATE ADDICTS: INDIVIDUAL VARIABLES AND DIFFERENTIAL RESPONSE Dr. Utpal Goswami Utpal, Dr. Debakanta Behera , Dr. Udayan Khastgir Dept. of Psychiatry, Lady Hardinge Medical College, New Delhi, 110 001, India Background: Around 70%of opiate addicts relapse to drug use within 6 weeks following successful treatment. This poor outcome may be a result of craving for drugs after abstinence. Craving may be classically conditioned to various drug related cues associated with drug use. Aim The present study was conceived with the aim to explore the psycho-physiological mechanisms of craving by an imagery cue exposure and the differential cue response in opiate addicts following detoxification. Material and methods: Opiate dependent subjects (N=38) following detoxification underwent imagery cue reactivity trials. Subjects were asked to describe verbally and then imagine their craving experiences. Craving was measured subjectively by using visual analogous scale and questionnaire methods and autonomic parameters of galvanic skin resistance (GSR), heart rate (HR), skin temperature(ST), and respiration rate(RR) were taken during drug related cue imagery. Spearman’s r and Wilcoxon signed ranks test where employed in analysis. Multivariate repeated measurement analysis (wilk’s Lambda) was employed wherever appropriate. Results: significant increase in subjective ratings on the measures of craving and significant change in HR, GSR, ST, RR were observed during drug related cue imagery as compared to neutral cues. The subjects were dichotomized according to the age of onset, duration of opioid use, attempts of abstinence, family history of substance abuse, motivation to leave the drug use habit, and the premorbid personality and the response to cue reactivity were compared between them. Conclusion: The results suggested that cue imagery elicited a powerful craving response in opiate addicts. Though differential cue reactivity was observed in relation to age of onset and motivation of the patients, no significant difference was observed for important variables such as high risk familial and personality factors.

CURRENT TRENDS IN ADDICTION EPIDEMIOLOGY, RESEARCH & TREATMENT David E. Smith, M.D. Haight Ashbury Free Clinics, Inc. Recent developments in the neuropharmacology and withdrawal syndrome of marijuana, as well as clinical and field research on the current abuse patterns of gamma-hydroxybutyrate (GHB), ketamine, aka “Vitamin K”, and other high social impact substances will be examined. Current drug use, presented in such a way as to provide a clinical perspective on public health and drug treatment issues, will be an important international concern for ISAM members.

THE DIRECT ETHANOL METABOLITE ETHYL GLUCURONIDE IS A SPECIFIC MARKER OF RECENT ALCOHL CONSUMPTION Wurst, F.M.1, Alt A2., Seidl S3., Sperker B4., Lauterburg BH5, Ladewig D1., Müller-Spahn F1, Metzger J.6 and the WHO/ISBRA study on biological state and trait markers of alcohol use and dependence Psychiatric University Hospital University of Basel, Switzerland; Departments of Legal Medicine, Universities of Ulm2 and Erlangen3, Germany; Departments of Clinical Pharmacology, Universities of Greifswald4, Germany and Bern5, Switzerland;6Department of Hydrochemistry and Hydrobiology, University of Stuttgart, Germany OBJECTIVE: Biological state markers with high sensitivity and specificity are required. Ethyl glucuronide (EtG) is a nonvolatile, water-soluble, stable upon storage marker of recent alcohol consumption that can be detected up to 80 h after the complete elimination of alcohol from the body. PATIENTS AND METHODS: (1) Urine samples of 304 patients from the WHO/ISBRA study were determined with an ESI-LC/MS-MS method. b) Studies on glucuronidation and glucuronidase activity in animals and humans. RESULTS: a) No correlation between EtG and other markers of alcohol consumption; Cross table analysis: With EtG three times more cases of alcohol consumption were detected than with HTOL/HIAA ratio. b) Formation and degradation of EtG takes place in different fluids, tissues and endoluminal to a highly variable extent. CONCLUSIONS: The findings emphasise that EtG is an sensitive, specific and reliable marker of recent alcohol intake, that via therapeutic intervention at early stages of lapsing behaviour can contribute to significant improvement in treatment outcome, therapy effectiveness and cost reduction. REFERENCES 1) Wurst, F.M.; Kempter Ch.; Seidl S.; Alt A. (1999) Ethyl glucuronide - a marker of alcohol consumption and a relapse marker with clinical and forensic implications. Alcohol Alcoholism 34:71-77 2) Wurst F.M.; Kempter Ch.; Metzger, J; Seidl S.; Alt A. (2000) Ethyl glucuronide - a marker of recent alcohol consumption with clinical and forensic implications. Alcohol 20: 111-116 THE INTRODUCTION OF ACUDETOX INTO THE ITALIAN PUBLIC DRUG AND ALCOHOL TREATMENT SERVICES David Blow, Giulio Picozzi, Grazia Rotolo National Acupuncture Detoxification Association Italy - Rome Key words: acupuncture, substance abuse, detoxification, public health detoxification services, Acudetox, NADA. Acupuncture detoxification is the initial treatment modality used in the Acudetox program for all patients requiring treatment for substance abuse. Clinical experience and published studies have shown that acupuncture is effective in the treatment of drug and alcohol withdrawal sympotoms, in the acute and post – acute stage as well in relapse management. Acupuncture helps clients reach quickly a state of physiological and mental equilibrium, allowing them to participate in other aspects of counselling and abstinence progression. Acupuncture detoxification is a painless and non threatening technique, that requires little verbal communication or interpersonal interaction. Especially at a time when a client may be experiencing acute physical withdrawal symptoms, and depression or incapacitating anxieties. Substance abuse acupuncture is provided in a group setting. A new acupuncture client is immediatly intoduced to a calm supportive group process. A patient recieves treatment, obtaining relief from withdrawal symptoms and is emotionally soothed thereby being motivated to continue treatment. The NADA Italy Association was founded in 1993 (following the NADA Association – USA in 1985). It is an organisation representative of experts in chemical dependency as well as Traditional Chinese Medicine (TCM). NADA’ s function is to provide training and consultation to treatment programs assuring clinical and ethical standards in the certification of acupuncture detoxification specialists. As acupuncture works in concert with traditional drug and alcohol abuse treatment approaches and noting the particular aspect that public detoxification services exist in every local community in Italy, the NADA Italian Association has focused over the last 8 years to offer this treatment modality to these public detoxification services. At the moment over 700 medical, paramedical staff and detox operators have been trained in over 120

different public health locations (SERT), hospital, residential rehabilitation comunities and prison setting in Italy. This paper will also cover the history and development of Acudetox not only in Italy but also where it originated in the USA along with other coutries as Australia, Saudia Arabia, India, Nepal, Pakistan, and in other European states amoung Germany, Austria, Switzerland, Portugal, Sweden, Netherlands, Hungary, Russia, and other Eastern European countries, where local NADA associations offer a standardezed training program similar in each state. HEROIN USE DURING PREGNANCY: THE IMPACT OF PRENATAL CARE AND DIFFERENT THERAPEUTIC REGIMENS ON PERINATAL OUTCOMES Salamina Giuseppe1, Tibaldi Cecilia2, Pasqualini Chiara2 1 2

Prenatal Centre for Drug-Addicted Women - Department of Gynaecology and Obstetrics, University of Turin. S. Anna Hospital, Turin. Centre for the Epidemiological Surveillance of Drug Dependence – Region of Piedmont - Turin

Background: Opioid dependence during pregnancy has been associated with increased risk of prematurity, low birth weight, perinatal morbidity, and mortality. To assess the efficacy of a comprehensive program of prenatal care and of various therapeutic regimens with respect to adverse obstetrical outcomes, we conducted a retrospective study among all drug-addicted women who attended the Prenatal Centre for Drug Addiction in Turin (Italy), between 1978 and 1999. Methods: Clinical records of 442 women were reviewed. Information was fully available for 349 women. Obstetrical outcomes, adequacy of care, and the type treatment for substance dependence were considered for the analysis. Results: All 349 women primarily abused heroin, 43 (12%) abused cocaine. Inadequate prenatal care was observed in 177 women (51%); 151 (43%) agreed to methadone maintenance; 85 (24%) patients underwent a detoxification, which was unsuccessful in 23 (7%) of cases. Newborns of drug-addicted mothers weighed on average 426 g less than those of general population. A total of 11 perinatal deaths were observed. Perinatal mortality was associated to cocaine abuse (RR=3.9; p=0.01) and to unsuccessful detoxifications (RR=8.5; p=0.01). Patients with inadequate care had a two-fold risk of preterm delivery and low birth weight. Conclusion: Our study strongly suggest that adequate prenatal care reduce the risk of adverse perinatal outcomes. Detoxification treatments should be limited to accurately selected patients. Methadone maintenance, promoting the access to services, represents the treatment of choice, but it increases the risk of neonatal withdrawal. It should emphasised, however, that in healthy newborns with adequate birth weight, the neonatal withdrawal syndrome can be easily treated without major consequences. ECSTASY-INDUCED NEUROTOXICITY A.O.Brundusino Institute of Medical Pharmacology IIa University of Pavia, Italy In many animal species MDMA shows its typical neurotoxic action on the thin axonal terminals of the serotoninergic neurons whose cellular bodies are in the nucleus of the dorsal rafe, sparing those having a greater diameter and spreading from the nucleus of the median rafe. The Fink-Heimer method shows the argentic impregnation of the degenerate axons. This degeneration starts within a few hours from the last MDMA administration and lasts for many months. Being spared the pyrenophores, the axons can be regenerated. The autoradiograph of the sites of 5-HT uptake and the immunocytochemical study of the reactive axons showed that the reinnervation noticed in albino rats and especially in squirrel monkeys 12/18 months after administration of 5 mg MDMA, i.p. and s.c. respectively, twice a day for four days, follows an abnormal pattern. It is characterized by the reorganization of the serotoninergic ascendent axonal projections, with dorsal cortex denervation and hyperinnervation of the tonsil and of the hypothalamus. From all the experimental models, with the exception of mice, who gave not always univocal results, it appears that MDMA administration, in a single high dose or after repeated treatments, causes reduction of cerebral 5-HT, liquoral 5-HIAA and tryptophanhydroxylasic activity. The loss of 5-HT cellular content takes place in two phases. The first one coincides with an acute 5-HT release, after which concentrations become normal within 24 hours. The second one corresponds to the long term reduction in 5-HT content which starts within three days and, being supported by the persistent decrease of tryptophan-hydroxylasic activity, lasts more than a year. In non-human primates, which are more sensitive than rats to the neurotoxic effects of MDMA, the alterations can be also seen after oral administration and small dosage increases cause remarkable increases in 5-HT depletion. The greatest decreases can be seen in

the neocortex, in the striate and in the hippocampus; the smallest, in the encephalic trunk and in the hypothalamus. PET images of a baboon‚s brain recently confirmed this toxicity pattern. Many studies on rodents tried to investigate the behavioural consequences of serotoninergic neurotoxicity. The animals treated with MDMA doses causing a 35-70% decrease in 5-HT levels in the striate and in the hippocampus don‚t show any important changes in emergence, hot plate response, auditory startle, complex maze performance, one and two way avoidance, swim test and eight radial arm maze. It has been shown, on the contrary, a decrease in ultrasonic vocalizations of young rats after separation from the mother. The behavioural patterns suffer the lack of specificity for the serotoninergic system, since presumably many neurotransmitters imply the observed behaviours. Recently, 15 young ecstasy users showed a remarkable decrease of the 5-HT membrane carrier, measured at PET with a carrier selective MCN-5652 radioligand. These observations suggest that in human beings the serotoninergic system can be influenced by the use of ecstasy; we should remember, however, that most recreational drug users are polyabusers and that their self-reports aren‚t very reliable. The apparent irreversibleness of the nervous lesions caused by ecstasy has been thoroughly studied. Particularly interesting are the results of a recent study that protracted to 7 years the observation of the neuroanatomical consequences of subchronic exposition to ecstasy in monkeys (8 doses in 4 days). The brains of these animals showed an abnormal serotoninergic innervation, with a remarkably decreased density of serotoninergic axons in areas like the neocortex, the striate and the hippocampus, while this density increased in the pale globe and in some thalamic nuclei. The serotoninergic axonal density in the hypothalamus and in most of the limbic regions seems, however, almost unchanged. Unfortunately, the observations made so far on man gave results similar to those obtained in subhuman species. PHARMACOLOGICAL EXTINCTION OF ALCOHOL ABUSE AND OTHER ADDICTIONS J. D. Sinclair and H. Alho Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki 00101, Finland Alcoholism and other drug addictions are now considered to be learned behavioral disorders. The addict’s responses of obtaining and taking the drugs have been reinforced so often and so powerfully that they dominate the behavior and thinking, and they often cannot be controlled by normal means. The nervous system has, however, not only a mechanism for strengthening those behaviors that produce reinforcement (i.e., learning) but also a mechanism for removing learned behaviors that no longer yield reinforcement: i.e., extinction. Therefore, A. Wikler in 1976 suggested that opiate addiction could be cured with extinction induced pharmacologically by blocking reinforcement with opioid antagonists such as naltrexone. The results from both preclinical and clinical tests have consistently supported his hypothesis. Preclinical studies demonstrated that opiate selfadministration by animals is extinguished when the behavior is made while an opioid antagonist is present. A large NIDA double-blind, placebo-controlled clinical trial showed that patients taking naltrexone before selfadministering heroin or methadone had significantly better results than did the patients on placebo, but there were no significant benefits from naltrexone under conditions precluding extinction: “the theory behind narcotic antagonist treatment involves extinction and the concept of extinction implies some use of narcotic drugs” (Renault, 1981, p. 17). Despite the evidence, pharmacological extinction of heroin use has not been put into general practice, perhaps because of the legal difficulties from having an addict self-administer an illegal substance as part of the treatment. A potential solution is to switch addicts to methadone (or other legal opiate), and then later (after temporary detoxification) use pharmacological extinction with naltrexone or nalmefene to terminate methadone maintenance (Sinclair, 1996). Alcohol drinking also is reinforced by the opioidergic system, probably through the release of endorphins. Consequently, it was proposed that pharmacological extinction with opioid antagonists would be effective in the treatment of alcohol dependence (Sinclair, 1989). Preclinical studies have demonstrated extinction of drinking and lever pressing for ethanol. Key features in the results are little or no effect initially followed by a progressive reduction in the behavior, continued reduction after the end of treatment even when all of the antagonist has been eliminated, and gradual relearning of the behavior if emitted when the antagonist is absent. Recent data from the Finnish factorial double-blind, placebo-controlled trial and from earlier clinical trials have consistently shown that opioid antagonists are effective in treating alcoholism when used with protocols favorable for extinction but not when instructions prevent extinction (e.g., taking naltrexone only during abstinence). Pharmacological extinction is a new form of medical treatment that could yield many medical applications. In theory, it should be effective in treating addiction to all drugs for which the reinforcement is mediated at least in part by the opioid system, and for treating other opioidergically-reinforced compulsive behaviors, such as compulsive gambling, sexual addictions, kleptomania, self-injurious behavior, and bulimia.

A COST-EFFECTIVE PROTOCOL FOR NALTREXONE TREATMENT OF ALCOHOLISM H. Alho and J. D. Sinclair Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki 00101, Finland A two factor double-blind placebo-controlled trial of the safety and effectiveness of naltrexone in 121 DSM-IV alcoholics was conducted with therapy supporting complete abstinence (Supportive) or therapy for coping with slips and aimed more at controlled drinking (Coping). The protocol differed from those used in early naltrexone trials by eliminating several features that were predicted to be unnecessary on the basis of preclinical studies and theoretical considerations: 1. Detoxification. Naltrexone (and placebo) was begun in patients still actively drinking. 2. Detention in an alcohol-free environment. All treatment was done on an outpatient basis. 3. Daily medication. After the first 12 weeks of treatment, medication was taken only when drinking was likely, i.e., on an “as-needed” or “targeted” basis. 4. Duration. The double-blind study lasted 32 weeks (in contrast to 12 weeks in most previous trials), and treatment continued on an open-label basis thereafter. Naltrexone with Coping therapy produced significantly fewer relapses to heavy drinking than either the Coping/Placebo treatment (p=0.008) or the Supportive/Naltrexone treatment (p=0.041). Reported drinking by the Coping/Naltrexone group progressively diverged below that of the other groups, the difference reaching significance (p=0.05) in the last 8 weeks. These results are consistent with those of earlier trials. We also found that Coping/Naltrexone produced significantly fewer side effects during the first week of medication than Supportive/Naltrexone. The results indicate that prior detoxification and detention in an alcohol-free environment are not necessary for effective treatment with naltrexone. Eliminating these in-patient steps sharply reduces the total cost of treatment. The Coping/Naltrexone group averaged 2.1 naltrexone pills per week during the 20 targeted weeks, thus amounting to a 70% reduction in the amount of medication used relative to daily usage. The greatest potential savings arise from this economical extension of the naltrexone treatment, and thus not having to start treatment over again. Follow-ups of previous trials prescribing naltrexone for only 12 weeks have shown that the benefits of naltrexone over placebo gradually disappear after the end of medication; the patients return to alcohol abuse and thus are in need of a duplication of treatment. Targeted naltrexone in our study maintained the naltrexone benefits for an additional 20 weeks at a cost of only about $10 a week.

THE USE OF LONG-ACTING NALTREXONE IN THE TREATMENT OF OPIOID ADDICTION AND ALCOHOLISM David E. Smith, M.D. Haight Ashbury Free Clinics, Inc. Naltrexone (an opioid receptor antagonist) has proven efficacious in the treatment of both opioid addiction and alcoholism. The key problem with the oral preparation is lack of patient compliance. DrugAbuse Sciences (in association with ASAM Members involved in medications research) have been working on a depo form of Naltrexone, that can provide a therapeutic blood level for up to one month, insuring compliance with a treatment plan that includes pharmacotherapy and psychosocial recovery. Such assured compliance will improve treatment outcome, as well as increasing acceptance of addiction treatment by such diverse bodies as medical boards treating addicted anesthesiologists with Naltrexone, to the correctional system in the United States. Eighty percent of the inmates in the U.S. correctional system have substance abuse problems, and only 5% get treatment; in part because of these disciplines questioning treatment because of skepticism over patient compliance. International exchange of information, as to the role of physician and medication development to improve patient compliance with treatment, will be an important topic of discussion for ISAM members.

NALMEFENE IN THE TREATMENT OF HEAVY DRINKERS Rauno Mäkelä*, Antero Kallio**, Sakari Karhuvaara**, from the Finnish Nalmefene Study Group *A-Clinic Foundation, Fredrikinkatu 20 B 18, FIN-00120 Helsinki, Finland ** Oy Contral Pharma Ltd, Kappelitie 6, FIN-02200 Espoo, Finland One hundred and fifty subjects (50 per treatment group) with impaired control over alcohol drinking were enrolled in a randomized parallel group study conducted at six A-Clinics in southern Finland. The subjects were allocated to receive placebo, 10 mg or 40 mg of nalmefene once daily for 16 weeks. The study subjects were allowed to receive general counseling, but no structured psychotherapy or other specific alcoholism treatment, including pharmacotherapy. Alcohol consumption was measured with the Time Line Follow Back Method. Number of heavy drinking days (HDDs; 5 or more drinks/day for male, 4 or more drinks/day for female) was the primary efficacy variable. Eighty % of the subjects completed drug treatment and full drinking data for 16 weeks was collected from 90 % of the subjects, with no differences between the treatment groups. Compared to pre-screening baseline, the monthly number of HDDs decreased during treatment in all groups. The reduction was largest, almost 40 %, in nalmefene 40 mg group and was evident already during the first weeks of treatment. The 10 mg dose appeared effective during the first month in treatment (almost 30 % reduction in HDDs) but the effect was transient, with drinking levels close to screening period during the two last months in the study. In the placebo group, the number of HDDs was approximately 25 % smaller than at baseline. The results for other drinking variables were in concordance with the results on HDDs. The increase in the number of abstinence days was greatest in 40 mg group, where, on average, one additional day without drinking per week was achieved during the study. Mean weekly consumption decreased by nearly 40 % reduction with 40 mg of nalmefene. The most frequently encountered adverse events (AEs) that were apparently more frequent for nalmefene than for placebo included dizziness, nausea, fatigue, insomnia, decreased appetite, constipation and tinnitus. AEs occurred predominantly at the beginning of treatment and subsided within a few days, with the exceptions of fatigue and nausea. AEs led to discontinuation in only few subjects. Neither the AEs nor clinical laboratory tests suggested any specific organ toxicity. It is concluded that nalmefene 40 mg once daily is safe and appears effective in the reduction of heavy alcohol consumption without structured psychosocial treatment. To formally and more unequivocally show a superior efficacy over placebo, a larger sample size would be needed. The efficacy of 10 mg once daily seems to be marginal and transient.

FROM RAPID OPIATE DETOXIFICATION TO RAPID ANTAGONIST INDUCTION: CHANGING CONCEPTS AND TECHNIQUES IN TREATMENT WITH ORAL AND IMPLANTED NALTREXONE. Dr Colin Brewer The Stapleford Centre, 25a Eccleston Street, London SW1W 9NPAs the effectiveness of treatment with properly supervised oral naltrexone (or the increasingly available depot preparations of naltrexone) is more widely recognised, the use of naltrexone in Rapid Opiate Detoxification (ROD) is being seen in a new context. The importance of ROD procedures is not simply that they can improve the speed, humanity and efficiency of detoxification but also that they facilitate the initiation of naltrexone treatment. They should therefore be conceptualised as Rapid Antagonist Induction (RAI). It is now clear that once naltrexone treatment is initiated, the subsequent outcome depends entirely on the programme and patient characteristics and has nothing to do with the method of detoxification. RAI is much more effective and cost-effective than induction following traditional detoxification techniques. It is also clear that naltrexone can be initiated in a variety of settings ranging from the patient's home to an intensive care unit. While deaths associated with ROD remain small in number, and although hardly any have occurred during the acute detoxification process, it looks as if techniques involving relatively light sedation may have less potential for problems than more invasive procedures. This paper will review developments in detoxification methods, long acting naltrexone preparations, treatment outcome and the possibility of using pharmacological antagonists to treat other types of drug dependence.

MEDICAL PRESCRIPTION OF HEROIN TO CHRONIC TREATMENT-RESISTANT HEROIN ADDICTS: A STATE OF THE ART TRIAL IN A SCEPTIC INTERNATIONAL ENVIRONMENT Wim van den Brink, Vincent M.Hendriks, Peter Blanken, Jan M. van Ree Central Committee on the Treatment of Heroin Addicts Utrecht, The Netherlands OBJECTIVE: In the Netherlands approximately 70% of the 25.000 heroin addicts are in contact with addiction treatment services. Of these about 70% are in methadone maintenance treatment. A substantial pro-portion of these latter patients is functioning less than optimal indicated by continued illegal drug use, poor physical and mental health and lacking social integration. The study aims to investigate the effect of the medical prescription of heroin in chronic treatment-resistant heroin addicts recruited from a methadone maintenance program. METHODS: A total of 625 treatment-resistant methadone maintenance patients will participate in a controlled study with a randomized waiting list design with five treatment arms of 125 patients each. A group of 250 patients with predominantly intravenous illegal heroin use will be randomized in two groups: one that will receive 12 months heroin immediately following randomization and another receiving heroin only after 12 months. A second cohort of 375 patients who predominantly inhale their illegal heroin will be randomized in three groups: one that will receive 12 months of heroine immediately following randomization, one that will receive heroin for 6 months only starting 6 months after randomization and finally one group receiving heroin only 12 months after randomization. Primary outcome variables include physical health (MAP-OTI), psychological well being (SCL90), and social integration (ASI) RESULTS: Currently all patients are enrolled in the study. No major medical or public order complications were encountered and treatment and study compliance is high. CONCLUSION: A controlled medical prescription of heroin to chronic treatment-resistant heroin addicts is feasible.

MEDICATIONS DEVELOPMENT FOR THE TREATMENT OF COCAINE DEPENDENCE AT NIDA Ahmed Elkashef, Frank Vocci Clinical/Medical branch, Division of Treatment Research and Development, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA, 20892 Cocaine dependence is a major public health problem associated with serious medical, psychiatric, social, and economic consequences. There are an estimated 2.1 million occasional users in the US and about 3.3 million hard-core users. Although many compounds have been evaluated for the treatment of cocaine dependence, none has been approved by the Food and Drug Administration (FDA) for this indication. The Division of Treatment Research and Development at NIDA is tasked with the challenging goal of finding effective pharmacotherapy for cocaine dependence in conjunction with psychosocial interventions. Current strategies to treat cocaine dependence include: 1) blocking its effects, 2) restoration of central nervous system homeostasis, 3) reducing craving, 4) treating underlying/co morbid conditions that may predispose subpopulations to relapse, 5) reducing stress, to minimize relapse. Currently there are over 50 medications in different phases of development in NIDA’s DTR&D portfolio. These include medications that are already marketed for specific indication (top down approach) and new molecular entities that are being developed specifically for cocaine addiction (bottom up approach). Some examples of medications that are currently in development are monoamines uptake inhibitors (GBR12909, and NS 2359) antidepressants (sertraline, venlafaxine, desipramine), dopamine agonists (cabergoline, amantadine), serotonine antagonists (ondansetron), mood stabilizers/antiepileptic medication (tiagabine, gabapentin), MAO inhibitor (selegiline), COMT inhibitor (tolcapone), and disulfiram. Promising positive signals of efficacy have been shown in early phase II clinical trials for Selegiline (NIDA selegiline study report), and Disulfiram (Carroll et al, 1998; Petrakis et al, 1999; George et al, 2000). Screening pilot trials of 22 medications noted positive signals for reserpine, sertraline and tiagabine (NIDA CREST I & II

reports). Two recent phase II trials of amantadine (Kampman et al, 2000), and desipramine (Kosten, et al in press) showed medication related reduction in cocaine use. Data from phase I safety trial of a cocaine vaccine are also promising. New interest has arisen in biological markers of addiction to identify subtypes of patients who may respond differently to specific medications. This approach may be promising in maximizing medication effect, or predicting relapse. To explore this further, NIDA is implementing specific neuroendocrine, electrophysiological or neuroimaging techniques to explore the subpopulation issue and response to medications. An overview of the NIDA medications development program for cocaine dependence will be presented with the focus on data from selective medications with positive signals.

COMPARISON OF RAPID OPIATE DETOXIFICATION AND NALTREXONE THERAPY WITH METHADONE MAINTENANCE IN THE TREATMENT OF OPIATE DEPENDENCE: A RANDOMISED CONTROLLED TRIAL Saunders JB, Jones R, Lawford BR, Young R, Connor J, Painter E, Dean A and Keen L. (Centre for Drug and Alcohol Studies, Department of Psychiatry, University of Queensland, and the Alcohol and Drug Service, Royal Brisbane Hospital, Queensland Health, Herston, Queensland, Australia) Despite the claims and counterclaims for the benefits of naltrexone treatment and agonist maintenance, there has not been a controlled trial that has directly compared these treatments with patients randomly assigned to one or other condition. We report the findings from such a trial conducted in Brisbane, Australia. We recruited 159 persons with a history of opiate dependence into two parallel controlled trials. The first trial comprised persons who were dependent on heroin, had attempted to detoxify several times previously, without success, and were not on agonist maintenance. They were randomly assigned to (1) rapid opiate detoxification under anaesthetic followed by naltrexone treatment for a year, (2) rapid opiate detoxification under sedation followed by naltrexone, or (3) commencement on methadone maintenance. The second trial comprised patients with a similar history of opiate dependence but who had been on methadone maintenance (for at least one year) and were interested in undergoing detoxification to achieve an abstinence goal. They were randomly assigned to (1) rapid opiate detoxification under anaesthetic followed by naltrexone, or to (2) continued methadone maintenance. Six months after randomisation, those allocated to methadone maintenance had the option of undergoing rapid opiate detoxification and continuing naltrexone treatment. In this presentation we shall report the outcomes of both trials at one month, three months and six months after randomisation. These outcomes will include (1) retention in treatment, (2) compliance with therapy, (3) heroin and other illicit opiate use (total abstinence rates and heroin-free days), (4) other drug use, (5) morbidity, and (6) quality of life scales. Those factors that influenced response to treatment with both naltrexone and with methadone maintenance will be summarised. The findings will be discussed in relation to the current debate about the role of antagonist, abstinence-orientated treatment and agonist maintenance. TRAMADOL ABUSE AND DEPENDENCE: AN ADDICTION MEDICINE PERSPECTIVE Greg Skipper, MD, FASAM Medical Director, Alabama Physician Health Program, Montgomery, Alabama, USA 36104 David Smith, MD, FASAM Medical Director, Haight Ashbury Free Clinic, Past President, American Society of Addiction Medicine, San Francisco, CA, USA Jim Tracy, DMD Vice President, Professional Recovery Program, Betty Ford Center, Ranco Mirage, CA, USA Tramadol, marketed as Ultram®, has been available in the United States as an uncontrolled prescription analgesic since 1995. During the evaluation process prior to approval of Tramadol the Food and Drug Administration, FDA, and its Drug Abuse Advisory Committee, DAAC, considered at length its abuse potential. Tramadol had an acknowledged potential for abuse based upon: (1) reports from Europe of abuse, where Tramadol had been available for years (2) its mode of analgesic action involving the stimulation of opiate mu receptors and (3) a concern regarding the history of other similar opiate analgesics being initially introduced in

the United States as “non-addictive” and later being found to have serious abuse problems requiring subsequent scheduling (e.g. Darvon, Stadol, Talwin, and others). However, despite these concerns, because the abuse potential appeared relatively low, based upon available information at that time, Tramadol was not scheduled, and a “wait and see” policy was adopted. The authors, who represent treatment providers and regulatory agencies, particularly those that work with health professionals, have observed continuing and increasing problems with Tramadol abuse and dependence. Collectively these authors have been involved with over 100 cases of Ultram abuse or dependence. Based on the number of potential subjects involved this represents a far higher incidence than would be expected from the post-marketing surveillance data. The purpose of this paper is to highlight an Addiction Medicine perspective regarding Tramadol and its abuse and dependence potential. We suggest that health professional are the “point men” who demonstrate abuse and dependence with new prescription drugs prior to problems in the general public. This is particularly true when the potentially addictive drug is released as an uncontrolled drug as it easily finds its way into physicians sample shelves and is readily available to them. It is suggested that the American Society of Addiction Medicine consider developing its own committee to assess the addictive potential of drugs.

MEDICATIONS FOR THE TREATMENT OF OPIATE DEPENDENCE: CURRENT THERAPIES AND NEW DEVELOPMENTS Frank Vocci Division of Treatment Research and Development, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA, 20892 Methadone is the primary medication used in the treatment of opiate dependence in the USA. The American Methadone Treatment Association estimates that 179,000 patients are being treated with opiate agonists, primarily methadone. Methadone was identified in the early 1960s by Dole, Nyswander, and Kreek as an orally effective, long acting medication capable of eliminating opiate withdrawal, reducing drug craving, blocking the effect of exogenously administered morphine, and normalizing physiological function. Subsequently, multiple clinical and epidemiological studies have substantiated that methadone can reduce or eliminate illicit opiate use and improve treatment retention. The beneficial effects of methadone on reduction of opiate use and treatment retention are dose-related. These effects result in a fourfold reduction in mortality risk and a seven fold reduction in HIV risk. Levomethadyl Acetate (LAAM) is a methadone congener that is converted to active metabolites, norLAAM and dinor-LAAM. LAAM is administered on a three times per week or an every other day basis. The effects of LAAM are similar to methadone; reductions in opiate use are dose-related. LAAM was approved by the US Food and Drug Administration (FDA) in 1993. Recently, LAAM has been relegated to second line status and a “black box” warning was placed in the LAAM product labeling, warning of QT prolongation and the possibility of toursade de pointes. Naltrexone is an orally active opiate antagonist that is approved for use in detoxified opiate addicted persons. Naltrexone has been demonstrated to reduce relapse and recidivism in formerly opiate dependent probationers. Problems with adherence to naltrexone therapy have resulted in the development of injectable dosage forms of naltrexone. Clinical pharmacology studies have documented significant opiate blockade for at least one month with a depot naltrexone dosage form. These dosage forms are currently in Phase II clinical testing. Buprenorphine is a mu opiate partial agonist that is currently marketed in several countries for the treatment of opiate dependence. Sublingual dosage forms of buprenorphine and buprenorphine/naloxone combination tablets are currently in development in the USA, having reached “approvable” status at the FDA. Evidence for the efficacy in the treatment of opiate dependence will be reviewed. NIDA is sponsoring a multicenter “best practices” trial of buprenorphine/naloxone in non-clinic settings to determine guidelines for patient visitation and buprenorphine/ naloxone prescribing practices. Lofexidine is an alpha 2 adrenergic agonist that is currently under evaluation for its effect to ameliorate the opiate withdrawal syndrome. New medications for the treatment of opiate dependence will be developed from an increased understanding of the neurobiology of opiate addiction. For example, there is evidence that the stress (corticotrophin releasing factor or CRF) system is dysregulated by chronic opiate dependence and may increase the propensity to relapse. CRF antagonists have been evaluated as possible medications to block the stress-induced increase in opiate intake.

CRAVING BY IMAGERY CUE REACTIVITY IN OPIATE DEPENDENCE FOLLOWING DETOXIFICATION Dr. Utpal Goswami, Dr. Debakanta Behera & Dr. Udayan Khastgir Dept. of Psychiatry, Lady Hardinge Medical College, New Delhi, 110 001, India Background: It is quite apparent from our clinical experience that, opioid addiction has a chronic course marked with frequent relapses. Around 70%of patients subsequently relapse to drug use following successful treatment. It has been argued that craving has an influential role in triggering opiate addicts to relapse. Numerous authors have postulated that exposure to various internal and external stimuli associated with drug use (drug cues), may trigger conditioned reactions, which in turn increases the drug taking behaviour in them. Aim: The present study was aimed at exploring the effects of imagery cue exposure on measures of craving and autonomic arousal in opiate addicts following detoxification. Material and methods: Opiate dependent subjects (N=38) following detoxification underwent imagery cue reactivity trials. In this procedure subjects were asked to describe verbally and then imagine their craving experiences. Craving was measured subjectively by using heroin craving questionnaire and autonomic parameters of galvanic skin resistance (GSR), systolic blood pressure (SBP), heart rate (HR), and skin temperature (ST) was taken during drug related cue imagery. Spearman’s r and Wilcoxon signed ranks test where employed in analysis. Multivariate repeated measurement analysis (wilk’s Lambda) was employed wherever appropriate. Results: significant increase in subjective ratings on the measures of craving and significant increase in GSR and non-significant trend towards increase arterial blood pressure and heart rate (R-R interval) and a significant decrease in ST were displayed during drug related cue imagery as compared to neutral cues. Conclusion: The results supports the earlier evidence that cue imagery is a powerful tool in eliciting craving as demonstrated by both subjective and physiological ratings.

THE DIFFERENCES BETWEEN HEROIN ADDICTS WITH AND WITHOUT COMORBIDITY Lovre_i_ M1,3, Dernov_ek MZ2, Tav_ar R2, Lovre_i_ B3 1

Centre for Prevention and Treatment of Illegal Drug Dependence, Koper, Slovenia University Psychiatric Hospital, Ljubljana – Polje, Slovenia 3 Regional Institute of Public Health, Koper, Slovenia 2

The aim of the study was to find out clinical and sociodemographic differences between heroin addicts without and with comorbidity (substance abuse and mental illness - SAMI) who seek help in outpatient methadone clinic. Fortyseven patients (32 males, 15 females) from outpatient methadone program in Koper, Slovenia were included (23 SAMI and 24 addicts without comorbidity (AWC)). AbSo questionnaire was used. Diagnoses were made according to ICD – 10 criteria. The most frequent comorbidity among SAMI patients was depression (n=17), while 5 patients had anxiety disorders and one patient had undifferentiated psychosis. Characteristics of the whole group were as follows: mean age 25.2 years, age at first contact with an illegal drug 18.5 years, age at continuos abuse 20.0 years and length of drug dependence 50.8 months. Most patients (n=34) were dependent only on heroin while 13 patients had dependency on several drugs. Mean dose of methadone in SAMI patients was 63.4 mg and in AWC 43.7 mg daily (p=0.10). Physical related problems were similary distributed in both groups. Only 15% of patients had insight. The following differnces between groups (SAMI: AWC) were found: anxiety (69.6% vs. 16.7%), affective symptoms (87.0% vs. 12.5%), sleeping problems (87.0% vs. 20.8%), inapetence (43.5% vs 8.3%), abuse of non – prescibed hypnotics before inclusion in treatment programme (56.5% vs. 29.2%), pre-inclusion amphetamine abuse (30.4% vs. 8.3%). Prior to inclusion in programme all SAMI patients used heroin more than once daily. Drugs as automedication used 39.1% of SAMI patients. Due to multiple problems, SAMI patients need intensive treatment approach directed towards managing their special needs.

SMOKING AND ALCOHOL USE IN A GROUP OF SUSPENDED SCHOOL STUDENTS. Lampropoulos B, Paediatrician, Department of Adolescent Medicine, The Children’s Hospital at Westmead and Westmead Hospitals, Sydney, Australia, Et al Background: Experimentation with smoking and alcohol is common amongst adolescents. Of this group some may engage in a more serious level of smoking and alcohol use. It is important to have a means of identifying this higher risk group so as to plan appropriate intervention. The Department of Education and Training in NSW Australia has a system for school suspension and expulsion for those students whose behaviour has reached unacceptable limits. These students may have multidimensional problems putting them in a higher risk category for substance use. We are exploring the health behaviours of these students. In this case we are looking at self report of alcohol use and smoking. Aims: To explore whether suspended school students presenting to our medical service have smoking and alcohol use rates which are higher than their peers. Methods: Those teenagers (aged over 14 years) referred to the Outpatient Department of Adolescent Medicine, Westmead Hospital were asked whether they had ever been suspended from school. Those who had were asked to complete the Health Behaviours of School Students questionnaire. This study looks at the responses to the smoking and alcohol use questions. These results were compared with the most recent statewide data from the 1996 NSW Health Behaviours of School Students survey. Results: The findings from this survey to date indicate that these suspended students have higher rates of smoking and drinking compared with the NSW sample. The suspended students were more than 5 times more likely to smoke more than 20 cigarettes per week as compared with the NSW sample. Discussion and Recommendations: The higher rates of smoking and alcohol use amongst our sample would suggest that suspended students are at higher risk of substance use. Strategies for intervention for this high risk group need to be further explored.

ALCOHOL AND AGGRESSION Belluscio A., Mauri B., Berretta F., D’Arista F., Fiorentino D., Freda A. Giaccio S., Ceccanti M. Alcohol Unit, Department of Clinical Medicine, University "La Sapienza"- Rome. Relationships (if any) between alcohol and aggression were investigated in this study. The subjects on study were 56, all males, age between 25 and 50 y., income 10,000-18,000 US dollars; education: high school. 20 subjects were alcoholics, 20 were social drinkers, according to WHO classification, 16 were abstinent. The aggressive behavior was analyzed into two components: direction of aggressiveness and kind of reaction. Rosenzweig P-F Study test was employed. For the direction of aggressiveness, extra-punitive (E) aggressiveness level was significantly (P