Addictions: Sharing InternationalResponsibilities in a Changing World

Programme Abstracts

2001 ISAM Meeting

Under the auspices of

Azienda Ospedaliera “Ospedali Riuniti di Trieste”Friuli-Venezia Giulia RegionMunicipality of TriesteTrieste Association of Medical Doctors and SurgeonsUniversity 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 PoldrugoUniversity of TriesteSchool of Medicine Community Health Agency, TriesteDepartments of Mental Health and AddictionsOffice for Research and Innovative Projects on Alcohol, Other Addictions and Mental HealthPiazzale Luigi Canestrini, 4 – 34126 Trieste (Italy)Tel. Italy + 040 350010 or Italy + 040 571077Fax Italy + 040 350010 or Italy + 040 370950e-mail: polydrug@univ.trieste.it

Organizing Secretariat

the office Via San Nicolo 14 – 34121 Trieste (Italy)Tel. Italy + 040 368 343 – Fax Italy + 040 368 808e-mail: isam@theoffice.itwebsite: www.theoffice.it/ISAM

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ISAM Board of Directors

PresidentDr. Nady el-Guebaly Canada

Vice PresidentsDr. Jorge Gleser IsraelDr. Flavio Poldrugo ItalyDr. G. Douglas Talbott USA

TreasurerDr. Joaquim Margalho Carrilho Portugal

Dr. Saul Alvarado PanamaDr. Gudbjorn Bjornsson IcelandDr. Colin Brewer UKProf. Cai Zhi-Ji ChinaDr. Maria Delgado-Pich ArgentinaDr. Joao Carlos Dias da Silva BrazilDr. Marc Galanter USAProf. Michael Krausz GermanyDr. Peter E. Mezciems CanadaDr. Davinder Mohan IndiaDr. Wayne Moran Hong KongDr. David Smith USA

32001 ISAM Meeting

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4

WEDNESDAY 12 SEPTEMBER 20019.00 – 13.00 RReeggiissttrraattiioonn

14.00 – 18.00

09.00 – 13.00 RRoooomm OOcceeaanniiaa (A+B)IISSAAMM BBOOAARRDD MMeeeettiinngg

14.30-16.00 RRoooomm OOcceeaanniiaa (A+B)PPUUBBLLIICC HHEEAALLTTHH OORRGGAANNIIZZAATTIIOONN AANNDD IINNTTEERRNNAATTIIOONNAALL AASSPPEECCTTSS ((PPAARRTT II))

CChhaaiirrmmaann:: GG.. DDeellll’’AAccqquuaa (Trieste – Italy)

NN.. eell--GGuueebbaallyy (Calgary, Alberta – Canada)Addiction Medicine: towars a global perspective

DD.. VVeerreeeenn (Washington, DC – USA)Substance Abuse Policy: a science-based approach

GG.. BBeennaaggiiaannoo (Rome – Italy)The Italian approach to addictions

GG.. DDeellll''AAccqquuaa (Trieste – Italy)Mental health, drugs: a community approach

GG.. NNiiccoolleettttii (Rome – Italy)Public health organization for addictions

16.00-17.30 RRoooomm OOcceeaanniiaa (A+B)GGLLOOBBAALL CCHHAARRTTEERR

CChhaaiirrmmaann:: FF.. PPoollddrruuggoo (Trieste – Italy)

The Geneva partnership on alcohol – a tool for alcohol policy formulationJJ.. OOrrlleeyy (Washington, DC – USA), SS.. NNaacclleerriioo (Miami, FL – USA), SS.. GGeennoovveessee (Rome – Italy)

17.30 – 19.00 RRoooomm OOcceeaanniiaa (A+B)IISSAAMM BBOOAARRDD MMeeeettiinngg

PROG

RAMM

E

52001 ISAM Meeting

THURSDAY 13 SEPTEMBER 2001 08.00 – 10.00 IISSAAMM CCoommmmiitttteeeess MMeeeettiinnggss

10.00 - 11.25 RRoooomm OOcceeaanniiaa (A+B)PPUUBBLLIICC HHEEAALLTTHH OORRGGAANNIIZZAATTIIOONN AANNDD IINNTTEERRNNAATTIIOONNAALL AASSPPEECCTTSS ((PPAARRTT IIII))

CChhaaiirrmmaann:: NN.. eell--GGuueebbaallyy (Calgary, Alberta – Canada)

Australian moves towards formal recognition of addiction medicine as a specialtyJ. Bell, PP..SS.. HHaabbeerr, K. Curry (Sydney, NSW – Australia)

Substance abuse in Israel: patterns, attitudes, policies and treatment strategiesJJ.. GGlleesseerr, D. Elisha, M. Reiter (Jerusalem - Israel)

Needs assessment in drug education: the view of staff in the Iranian schoolTT.. DDoooossttgghhaarriinn (Teheran - Iran)

Belgrade multisystemic model in alcoholism: 40 years’ evolution of clinical experience and research projectsBB.. GGaacciicc (Belgrade – Yugoslavia)

The war on drugs and criminal justice system YY.. EE.. RRaazzvvooddoovvsskkyy (Grodno - Belarus)

Dependencies, the need for an integrated, intersectorial approachAA.. BBeerrlliinn (Paris – France), L. Chabot (Montreal, Quebec – Canada)

11.25 – 11.35 CCooffffeeee BBrreeaakk

11:35-13:00 RRoooomm OOcceeaanniiaa (A+B)IIMMPPAAIIRREEDD HHEEAALLTTHH PPRROOFFEESSSSIIOONNAALLSS AANNDD TTHHEE RROOLLEE OOFF TTHHEE GGEENNEERRAALL PPRRAACCTTIITTIIOONNEERRSS ((WWIITTHH TTHHEE PPLLIINNIIUUSS MMAAIIOORR SSOOCCIIEETTYY CCOONNTTRRIIBBUUTTIIOONN))

CChhaaiirrmmaann:: FF.. PPoollddrruuggoo ((TTrriieessttee –– IIttaallyy))

JJ.. BBaarrrriiaass (Porto - Portugal)Some aspects on alcohol consumption in an environmental perspective

NN.. eell--GGuueebbaallyy (Calgary, Alberta – Canada)Physician education in substance-related disorders: challenges and opportunities

BB.. MMoonnhheeiitt, L. McCall, L. Waters (Melbourne, VIC – Australia)An Interactive drug and alcohol training course for general pactitioners

OO.. LLeesscchh (Wien – Austria)Barriers to the General Practitioners management of alcohol-related problems: coherence of alcohol treatment networks in Austria

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DD.. HH.. AAnnggrreess, K. Bettinardi-Angres (Drowners Grove, IL - USA)Diagnosis and treatment of chemically dependent physicians

J. D. Beasley, MM.. DDeellggaaddoo--PPiicchh (Cordoba – Argentina)Diagnosing and managing chemical dependency. Addictionend.com.project

G. Douglas Talbott (Atlanta, GA –USA), PP.. EE.. MMeezzcciieemmss (Guelph, ON – Canada)Physician impairment – alcohol and drug addiction – a global problem

11:35-13:00 RRoooomm OOcceeaanniiaa (C)SSYYMMPPOOSSIIUUMM OONN TTHHEE CCOOUURRSSEE OOFF AADDOOLLEESSCCEENNTT DDRRUUGG AANNDD AALLCCOOHHOOLL AABBUUSSEE:: TTRRAAJJEECCTTOORRIIEESS OOFF UUSSEE AANNDD PPAATTTTEERRNNSS OOFF CCHHAANNGGEE

CChhaaiirrmmaann:: HH.. BB.. WWaallddrroonn (Albuquerque, NM – USA)

Multiple pathways to adolescent drug use and abuse: differential implications for preventionHH.. HHooppss, B. Davis, F. Lee (Eugene, OR – USA)

Latent classes of familial alcoholism and depression: relations to neuropsychological functioning in late adolescence and adulthoodMM.. EE.. BBaatteess, V. L. Johnson, S. Buyske (New Brunswick, NJ – USA)

Immediate and longer-term treatment oucomes for adolescent drug and alcohol abuseHH.. BB.. WWaallddrroonn, 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 adolescentsCC..WW.. TTuurrnneerr, H. B. Waldron, J. L. Brody, T. R. Peterson, T. Ozechowsky (Albuquerque, NM – USA)

Course of adolescent alcohol use disorders across 3 year after treatmentCC.. SS.. MMaarrttiinn, T. Chung (Pittsburgh, PA – USA)

11:35-13:00 RRoooomm VVuullccaanniiaa 22WWOORRKKSSHHOOPP OONN WWOORRKKIINNGG WWIITTHH DDRRUUGG AAFFFFEECCTTEEDD TTEEEENNAAGGEERRSS -- KKEEYY SSTTRRAATTEEGGIIEESS FFOORR IINNTTEERRVVEENNTTIIOONN

CChhaaiirrppeerrssoonnss:: BB.. LLaammpprrooppoouullooss,, PP.. SS.. HHaabbeerr (Sydney, NSW – Australia)

11.35-13.00 RRoooomm MMaarrccoonnii ((22nndd fflloooorr))WWOORRKKSSHHOOPP OONN VVAALLIIDDIITTYY OOFF UU..SS.. PPLLAACCEEMMEENNTT CCRRIITTEERRIIAA FFOORR DDRRUUGG AABBUUSSEE TTRREEAATTMMEENNTT

11:35-12.15 EE.. SShhaarroonn,, D.R. Gastfriend (Boston, MA – USA)“Rationale, methodology and validity of replication studies using the ASAM Criteria"

72001 ISAM Meeting

12.15-12.40 SS.. PPiirraarrdd, 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 DDiissccuussssiioonn

13.00 – 13.30 PPOOSSTTEERR SSEESSSSIIOONN ((mmaaiinn hhaallll))CChhaaiirrmmeenn:: MM.. GGaallaanntteerr (New York, NY - USA), JJ.. GGlleesseerr (Jerusalem, Israel)

Craving by imagery cue reactivity in opiate dependence following detoxificationUU.. GGoosswwaammii, D. Behera, U. Khastgir (New Delhi – India)

The differences between heroin addicts with and without comorbidityMM.. LLoovvrreeččiičč (Koper – Slovenia), M. Z. Dernovšek, R. Tavčar (Ljubljana-Polje – Slovenia), B. Lovrečič (Koper – Slovenia)

Smoking and alcohol use in a group of suspended school studentsBB.. LLaammpprrooppoouullooss, C. Clarke, A. Bauman, M. Kohn, K. Williams, S. Roman (Sydney, NSW – Australia)

Alcohol and aggressionAA.. BBeelllluusscciioo, 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 subjectsMM.. CCeeccccaannttii, 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 reportM. Ceccanti, FF.. DD’’AArriissttaa, F. Lucidi, F. Berretta, S. Giaccio, B. Mauri, D. Fiorentino, M. L. Attilia, G. Balducci (Rome – Italy)

Characteristic of drug-abusers in the early treatmentJJ.. GGaalliićć, S. Jelić, S. Šalamon, K. Butorac, L. Sabljić, A. Rogar, A. S. Hotujac (Zagreb – Croatia)

Psychosocial issues in female opioid dependence – an Indian scenarioUU.. KKhhaassttggiirr, U. Goswami, U. Kumar, D. Behera (New Delhi – India)

Mode of previous heroin use and methadone dose in maintenanceLL.. OOkkhhrruulliiccaa, M. Rakova, D. Klempova (Bratislava – Slovak Republic)

Alcohol-related neuromuscular damage in young patientsGG.. TTaammaarroo, R. Simeone, S. Renier, G. B. Modonutti (Trieste – Italy)

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14:30-16:30 RRoooomm OOcceeaanniiaa (A+B)CCAAMMPPRRAALL SSYYMMPPOOSSIIUUMMPPRROOGGRREESSSS IINN AALLCCOOHHOOLLIISSMM MMAANNAAGGEEMMEENNTT AACCAAMMPPRROOSSAATTEE FFIIRRSSTT LLIINNEE IINN RREESSEEAARRCCHH AANNDD TTRREEAATTMMEENNTT CChhaaiirrmmeenn:: PP.. DDee WWiittttee (Louvain - Belgium), KK.. MMaannnn (Mannheim,- Germany)

MM.. PPrreennddeerrggaasstt (Lexington, KY – USA)Acamprosate: modulator of NMDA receptor

RR.. LLuutthhrriinnggeerr (Rouffach – France)Acamprosate effects measured by cerebral mapping

BB.. MMaassoonn (Miami, FL – USA)Effects of acamprosate on alcohool and drug use in the American clinical study

II.. PPeellcc (Brussels – Belgium)Results of the Capriso study

FF.. PPoollddrruuggoo (Trieste – Italy), P. Lehert (Mons – Belgium)Acamprosate and quality of life

AA.. PPaallmmeerr (Basel – Switzerland)Overview of acamprosate cost effectiveness studies

16.30-16.45 CCooffffeeee BBrreeaakk

16:45-18:15 RRoooomm OOcceeaanniiaa (A+B)SSUUBBJJEECCTTSS WWIITTHH DDUUAALL DDIIAAGGNNOOSSIISSCChhaaiirrmmaann:: BB.. SSppaazzzzaappaann (Gorizia – Italy)

Psychiatric comorbidity of substance dependance - TT.. MM.. SS..AA.. GGaawwaadd (Cairo - Egypt)

The implementation of the Joint Services Development Unit (JSDU) for the management ofpsychiatric and substance using conditions. The development of an integrated model of cli-nical care and professional development in Western AustraliaSS.. RRyyaann (Claremont, WA – Australia)

Pain reduction with opioid elimination - EE.. CCoovviinnggttoonn (Cleveland, OH – USA)

Organ transplantation – the role of addiction medicine - MM.. MM.. KKoottzz (Cleveland, OH – USA)

Addiction comorbidity in pathological gambling - BB.. SSppaazzzzaappaann, P. Lenassi (Gorizia, Italy)

Pathological gambling: a stepped care model of interventionsNN.. eell--GGuueebbaallyy (Calgary, Alberta – Canada)

20.00 GGaallaa DDiinnnneerr –– CCaafffféé ddeeggllii SSppeecccchhii((PPiiaazzzzaa UUnniittaa dd’’IIttaalliiaa))

92001 ISAM Meeting

FRIDAY 14 SEPTEMBER 200108.00 – 09.00 RRoooomm OOcceeaanniiaa (A+B)

BBuussiinneessss MMeeeettiinngg

09.00 – 10.30 RRoooomm OOcceeaanniiaa (A+B)AAEEPP--IISSAAMM SSYYMMPPOOSSIIUUMM.. AALLCCOOHHOOLL--RREELLAATTEEDD PPRROOBBLLEEMMSS:: AA CCHHAALLLLEENNGGEE FFOORR TTHHEE IINNSSUURRAANNCCEE CCOOMMPPAANNIIEESS

CChhaaiirrmmaann:: KK.. MMaannnn (Mannheim - Germany)

DD.. EEsscchheerr (Milan – Italy)The insurers’ initiative to reduce alcohol abuse

JJ.. AAlllleenn (Bethesda, MA – USA)The role of biomarkers of heavy drinking in health care management

AA.. PPaallmmeerr (Basel – Switzerland)Cost and benefit of intervention for alcohol-related problems

BB.. BBooiisssseett (Paris – France)Medical consequences of alcohol: a treatment program devised by an insurance company

10.30-12.00 RRoooomm OOcceeaanniiaa (A+B)TTRREEAATTMMEENNTT OOFF AADDDDIICCTTIIOONNSS ((PPSSYYCCHHOOLLOOGGIICCAALL AANNDD EEPPIIDDEEMMIIOOLLOOGGIICCAALL IISSSSUUEESS))

CChhaaiirrppeerrssoonn:: MM.. CC.. DDeellggaaddoo--PPiicchh (Cordoba – Argentina)

Women and the twelve stepsMM.. CC.. DDeellggaaddoo--PPiicchh, C. Bergoglio, D. Gigena (Cordoba – Argentina)

Alcoholism and drug problems in industryDD.. EE.. SSmmiitthh (San Francisco, CA – USA)

Incidence estimates of substance use disorders in a cohort studyDD.. MMoohhaann, H. Sethi, A. Chopra (New Dehli – India)

The substance abuse subtle screening inventory (SASSI) use in research of addicted familiesMM.. RRuuss--MMaakkoovveecc, 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 alcoholismPP.. LLeehheerrtt (Mons – Belgium), F. Poldrugo (Trieste – Italy)

Imagery cue reactivity in opiate addicts: individual variables and differential response UU.. GGoosswwaammii, D. Behera, U. Khastgir (New Delhi – India)

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10:30-11:15 RRoooomm VVuullccaanniiaa 22DDEETTEENNTTIIOONN VVEERRSSUUSS AALLTTEERRNNAATTIIVVEE MMEEAASSUURREESS

CChhaaiirrppeerrssoonn:: AA.. BBaaeezz MMooqquueettee (Trieste – Italy)

Law enforcement officers survey on drug control policyYY.. RRaazzvvooddoovvsskkyy (Grodno - Belarus)

Public attitudes towards drug control policies YY.. RRaazzvvooddoovvsskkyy (Grodno - Belarus)

Drug addiction and jail. The role of the network between community servicesAlternative measures to detention AA.. BBaaeezz MMooqquueettee, G. Rossi (Trieste, Italy)

11:15-12:00 RRoooomm VVuullccaanniiaa 22SSMMOOKKIINNGG

CChhaaiirrmmaann:: AA.. MMuunnoozz (Las Condes, Santiago – Chile)

The predictive determinants of smoking cessation programs in EgyptMM.. HHaasshheemm BBaahhrrii, A. S. Al-Akabawi, M. SH. Omar, A. B. Farghaly (Cairo – Egypt)

Addressing nicotine dependence in addiction treatmentM.. CC.. DDeellggaaddoo--PPiicchh, 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 surveyGG.. LL.. MMoonnttiinnaa, F. Pivotti, C. Poropat, E. Cariello, P. Todaro, M. L. Onor, F. Poldrugo (Trieste – Italy)

10:30-12:00 RRoooomm OOcceeaanniiaa (C)TTRREEAATTMMEENNTT OOFF AADDDDIICCTTIIOONNSS ((MMEEDDIICCAALL IISSSSUUEESS))

CChhaaiirrmmaann:: AA.. KKaasstteelliičč (Ljubljana - SLOVENIA)

Current trends in addiction epidemiology, research & treatmentDD.. EE.. SSmmiitthh (San Francisco, CA – USA)

The direct ethanol metabolite ethyl clucuronide is a specific marker of recent alcohol consumptionFF.. WWuurrsstt (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)

112001 ISAM Meeting

The introduction of Acudetox into the Italian public drug and alcohol treatment servicesDD.. BBllooww, G. Picozzi, G. Rotolo (Rome – Italy)

Heroin use during pregnancy: the impact of prenatal care and different therapeutic regimens on perinatal outcomesGG.. SSaallaammiinnaa, C. Tibaldi, C. Pasqualini (Turin – Italy)

Ecstasy-induced neurotoxicityAA.. OO.. BBrruunndduussiinnoo (Pavia – Italy)

12:00-13:30 RRoooomm OOcceeaanniiaa (A+B)TTRREEAATTMMEENNTT OOFF AADDDDIICCTTIIOONNSS ((PPHHAARRMMAACCOOLLOOGGIICCAALL IISSSSUUEESS))CChhaaiirrmmaann:: FF.. VVooccccii (Bethesda, MA – USA)

From rapid opiate detoxification to rapid antagonist induction: changing concepts and techniques in treatment with oral and implanted NaltrexoneCC.. BBrreewweerr (London – UK)

Medical prescription of heroin to chronic treatment-resistant heroin addicts: a state of the art trial in a sceptic international environmentWW.. vvaann ddeenn BBrriinnkk, V. M. Hendriks, P. Blanken, J. M. van Ree (Utrecht – The Netherlands)

Medications development for the treatment of cocaine dependence at NIDAAA.. EEllkkaasshheeff, 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 trialJJ.. BB.. SSaauunnddeerrss, 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 perspectiveGG.. SSkkiippppeerr (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 developmentsFF.. VVooccccii (Bethesda, MA – USA)

12

12:00-13:30 RRoooomm OOcceeaanniiaa (C)RREECCEENNTT DDEEVVEELLOOPPMMEENNTT IINN NNAALLTTRREEXXOONNEE TTRREEAATTMMEENNTT

CChhaaiirrmmaann:: DD.. EE.. SSmmiitthh (San Fiancisco, CA – USA)

Pharmacological extinction of alcohol abuse and other addictionsDD.. SSiinnccllaaiirr, H. Alho (Helsinki – Finland)

A cost-effective protocol for Naltrexone treatment of alcoholismHH.. AAllhhoo, J. D. Sinclair (Helsinki – Finland)

The use of long-acting Naltredxone in the treatment of opioid addiction and alcoholismDD.. EE.. SSmmiitthh (San Francisco, CA – USA)

Nalmefene in the treatment of heavy drinkersRR.. MMääkkeellää (Helsinki – Finland), A. Kallio, S. Karhuvaara (Espoo - Finland)

13:30-14:00 RRoooomm OOcceeaanniiaa (A+B)CCoonncclluussiioonnss

132001 ISAM Meeting

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

LLAANNGGUUAAGGEEThe conference language is English.

IINNSSUURRAANNCCEParticipants are advised to purchase comprehensive travel insurance coverage. The OrganizingCommittee and/or the office shall not be held liable for loss or damage to property belonging toconference participants, or for personal injuries sustained during or as a result of the conferen-ce or during the tours arranged by the office.

RREEGGIISSTTRRAATTIIOONN FFEEEESS ((AAfftteerr 3311 MMaayy 22000011))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 (namebadge, 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 13September, the invitation to the Gala Dinner (Thursday evening) and the visit of Aquileia andGrado (Friday 14 September).

TTOOUURRSSThursday 13 September 2001 (9.00 – 13.00)Guided tour of Trieste including the visit of the Miramare Castle. Departure at 9.00 from the mainentrance 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 allover 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, anumber 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 ondrugs” 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 healthprofessionals, 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 addictionsand specified that this objective is to be achieved through the integration of socila and health policies andinterventions.Italy has fully endorsed this approach which calls for a redefinition of principles and models of socialorganization and structures, in order to offer better services to individuals, bearing in mind global personalneeds, 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 requirementthat also take into consideration non medical aspects, such as social class, lifestyle, religion, interpersonalrelations, 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 useand 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 avariety of measures including decriminalization of personal drug use, while trying to protect them from thepressure brought by the criminal activities of dealers.In this way Italy wishes to distinguish itself from those countries where use and trafficking are basically treatedin the same manner; the underlying philosophy is that an illegal drug abuser is a sick individual and notnecessarily 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 todo so by treating, rather than prosecuting the individual abuser.

THE GENEVA PARTNERSHIP ON ALCOHOL – A TOOL FOR ALCOHOL POLICYFORMULATION

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 forthe development of alcohol policies, at the global, national and local level. Developed as a collaborative effortby international experts from public health, research, industry, government, and others with a stake in alcoholpolicy, 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 itscontent and the particular areas on which it focuses. Discussion will also focus on ways in which the documentaddresses the reduction of the risk of alcohol abuse and health damage and the need for policies covering suchissues. Some of the areas included in the document are: a) controlling access to alcohol, b) regulatingadvertising, c) ensuring that information and education is available widely on the effects of alcohol onbehaviour, d) enforcing laws and regulations on such matters as drinking and driving, e) encouraging people todrink 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 aspossible 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 ofsociety as a whole. It looks at the role of the state, as well as that of private enterprise in encouraging a safedrinking environment; it makes proposals to ensure that beverage alcohol is consumed and sold responsibly; itmakes clear that consumers, producers and sellers alike have a stake in reducing the abuse of alcohol andproblems potentially associated with it.

This document was developed as a co-operative process involving the public health and scientificcommunities, the beverage alcohol industry, governments and the non-governmental sector. Co-operationbetween these same players is required in the development of alcohol policies and the Charter provides anappropriate building block in the process.

AUSTRALIAN MOVES TOWARDS FORMAL RECOGNITION OF ADDICTION MEDICINE AS ASPECIALTY

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, AustraliaDirector, 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 toattract and retain practitioners to work in the field and receive specialist rates of remuneration (3) to contributeto undergraduate and post-graduate generalist medical education. Australian specialists receive their credentialsthrough medical Colleges but the likely number of specialists in Addiction Medicine is insufficient to support anindependent College. Negotiations are being held to enable the training and certification to occur within theRoyal Australasian College of Physicians. A series of working groups has identified core competencies inaddiction medicine, and a training syllabus is being developed. Core training experience will include ambulatoryand residential detoxification, general hospital consultation-liaison, methadone and other pharmacotherapies,hospital-based internal medicine (notably gastroenterology and neurology), public health aspects of drug andalcohol use and psychiatry. Other recommended training experience should include pain medicine, clinicalpharmacology, emergency medicine, and clinical research. As with other specialty training (such as psychiatryand internal medicine) the total duration of training will be 6 years. Assessment will be continuous, with writtenand 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, andrecruitment to training posts should begin during 2002. The skills of selected established practitioners will berecognised by a "grandfather clause". A program of continuing education is under concurrent development.

SUBSTANCE ABUSE IN ISRAEL: PATTERNS, ATTITUDES, POLICIES AND TREATMENTSTRATEGIES

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 understandingtrends and patterns of substance abuse problem in the country throughout its brief history. An attempt will bemade to identify the patterns of substance abuse in each period, the prevailing community attitudes toward theproblem, 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 socialchanges as well as a rapid cultural transformation. These events may be attributed primarily to the fact thatIsrael has absorbed millions of immigrants during its turbulent history and that its population grew ten foldfrom 600,000 in its first year of statehood (1948) to 6 million in 2000. The absorption of millions of Jewishimmigrants has been mostly quite successful. Yet, many of them experienced cultural shock as well as serioussocial and economic problems due to relocation. The result was the emergence of distressed neighborhoodscharacterized by economic stagnation and social ills typically associated with anomie and disintegration. Thesecommunities 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 significantdevelopments in the political and sociological sphere. The Israeli society as a whole moved away from thepioneering and socialist spirit toward a more liberal, permissive and materialistic society. The influx ofAmerican and European young volunteers introduced many Israelis to the drug culture while the opening ofborders in 1967 and after the Lebanon war in 1982, made drugs more accessible as smugglers had easier timeimporting 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 increasingsubstantially recreational use of alcoholic beverages and illicit drugs including hallucinogens imported from theUSA and Western Europe .New waves of immigrants reached Israel again in the late seventies and the nineties, mostly from the formerSoviet Union. Mostly they were productive and well adjusted individuals but some came to Israel with problemssuch 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 drug-subculture of Israeli youngsters creating a strain on the substance abuse treatment centers necessitating anexpansion 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) showsthe increasing concern for the problem of addiction. Most substance abusers who seek treatment today areadmitted promptly or within one month of their request, nevertheless attention must be given to sudden politicaland 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 policysciences of Bath University, UK

This paper examines staffs’ views of drug education in Iranian schools as indicated by the findings of a surveyof schools at the national level.Staffs in schools overwhelmingly expressed the need for drug education. However, they were divided over theneed for beginning of teaching pupils specifically about illegal drugs. Respondents were generally optimisticabout the potential positive impact of drug education on young people’s drug use. However, the majority ofthem stated that school should not be seen as the sole source of drug education for young people. Thecommunity, 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 wantedgood in-service support, including training and support for schools in the planing and delivery of drugeducation. In additions they wanted some publications that could be easily understood and used in theclassroom.It appeared that a unique drug education at the national curriculum should not be considered. Based on thedifferent areas of the country and the frequency of the drug problem in each area different kind of drugeducation 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 ofcontinuous clinical and research work in alcoholism in which the author participated constantly. Evolution onBelgrade Multisystemic Model in Alcoholism is described chronologically – as the interrelationship betweenclinic 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 bythe author in 1973 and constantly developed up to now, is illustrated by schematic diagram of its developmentduring past four decades.

In conclusion, the most important results are summerized and discussed. Belgrade Model combinesmultisystemic 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 characterof today’s policy reflects a punitive approach to control. According to legislation use of drug is not a crime, atthe same time possession of it is illegal and presuppose punishment of imprisonment for up to 3 years. 70 percent of those convicted for drug-related crimes were imprisonment according this article of the law. This factonce more proves that repressive measures are taken against drug addicts, but not against drug dealers. Theconfusion has not been resolved yet. What is the aim of the repressive policy towards drug addicts? To isolatethem from the society? To punish them for their disease? To frighten potential drug users? Obviously, in such away the state admits its inconsistency in helping the sick people. In our opinion, while approaching drug-relatedcrimes, it is necessary to differentiate between possession of drug for personal use, and connected withnarcobusiness on the one hand and committed by drug addicts on the other. Sharp growth in the number of drugaddicts in recent years, on the one hand and growth in the activity of law enforcement institutions on the otherhas lead to such a situation in which criminal justice system has to deal with still growing number of drugaddicts. In this situation the role of it in solving drug-related problems becomes very important. As our datemanifest imprisonment of drug addicts to increase of their criminality and isolation from the society. Most ofdrug addicts after released from prison continue taking drugs. Therefore, in order to break the cycle of drugabuse 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 non-violent drug law offenders. Sending convicted drug addicts to special treatment establishments of prison typecan be considered as an alternative to imprisonment. Such establishments exist in the system of the Ministry ofInternal affairs and their purpose is to provide compulsory treatment for drug addicts. Another alternative is tosend convicted drug addicts in special labor establishment of open type, where they are supervised by criminaljustice 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 ForumMontreal 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 oftendevelopment. However these issues are handled in international fora most frequently through vertical sectoralapproaches. 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 23-27September 2002 is attempting such an approach.

The Forum will consider the human, social and economic impact of substance abuse and other dependencies atall levels of society. It will cover both illicit drugs (including synthetic ones), and licit drugs (alcohol andtobacco), as well as compulsive gambling. It is aimed at providing a non-confrontational platform forinteractions between approaches, disciplines, domains of activities and individuals (professional from varioussectors – researchers, educators, clinicians, government health workers – public policy officials and decisionmakers at all levels of society, voluntary agencies staff, associations leaders, and people everywhere concernedby 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, increasepublic awareness towards dependencies issues leading to increased priority at policy/political level. It will alsofacilitate 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 ofdrugs and dependencies, by stressing an integrated approach and by devoting special attention to youth, theworld 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 theparticipants will be solicited. ISAM has agreed to be one of the main co-sponsors of this event and to takecharge of the organization of a session devoted to the medical treatment of substance abuse.

PHYSICIAN EDUCATION IN SUBSTANCE-RELATED DISORDERS: CHALLENGES ANDOPPORTUNITIES

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 acquisitionof knowledge, a desired attitudinal shift (often the most difficult to achieve) and behavioral skills. Both passiveand interactive learning reinforced at regular intervals and supported by national and international interestgroups appear to offer the best promise for sustaining positive behavioral change by physicians.

Drawn from the Canadian experience, programs aimed at improving physicianawareness about alcohol will be briefly described. A new educational initiative is built upon society's wish tomake 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 prerequisitefor physicians volunteering to manage individuals with opiate addiction.

Resulting opportunities and limitations will conclude the presentation.

AN INTERACTIVE DRUG AND ALCOHOL TRAINING COURSE FOR GENERALPRACTITIONERS

*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 oftheir primary care work. However, the community, government and patients see doctors as being the mainprovider of credible advice and medical treatment for addiction. The introduction of new pharmacotherapiessuch as naltrexone, buprenorphine and acamprosate in Australia over the past three years have made GPs awareof 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 andalcohol course. It is run by and is designed for GPs and utilises case discussions, an interactive format as well asbackground 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 ofthe 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 utiliseteleconferencing facilities to link different GP groups. Two large TV screens are utilised at each learning site toprovide instant interaction between all participants and with the lecturer. After initial hesitation and technicalproblems, participants now feel comfortable with this medium.

Evaluation of the course shows great satisfaction with the content and format. Follow up of participants revealedincreased confidence and a reported increase in drug and alcohol work performed by the GPs.

BARRIERS TO THE GENERAL PRACTITIONERS MANAGMENT OF ALCOHOL-RELATEDPROBLEMS: COHERENCE OF ALCOHOL TREATMENT NETWORKS IN AUSTRIA

OM Lesch1,2, H Walter1, I Hertling1, H Lind1, K Ramskogler1

1Department 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 anetwork of different treatment facilities is now available all over Austria. At hand of the facilities of API , upperAustria and Burgenland the treatment network for prevention, inpatient - , outpatient treatment and aftercare willbe presented.General practitioners hold a key role in all therapeutic stages and are thereby well integrated in the addictionlong - term treatment. As long – term treatment is basic to this concept, we are able to follow – up our patientsfor years. This led to a long term study which resulted in the establishment of subgroups of alcoholism illnesscourse. These subgroups enable us to offer our patients an individual, “ tailer-made “ , therapy. Especially inType 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 totarget 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 generalpopulation. Estimated lifetime prevalence of chemical dependency for physicians have been suggested fromanywhere between 12 to 20 percent of the physician population. Physicians have particular risk factors thatcontribute to the disease of chemical dependency. They also have a higher degree of accountability in theirprofession.

This particular presentation will outline what is involved in making the diagnosis of chemical dependency in theoften highly defended physician with this disease. The presentation will also go into detail in regards thespecific risk factors that contribute to physicians becoming chemically dependent and having potentialimpairment in the workplace.

There will also be an emphasis on specialized treatment for chemically dependent physicians. The detailsinvolved with specialized treatment for chemically dependent physicians will be highlighted. Also outcomestudies indicating overall abstinence rates as well as looking at prognostic indicators will be detailed. Theextensive aftercare-monitoring program with utilization of state medical society’s assistance programs will alsobe discussed.

Kathy Angres, MS, RN, will discuss family involvement, critical to chemical dependency treatment in generaland physicians in particular.

The risk for physicians becoming chemically dependent is a worldwide phenomenon. When appropriatelydiagnosed and treated, particularly in a specialized fashion, the addicted physician has as a rule excellentoutcome. The above presentation will utilize clinical observations and research described in the book, Healingthe 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 clinicalpractice. Clinicians know the importance of diagnosis as the first step or doorway to treatment. Over the yearsthis doorway has been open, but frequently passed by many when attempts are made to search for the cause andeffects 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 andare referred to in a generalized manner. Many times, alcohol/drug abuse becomes a secondary diagnosis that islost or put aside while other clinical symptoms are treated. Frequently the patient is referred for further diagnosisand 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 diagnosesof substance abuse and dependence.

These references are not always readily helpful to clinicians who are looking for simple descriptivelanguage to describe the patient’s clinical syndrome of alcohol/drug abuse or dependence. Neither do theyalways help pull together the patient’s history in order to help formulate the diagnosis. Consequently, treatmentfor 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, alongwith the companion website “Addictionend.com” is designed for professionals but adapted by glossary for useas an educational tool to help the professionals educate their staff and patients under their supervision. Bothpublications are a concise, practical and step by step guide for the diagnosis, treatment and prevention foralcoholism 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 readyreference source and format has been demonstrated to be extremely helpful to thousands of clinicians. Theprecise but simplified language is of great help in providing the necessary diagnosis and treatment for the patientat the earliest possible stage. This is a non-profit interactive project. We need and invite your help to improvethe 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 HealthCentre , Guelf, Ontario, Canada

Alcohol and drug addiction in physicians is a global problem with an incidence of 10% in Europe and theAmericas. The factors leading to these addictions in physicians are presented. Indentification continues to be amajor problem. The six major elements of early and verified identification are detailed. Intervention is anecessity with the denial of physicians and the conspiracy of silence within the medical community. Successfulintervention leads to a multidisciplinary assessment where treatment options are presented. Criteria are detailedand dictate whether inpatient, outpatient, or intensive residential outpatient will be recommended. Treatmentelements 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 impairedphysicians program that have global applications are outlined and characterized with a data base of over 1,500impaired 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 DIFFERENTIALIMPLICATIONS 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 throughmedia and school prevention efforts, and despite an apparent declining trend during the 1980s in the USA, thelast few years have witnessed an increase in the prevalence of drug use, particularly the illicit ones. These datasuggest that prevention and/or intervention strategies may have to be examined from a different conceptualframework than has been done for traditional programs. We need to focus on more distal variables that predictsubstance use acquisition since by early adolescence, the child may be well along a drug use/abuse trajectoryand the possible effectiveness of intervention procedures may be limited. Second, while males usually havehigher rates of drug use compared to females early in adolescence, the evidence for the possible antecedents thatdiffer by gender that could inform prevention strategies have been largely ignored. Third, it is likely that thedevelopmental patterns leading to the onset of substance use and potential for abuse are not similar for allchildren. Evidence suggests at least two different trajectories leading to early onset, i.e., prior to age 15, and lateonset, during late adolescence or young adulthood.The purpose of this presentation is to illustrate differential trajectories leading to alcohol and other drug use thatcould provide critical information for the development of prevention and intervention activities, using the resultsfrom two different longitudinal studies that span the range from elementary school to young adulthood. The firststudy examined a normative group of elementary school students during grades two to five who were followedup during grades nine and ten in high school. Extensive data was collected at each time point with heavyemphasis on multiple methods and informants. The results showed differential predictors by gender over a five-year period. The second study used five waves of a 19-year longitudinal study whose primary goal was theidentification 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 growthmixture modeling to multiwave panel data spanning the period from early adolescence, late adolescence, andinto young adulthood resulting in two distinct latent developmental trajectory classes. Class 1, with a high initialstatus of alcohol use at Grade 6, showed an upward increase in trajectory only during high school whereas Class2, with a low initial status of alcohol use at Grade 6, showed a linear increase in middle school with a secondgrowth spurt at high-school entry and continuity in growth throughout the high school years. The results alsofound differential predictors of these two latent classes. The results will be discussed in terms of improvingprevention and intervention efforts designed to reduce or eliminate problematic substance use among childrenand adolescents.

LATENT CLASSES OF FAMILIAL ALCOHOLISM AND DEPRESSION:RELATIONS TO NEUROPSYCHOLOGICAL FUNCTIONING IN LATE ADOLESCENCE ANDADULTHOOD

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 neuropsychologicalimpairments, 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 presentin FHA+ offspring would be most likely to manifest in neuropsychological impairment in the context of otherrisk factors that lower the threshold for impairment. We suggest that increasing age and familial histories ofother psychiatric disturbances such as depression may diminish brain reserve and thus increase liability forneuropsychological deficit in FHA+ offspring. Further, a longitudinal follow up of adolescents may benecessary to detect a developmental unfolding in vulnerability. This study examined differences inneuropsychological abilities between familial history groups during late adolescence and again 7 years laterusing data from the Rutgers Health and Human Development Project (N = 1271). Our family historyclassification system took into account alcohol use disorders and depression on the part of parents as well assubstance use disorders and depression on the part of siblings of participants. Family risk groups were classifiedusing 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 indicatedsignificant improvements in model fit up to 3 classes. Class 1, the Low Risk Comparison Class (63% of the totalsample), was characterized by no or a low probability of alcohol and depression diagnoses in first degreerelatives. Class 2, the Limited Parental Risk Class (22% ), was characterized by a heightened probability ofdepressed mothers, somewhat elevated probability of alcoholic or depressed fathers, but low probabilities of analcoholic mother or affected siblings. The High Risk Class 3 (15%) was very heavily weighted with siblingdiagnoses and with multiple parental diagnoses. Controlling for age cohort and sex, an omnibus MANOVA totest for differences between latent classes in performance on the eleven neuropsychological tests indicated thatthere were no a significant differences between classes during late adolescence. However, a parallel MANOVAconducted on neuropsychological test scores 7 years later, revealed significant differences between family riskclasses. Post hoc analyses showed that the High Risk Class performed significantly more poorly than the othertwo risk classes in verbal ability, abstraction, cognitive flexibility, and symbol coding. Effect sizes were in thesmall to moderate range. Although the High Risk Class comprised a larger number of participants with alcoholuse disorders and major depression than did the Low and Limited Risk Classes, these disorders did not mediatenor moderate familial risk effects on neuropsychological functioning. The results suggested that youth withheavy loadings of first degree relatives including siblings with alcohol and substance use disorders anddepression have heightened neurocognitive vulnerability, but that neuropsychological deficits may not becomeevident until adulthood.

IMMEDIATE AND LONGER-TERM TREATMENT OUTCOMES FOR ADOLESCENT DRUG ANDALCOHOL 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 andexamining treatment outcomes across time have been rare. This presentation will focus on findings from threetreatment outcome studies, each conducted with a different clinical sample of youth referred for substance abusetreatment. 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. Theintervention was designed to enlist parents (n=44) as change agents to increase adolescents’ engagement intreatment and thereby ultimately impact substance abuse. Parents successfully engaged 71% of youth intotreatment and showed significant improvements in depression, anxiety, self-esteem, and medical and physicalsymptoms. 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 wereexamined 4-months, 7-months, and 18-months after the initiation of therapy for the four treatments conditionsfor two outcome measures: percent days of use and percent of youths achieving minimal use. Each interventiondemonstrated some efficacy, although differences occurred for outcome measured, speed of change, andmaintenance of change. From pretreatment to 4 months, significantly fewer days of use were found for thefamily alone and combined interventions. Significantly more youth had achieved minimal use levels in thefamily and combined conditions and in CBT. From pretreatment to 7 months, reductions in percent days usewere significant for the combined and group interventions and changes in minimal use levels were significantfor 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 problemdrinking. Preliminary outcomes for 48 youth and their families replicate our previous findings, demonstratingsignificant pre- to post-treatment reductions in alcohol use. Taken together, the three studies provide empiricalevidence for the efficacy of psychosocial treatments for adolescent substance abuse. The implications of thedifferential patterns of change over time for improving treatments and matching clients to treatment will bediscussed.

PROFILES OF CHANGE IN DRUG USE DURING AND AFTER TREATMENT FOR SUBSTANCEABUSING ADOLESCENTS

Charles W. Turner, Ph.D., Holly B. Waldron, Ph.D., Janet L. Brody, Ph.D., Thomas R. Peterson, M.S., andTimothy 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 studyevaluated patterns of change during and after treatment for youths receiving cognitive-behavioral and familytherapy interventions for their substance use disorders. Adolescents were randomly assigned to one of the fourintervention conditions: individual cognitive-behavioral therapy (CBT), Functional Family Therapy (FFT), anintegrative treatment including both FFT and CBT, or an education/ skills group comparison condition. Thesample included 114 youth, ages 13-17, and their parents, with 75% male adolescents, and 39% Anglo-American, 43% Hispanic-American, 8% Native American, and 10% of other or mixed ethnicity adolescentsparticipating. Treatment outcomes were examined 4-months, 7-months, and 18-months after the initiation oftherapy for the four treatments conditions. Outcomes were percent days of marijuana use and percent of youthsachieving minimal use. Each intervention demonstrated some efficacy, although differences occurred foroutcome measured, speed of change, and maintenance of change. The present analysis examined profiles ofchange during and after treatment. The dependent variables were the percent days use of marijuana for eachyouth at the four measurement periods. We used k-means cluster analysis procedures to identify 6 profiles ofchange across the measurement periods. The findings from these profile analyses suggest that familyinterventions produced more rapid improvement in problem behaviors and better resistance to relapse. Theclinical significance of these findings in relationship to those adolescents who have been able to achieve andmaintain abstinence will be presented. Implications for improving treatments for adolescent substance usedisorders will also be discussed.

COURSE OF ADOLESCENT ALCOHOL USE DISORDERS ACROSS 3 YEARS AFTERTREATMENT

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 usedisorders (AUDs). We examined the course of AUDs over three years in adolescents recruited from a variety ofaddictions treatment programs. Adolescents age 14-18 were assessed 2-6 weeks after beginning an indexepisode of treatment, and participated in 1-year (n=334) and 3-year (n=172) follow-up assessments. The samplewas 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 structuredinterview. The data show a substantial decrease in alcohol use and problems over time in the majority of treatedadolescents. At baseline, 42% of the sample had DSM-IV alcohol dependence and 29% alcohol abuse; most ofthe other subjects reported heavy drinking and alcohol problems. Adolescents with dependence were aboutequally likely to show a full remission of symptoms or remain dependent at 1-year and 3-years; relatively fewwere in partial remission status. Alcohol abusers tended to remit to no diagnosis or remain abusers, although15% and 24% became dependent during the two follow-up intervals. Adolescents without a DSM-IV AUDtended 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. Thedata also indicate that adolescents whose AUD symptoms remitted were more likely to report non-problemdrinking than abstinence. The quantity and frequency of alcohol use during the first year of follow-up in thenon-problem drinkers (averaging 3.0 drinks 4.2 times/month) was significantly lower than those with continuingAUD diagnoses or symptoms (averaging 8.8 drinks 8.5 times/month). Non-problem drinkers also showedincreases in social functioning and decreases in drug use. Among non-problem drinkers at 1-year, 57% retainedthis status through the 3-year assessment, 10% became abstinent and 33% returned to problem use. Non-problem drinking at 3-years occurred in 26% of those who were problem drinkers at 1-year, and 50% of thosewho 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 teenagersglobally. There is evidence that substance abuse is becoming more common amongst teenagers and commencingat an earlier age. Drug affected teenagers are particularly difficult to connect with medical and drug treatmentservices. Specialised services for substance using teenagers are not available everywhere. Thus generalistclinicians and adult oriented drug and alcohol services are often called upon to play a role in the care of patientswho are in their early teens. The purpose of this interactive workshop is to explore strategies and techniques that allow the development oftherapeutic relationships with drug affected teenagers. These range from systemic issues (such as the setting) tospecific skills which allow engagement in an individual consultation (such as confidentialty, use of theHEADSS assessment, motivational skills).We will look at understanding why these strategies and techniques are important and how to put them intopractice 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 patientshould 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 nowendorsed by over 20 US states, the US Veterans Administration and the US Department of Defense, the ASAMCriteria have only recently undergone prospective testing. Two naturalistic studies and one random controlledtrial in three distinct samples have now tested whether the ASAM Criteria are feasible and valid. Results arepromising, indicating that the ASAM Criteria: 1) can achieve a quite satisfactory inter-rater reliability; 2) dodifferentiate patients into levels of care; 3) may not be easily accepted by patients without system supports, and4) 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 decisiontree. These three studies indicate the potential advantage of a single software implementation for use in multi-site studies and across multiple populations. This finding has implications for research and treatment ininternational 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 BelgianAmerican 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 hospitalsin Cairo. The aim of the study was to assess the impact of psychiatric comorbidity on the severity of substancedependance.According to the results of the structured clinical interview for DSMIII R - patient edition ( SCID-P ), patients were divided into two groups i.e. the Comorbid group and the Non-comorbid group. The distribution of psychiatric diagnoses revealed that antisocial personality disorder was thecommonest comorbid diagnosis (31.4%) followed by major depressive disorder (14.2%). Other psychiatricdiagnoses were marginally represented. The Addiction Severity Index (ASI) , which is a semi-structured clinicalinterview assessing the severity of substance dependance by exploring six major areas of functioning, wasapplied to the whole sample. The result of the ASI showed no statistically significant difference between the twogroup.

THE IMPLEMENTATION OF THE JOINT SERVICES DEVELOPMENT UNIT (JSDU) FOR THEMANAGEMENT OF PSYCHIATRIC AND SUBSTANCE USING CONDITIONS

THE DEVELOPMENT OF AN INTEGRATED MODEL OF CLINICAL CARE AND PROFESSIONALDEVELOPMENT 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 beennumerous studies that indicate a significant number of people with mental illness are also dually diagnosed witha substance abuse disorder. Whilst research methodologies have varied, the data indicates that up to 40% ofpeople 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 supportfrom mental health professionals and substance abuse support from drug and alcohol professionals. This hasresulted in fragmentation of care for consumers. Consumers with dual diagnosis are either intense users ofmental health services (particularly inpatient facilities) and drug and alcohol service or they slip through thegaps.

Philosophy of the JSDUThe overall operating philosophy of the JSDU is that persons with co-occurring mental health and drugdependence disorders are best served by holistic, individually tailored, and integrated interventions. Suchinterventions are best provided in the least restrictive manner and are most effective if they are based on a highquality helping alliance.

It is considered that, wherever possible, individuals with co-occurring conditions are best managed within asingle agency. However, increasing severity of mental health disorders may necessitate a move to parallelagency input. In order to ensure that customers benefit from joint agency input such interventions will need to becarefully coordinated and case managed.

Given the desirability of single agency interventions staff in both the mental health and drug sectors will need tobe 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 helpingalliances that are established. The enhancement of clinicians’ abilities to establish and maintain high qualitytherapeutic relationships will be a central focus of JSDU activity.

Demonstration sitesIt is envisaged that JSDU will provide an intensive clinical education and consultancy service to a number ofpre-selected demonstration sites. In the first instance these sites will include a tertiary inpatient unit, bothgovernment and non-government alcohol and drug agencies, a community mental health/drug service and a ruraland 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 consultancyand 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 suchclients. 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 inhow best practice is most effectively achieved.

The process of the implementation of these demonstration sites will be presented and the evaluation process willbe 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 substancethat 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) wasinadvisable in nonmalignant pain. Numerous articles report that there is sustained pain reduction with chronicopioid therapy.

Opioids have clearly been shown to be very safe in long term use, even at high doses. However, thequestion of efficacy remains. Studies of intrathecal opioids suggest that very high levels of patient satisfactionand 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 representan 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 theircognition improved with opioid weaning. They commonly described “getting myself back” after elimination ofopiods. 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 concernsat a time when availability of organs is extremely limited . Although transplantation may be life-saving forthose with many diseases, it is not available to everyone. Patients’ use of alcohol and other drugs is acontroversial issue in the transplant community. While compliance with medical requirements is important forall 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 medicalnoncompliance and exposes the graft organ to a toxic substance. Local, regional and national regulations haveaffected organ allocation.

The Ohio Solid Organ Transplant Consortium was formed to ensure equitable access to donor organs withoutregard to financial or other considerations. At The Cleveland Clinic, a tertiary care facility in Ohio, a chemicaldependence transplant team was formed in response to criteria established by the OSOTC for transplant patientswith addictive disorders. The assessment, treatment and monitoring of patients with comorbid organ failure andaddictive disorder require specific expertise. A prominent role for specialists in addiction medicine on thetransplant team has resulted.

This presentation will describe the responsibilities of the chemical dependence transplant team, the scope ofthe 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 PGand the international classifications show common pathways with the Obsessive-compulsive spectrum in thegroup of Impulse control disorders. The comorbidity with other addictions is high. This depends onsimilarpsychobiological and personality traits. In young people PG may be included inthe area of sensation seeking and/or risk seeking behaviours. A bio-psycho-social therapeutical approach is themost 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, CanadaDavid 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) andtheir change strategies. These strategies formed the basis for the development of a workbook “Becominga 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 amotivational telephone interview. Gamblers reported reading the manual and following the strategies withsignificant 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 managementof pathological gambling. A range of pharmacological and psychological treatments is available forclinicians 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, coupletherapy and comprehensive inpatient treatment. There is one open label trial of medication, 2 pending andone 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 strictselection 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 availableon the topic. Despite this large corpus of scientific information, the translation of findings to applied clinicalutilization has been limited.

The proposed presentation attempts to partially bridge the research-practice gap by describing severalcurrently available tests with particular emphasis on their capabilities as well as their sources of false positiveand false negative errors. This is followed by discussion of how markers can be used in medical practice foralcohol problem screening, facilitating differential diagnosis, motivating patient change, monitoring relapsestatus, and evaluating new medications for alcoholism treatment.

Research dealing with the relationship of biomarker findings and medical care issues (e.g. predicting futurehealth 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 andinsurance contexts.

MEDICAL CONSEQUENCES OF ALCOHOL: A TREATMENT PROGRAM DEVISED BY ANINSURANCE 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 dela France entière.

Le département d’alcoologie repose sur l’action d’une petite équipe pluridisciplinaire qui a développé unimportant travail en réseau.

L’approche théorique qui a présidé au montage des différents protocoles s’appuie sur le cognitivisme et laphénoménologie.

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 réalisersans 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 whomand in what measures should drugs be controlled. Opinion of those, who puts drug control measures intopractice, may be of interest in this respect. Applying the methods of structured interview, including questionsrelating to drug control policy measures, we surveyed law enforcement officers. The results of the interviewshowed that the majority of the respondents have negative attitude to the idea of legalization of both soft andhard drugs. At the same time, most of them considered, that use and possession of drugs in small amountsshould not be a reason for imprisonment – only administrative punishment would do. Repressive measuresshould be taken against drug dealers, but not users. As far as the former is concerned, their punishment shouldbe reinforced. The results of the survey manifest predominance of the point of view, according to which drugaddicts are sick people and they need treatment, but not punishment. Prolonged compulsory treatment in specialestablishments of closed type that exist in the system of the Ministry of Internal Affairs is considered to beoptimal variant of the policy aimed at drug addicts. The majority of those interviewed think that imprisonmentof 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 drugaddicts continue drug taking in prison. At the same time half of the interviewed consider imprisonment of drugaddicts to be a good preventive measure. It means, fear of punishment is a preventive factor for potential drugusers. Most of those interviewed state that keeping in prison d.a. together with criminal population might causenumerous problems. Thus, the majority of the respondents admit the restricted possibility of punitive approachto solving drug-related problems. There prevails the point of view according to which effective drug controlpolicy 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 carriedaut in this field reflect public support of this policy. The goal of any drug policy is to reduce harm. Today thereis many debates about legalization of drugs. Legalization proposals are often presented under the guise of harmreduction. As far the experiens show, when drugs are legalized, they are used more widely and the total cost oftheir use go up if compared with the costs of drugs which are still under prohibition. And vice versa: restrictedavailability and high prices can help to hold down the number of first-time users and reduce the human, socialand economic costs of drug abuse. It is known that policy-making apparatus is influenced by public opinion. Inthis paper the results of the survey of public attitudes towards drug control policy are discussed. 562 citizens ofBelarus of different sex and ages took part in the survey. Methods of structured interview was applied. Theresults are as follows: 76 per cent of respondents think that legalizing of drugs is a bad idea. 71 per cent of thoseinterviewed consider that law should punish drug taking. 91 per cent agree that it is necessary to make thepunishment for sailing drugs more strict. 90 per cent of people, participating in the survey consider that drugaddicts should be treated but not punished. As far as alcohol is concerned, 36 per cent agreed to the idea ofincreasing prices for alcohol and at the same time 14 per cent expressed their negative attitude to this. 20 percent 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 negativeattitude of the society to the idea of legalization of drugs and sanctioning of repressive measures towards drug-dealers and drug-users. At the same time, the majority of population considers drug addicts to be sick people. Itmeans, they support the ‘medical model’.

DRUG ADDICTION AND JAIL. THE ROLE OF THE NETWORK BETWEEN COMMUNITYSERVICES. 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 forthe prevention, treatment and rehabilitation programs of the drug addicts. A network formed by public healthand social services, therapeutic communities and private social services who had learned, in the course of theyears,to construct solid synergies and to offer different ways of personalized cure, rehabilitation and attention tothe specificity of the persons.Sanitary services for drug addictions (SER.T) are present in the penitentiaries Institutes since 1990 to aim toguarantee the continuity of the therapeutic relationships wih the drug addicts subjects imprisoned. More over, inbase to article 135 of the Unified Text of Laws in narcotic matter (T.U. n° 309) Penitentiary Amministrationhas institued and organized a serviced of support called “Sanitary office for the drug addictions, alcoholaddiction and support to the prisoners affected from HIV” in which they operate medical doctors, psychologistand professional nurses.The priority objectives of the collaboration in action between the services for the drug addictions (SER.T) andthis 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 thefield of prevention and attention to the drug addicts prisoners and inmates are transferred to the National HealthService.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 therapeuticprogramms in support of the drug addicts with definitive sentences,imprisoned or free,to the aim to obtain theconcession of one alternative measure of the detention as previewed by the Law: Art. 94 T.U. 309/90, domiciledetention ( Art. 47 ter), semifreedom (Art. 92, comma 3) and more over in order to activate the useful resourcesof 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 developingcountries 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 withparticipation attrition and successful out come in smoking cessation programs.

Methodology: 300 Egyptian smokers attending the antismoking center, Cairo were subjected to: personalinterview; physical and psychological examination, chest X-ray, ECG, pulmonary function test (FEV1), bloodsugar and cholesterol. Each participant will then eligible to Join the smoking cessation program for 2 weekswhich depends mainly on behavioral, cognitive therapy, the electric nerve stimulation therapy and heatheducation 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 importantpredictive 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 previouscessation experience, less number of smoked cigarettes, short duration, pleasurable feeling when smoke, nopsychiatric problems, health problems especially if FEV1 is impaired. Continuers have stress personalitydisorders 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 addictiontreatment. Statistics show that Argentina has a serious problem with tobacco smoking. 35% of the adultpopulation (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 breastcancer).Estimates indicate that by the year 2020 nicotine addiction could be the primary cause of death forArgentineans. 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. Theprogram requires an individualized plan that addresses level of motivation, circumstances and needs. Variouspsychotherapeutic, pharmacological and relapse prevention approaches are offered in a three month / three phaseprogram. Phase I- Preparation, Phase II- Action, and Phase III- Maintenance. Assessment and treatmentplanning are required at each phase. 40%-50% of the chemically dependent and dual-disorder patients whosought treatment for their nicotine dependence were able to stop smoking, and remained nicotine free during thefirst year of treatment. Further considerations about relapse events and continuos encouragement on beingchemical free are discussed.

EFFECTIVENESS OF INTERVENTIONS FOR HELPING PEOPLE STOP SMOKING IN THETRIESTE 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 beenshown that the provision of advice and counseling to small groups of smokers is effective in 10 to 25% of casesat 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 anintensive smoking cessation course held by 1 of the 3 associations active in Trieste (Lega Italiana per la Lottacontro i Tumori – LILT, Lega Vita e Salute – LVS ed Associazione Hyperion – AH) were studied. The threeassociations have different strategies:LILT courses: held by trained personnel (doctors,teachers), are homogeneous throughout Italy, and consist of 10meetings 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 of10 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 “fullimmersion” treatment consisting of 5-consecutive-day meetings of 3 hours each, followed by 8-10 sessionsdedicated to smaller groups (15-20 people).All the protocols included questionnaries investigating the degree of addiction (Fagestrom) and the motivationsto 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 period75% of quitters relapsed (the majority – 67% - within 3 months after havig stopped smoking), and 25% was stillabstinent.Conclusions. The results of the present study are in agreement with those reported in literature. The highpercentage of relapses within few months after quitting, and the analysis of the questionnaires filled up duringthe 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 havean 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 actas barriers; also, inadequate training and awareness by healthcare professionals and a lack of women sensitivetreatment services. Over the past several years we have seen an increased acceptance and efforts in theprofessional community about women specific issues and attempts to develop andcreate treatment programs thatovercome some of the barriers.This presentation attempts to highlight components of women-oriented treatment and support groups forwomen. From the treatment model, a progression to looking at the 12 Steps in a women oriented manner isutilized 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 focuson drug abuse and industry. The Drug Free Workplace Act covers all United States industries that receive anyform of public funding, and includes a requirement for supervisory training, as well as employee drug educationtreatment and random drug testing. Evidence that developed from this drug free work place initiative indicatesthat 66% of substance abusers in the United States are employed. Since health insurance in the United States isa key to chemical dependency treatment, the random drug testing has served as a basis for early intervention andtreatment for employed individuals. ASAM initiated Medical Review Officer training in the United States hasbeen a very important force for medical training in this important area, as the Drug Free Workplace Act hasdemonstrated a significant decrease in workplace accidents and health care claims. With the globalization of theworld economy, Medical Review Officer training and the expanded role of the addiction medicine physician inthis 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 ofsubstance 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 onDSM 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. Theincidence rates for any drug use, tobacco , alcohol was 5.9% ,4.9% and 4.2 percent respectively. Theincidence of tobacco among non users and alcohol users was 4.7% and 9.6% ( OR=2.1, CI= 1.3-3.6) whereasthe 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 Incidenceof tobacco use among those upto the age of 20 years was 1.7 percent, and showed an almost consistent rate ofaround 4.0 percent in all the subsequent age groups.Conclusions Substance use disorders with high prevalence and incidence rates in this general populationsuggests the need for a balanced and integrated approach to its treatment?

THE SUBSTANCE ABUSE SUBTLE SCREENING INVENTORY (SASSI) USE IN RESEARCH OFADDICTED FAMILIES

Rus-Makovec Maja, PhD, MD, Sernec Karin, MSs, MD, _eba_ek-Travnik Zdenka, PhD, MD; UniversityPsychiatric 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 drugaddicted children. It is also meant to test a new instrument in Slovenia named »The Substance Abuse SubtleScreening Inventory« (SASSI). SASSI covers a lot of different subscores, which identify possible negation ofsubstance 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 groupconsisted 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 relevantpsychosocial 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 andfinancial status and family climate; data about depression (Zung); data about self-esteem (Rosenberg); use ofpsychoactive substances (self – report questions, AUDIT, SASSI).

Results: With the regard to literature data we were expected the high rate of parental alcoholism would befound in experimental group. The results showed that there were no signifficant differences found betweenparents from the experimental group and the control group considering the probability of PAS addiction in theparents, except in the SASSI subscores OAT and DEF of fathers. The results showed that the parents who werewilling to be included in the experimental group were more “healthy” in the field of addiction (only 17 % ofparents of addicted adolescents returned the questionnaire). Several signifficant correlations were found betweenthe parental SASSI subscores and adolescent dependent variables which are relevant for adolescentpsychological status (self-esteem, the level of depression, adolescent selfevaluation of physical and mentalhealth). The SASSI instrument has proved to be very useful for the research on addiction, both in screening andin study of family interactions.

(1) Miller FG, Roberts J, Brooks MK, Lazowski LE. The SASSI Institute. SASSI-3 user's guide. BaughEnterprisses, 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 TOALCOHOLISM

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, fewresearch was devoted to this topic.MOS-SF36, a generic Health Related QoL Instrument was employed,and studies concluded into adequate metriccharacteristics. However, not based on specific symptoms of alcoholism, SF36 sensitivity was found low, andconversely, were unusefully redundant. It was conjectured that a short form concentrating on specific aspect ofalcoholism 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, wasused 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. Thispaper describes in detail this optimisation, and outlines the metric characteristics of this short scale. Finally, acausal model was derived through Structural Equation Modelling SEM technique, to test the invariance of theproposed scale to country specificities. A clinical interpretation is still needed at this stage, however, on thebasis of these findings, AlQoL9 can be considered as a fully validated QoL instrument in alcoholism.

IMAGERY CUE REACTIVITY IN OPIATE ADDICTS: INDIVIDUAL VARIABLES ANDDIFFERENTIAL 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 conditionedto various drug related cues associated with drug use. Aim The present study was conceived with the aim toexplore the psycho-physiological mechanisms of craving by an imagery cue exposure and the differential cueresponse 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 andthen imagine their craving experiences. Craving was measured subjectively by using visual analogous scale andquestionnaire methods and autonomic parameters of galvanic skin resistance (GSR), heart rate (HR), skintemperature(ST), and respiration rate(RR) were taken during drug related cue imagery. Spearman’s r andWilcoxon signed ranks test where employed in analysis. Multivariate repeated measurement analysis (wilk’sLambda) was employed wherever appropriate. Results: significant increase in subjective ratings on themeasures of craving and significant change in HR, GSR, ST, RR were observed during drug related cue imageryas compared to neutral cues. The subjects were dichotomized according to the age of onset, duration of opioiduse, attempts of abstinence, family history of substance abuse, motivation to leave the drug use habit, and thepremorbid personality and the response to cue reactivity were compared between them. Conclusion: Theresults suggested that cue imagery elicited a powerful craving response in opiate addicts. Though differentialcue reactivity was observed in relation to age of onset and motivation of the patients, no significant differencewas 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 clinicaland 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 toprovide a clinical perspective on public health and drug treatment issues, will be an important internationalconcern for ISAM members.

THE DIRECT ETHANOL METABOLITE ETHYL GLUCURONIDE IS A SPECIFIC MARKER OFRECENT ALCOHL CONSUMPTION

Wurst, F.M.1, Alt A2., Seidl S3., Sperker B4., Lauterburg BH5, Ladewig D1., Müller-Spahn F1, Metzger J.6and 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, Universitiesof Ulm2 and Erlangen3, Germany; Departments of Clinical Pharmacology, Universities of Greifswald4,Germany and Bern5, Switzerland;6Department of Hydrochemistry and Hydrobiology, University of Stuttgart,GermanyOBJECTIVE:Biological state markers with high sensitivity and specificity are required. Ethyl glucuronide (EtG) is a non-volatile, water-soluble, stable upon storage marker of recent alcohol consumption that can be detected up to 80 hafter 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 alcoholintake, that via therapeutic intervention at early stages of lapsing behaviour can contribute to significantimprovement in treatment outcome, therapy effectiveness and cost reduction.REFERENCES1) Wurst, F.M.; Kempter Ch.; Seidl S.; Alt A. (1999) Ethyl glucuronide - a marker of alcohol consumption anda relapse marker with clinical and forensic implications. Alcohol Alcoholism 34:71-772) Wurst F.M.; Kempter Ch.; Metzger, J; Seidl S.; Alt A. (2000) Ethyl glucuronide - a marker of recent alcoholconsumption with clinical and forensic implications. Alcohol 20: 111-116

THE INTRODUCTION OF ACUDETOX INTO THE ITALIAN PUBLIC DRUG AND ALCOHOLTREATMENT 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 patientsrequiring treatment for substance abuse.Clinical experience and published studies have shown that acupuncture is effective in the treatment of drug andalcohol withdrawal sympotoms, in the acute and post – acute stage as well in relapse management. Acupuncturehelps clients reach quickly a state of physiological and mental equilibrium, allowing them to participate in otheraspects of counselling and abstinence progression.Acupuncture detoxification is a painless and non threatening technique, that requires little verbal communicationor interpersonal interaction. Especially at a time when a client may be experiencing acute physical withdrawalsymptoms, and depression or incapacitating anxieties.Substance abuse acupuncture is provided in a group setting. A new acupuncture client is immediatly intoducedto a calm supportive group process. A patient recieves treatment, obtaining relief from withdrawal symptomsand 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 anorganisation 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 ethicalstandards in the certification of acupuncture detoxification specialists.As acupuncture works in concert with traditional drug and alcohol abuse treatment approaches and noting theparticular aspect that public detoxification services exist in every local community in Italy, the NADA ItalianAssociation has focused over the last 8 years to offer this treatment modality to these public detoxificationservices. 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 inItaly.This paper will also cover the history and development of Acudetox not only in Italy but also where it originatedin the USA along with other coutries as Australia, Saudia Arabia, India, Nepal, Pakistan, and in other Europeanstates amoung Germany, Austria, Switzerland, Portugal, Sweden, Netherlands, Hungary, Russia, and otherEastern European countries, where local NADA associations offer a standardezed training program similar ineach state.

HEROIN USE DURING PREGNANCY: THE IMPACT OF PRENATAL CARE AND DIFFERENTTHERAPEUTIC REGIMENS ON PERINATAL OUTCOMES

Salamina Giuseppe1, Tibaldi Cecilia2, Pasqualini Chiara2

1 Prenatal Centre for Drug-Addicted Women - Department of Gynaecology and Obstetrics, University ofTurin. S. Anna Hospital, Turin.

2 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, lowbirth weight, perinatal morbidity, and mortality. To assess the efficacy of a comprehensive program of prenatalcare and of various therapeutic regimens with respect to adverse obstetrical outcomes, we conducted aretrospective study among all drug-addicted women who attended the Prenatal Centre for Drug Addiction inTurin (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 forthe analysis.Results: All 349 women primarily abused heroin, 43 (12%) abused cocaine. Inadequate prenatal care wasobserved in 177 women (51%); 151 (43%) agreed to methadone maintenance; 85 (24%) patients underwent adetoxification, which was unsuccessful in 23 (7%) of cases. Newborns of drug-addicted mothers weighed onaverage 426 g less than those of general population. A total of 11 perinatal deaths were observed. Perinatalmortality 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 perinataloutcomes. 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 neonatalwithdrawal. It should emphasised, however, that in healthy newborns with adequate birth weight, the neonatalwithdrawal 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 theserotoninergic neurons whose cellular bodies are in the nucleus of the dorsal rafe, sparing those having a greaterdiameter and spreading from the nucleus of the median rafe. The Fink-Heimer method shows the argenticimpregnation of the degenerate axons. This degeneration starts within a few hours from the last MDMAadministration and lasts for many months. Being spared the pyrenophores, the axons can be regenerated. Theautoradiograph of the sites of 5-HT uptake and the immunocytochemical study of the reactive axons showed thatthe reinnervation noticed in albino rats and especially in squirrel monkeys 12/18 months after administration of5 mg MDMA, i.p. and s.c. respectively, twice a day for four days, follows an abnormal pattern. It ischaracterized by the reorganization of the serotoninergic ascendent axonal projections, with dorsal cortexdenervation and hyperinnervation of the tonsil and of the hypothalamus. From all the experimental models, withthe exception of mice, who gave not always univocal results, it appears that MDMA administration, in a singlehigh dose or after repeated treatments, causes reduction of cerebral 5-HT, liquoral 5-HIAA and tryptophan-hydroxylasic activity. The loss of 5-HT cellular content takes place in two phases. The first one coincides withan acute 5-HT release, after which concentrations become normal within 24 hours. The second one correspondsto the long term reduction in 5-HT content which starts within three days and, being supported by the persistentdecrease of tryptophan-hydroxylasic activity, lasts more than a year. In non-human primates, which are moresensitive than rats to the neurotoxic effects of MDMA, the alterations can be also seen after oral administrationand 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 thehypothalamus. PET images of a baboon‚s brain recently confirmed this toxicity pattern. Many studies on rodentstried to investigate the behavioural consequences of serotoninergic neurotoxicity. The animals treated withMDMA doses causing a 35-70% decrease in 5-HT levels in the striate and in the hippocampus don‚t show anyimportant changes in emergence, hot plate response, auditory startle, complex maze performance, one and twoway avoidance, swim test and eight radial arm maze. It has been shown, on the contrary, a decrease in ultrasonicvocalizations of young rats after separation from the mother. The behavioural patterns suffer the lack ofspecificity for the serotoninergic system, since presumably many neurotransmitters imply the observedbehaviours. 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 humanbeings the serotoninergic system can be influenced by the use of ecstasy; we should remember, however, thatmost recreational drug users are polyabusers and that their self-reports aren‚t very reliable. The apparentirreversibleness of the nervous lesions caused by ecstasy has been thoroughly studied. Particularly interestingare the results of a recent study that protracted to 7 years the observation of the neuroanatomical consequencesof subchronic exposition to ecstasy in monkeys (8 doses in 4 days). The brains of these animals showed anabnormal serotoninergic innervation, with a remarkably decreased density of serotoninergic axons in areas likethe neocortex, the striate and the hippocampus, while this density increased in the pale globe and in somethalamic 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 thoseobtained 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’sresponses of obtaining and taking the drugs have been reinforced so often and so powerfully that they dominatethe 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) butalso 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 byblocking reinforcement with opioid antagonists such as naltrexone. The results from both preclinical andclinical tests have consistently supported his hypothesis. Preclinical studies demonstrated that opiate self-administration by animals is extinguished when the behavior is made while an opioid antagonist is present. Alarge NIDA double-blind, placebo-controlled clinical trial showed that patients taking naltrexone before self-administering heroin or methadone had significantly better results than did the patients on placebo, but therewere no significant benefits from naltrexone under conditions precluding extinction: “the theory behind narcoticantagonist 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 intogeneral practice, perhaps because of the legal difficulties from having an addict self-administer an illegalsubstance 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 toterminate 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 thetreatment of alcohol dependence (Sinclair, 1989). Preclinical studies have demonstrated extinction of drinkingand lever pressing for ethanol. Key features in the results are little or no effect initially followed by aprogressive reduction in the behavior, continued reduction after the end of treatment even when all of theantagonist 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 haveconsistently shown that opioid antagonists are effective in treating alcoholism when used with protocolsfavorable for extinction but not when instructions prevent extinction (e.g., taking naltrexone only duringabstinence).

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 leastin part by the opioid system, and for treating other opioidergically-reinforced compulsive behaviors, such ascompulsive 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 121DSM-IV alcoholics was conducted with therapy supporting complete abstinence (Supportive) or therapy forcoping with slips and aimed more at controlled drinking (Coping). The protocol differed from those used inearly naltrexone trials by eliminating several features that were predicted to be unnecessary on the basis ofpreclinical 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 drinkingby the Coping/Naltrexone group progressively diverged below that of the other groups, the difference reachingsignificance (p=0.05) in the last 8 weeks. These results are consistent with those of earlier trials. We also foundthat Coping/Naltrexone produced significantly fewer side effects during the first week of medication thanSupportive/Naltrexone.

The results indicate that prior detoxification and detention in an alcohol-free environment are notnecessary for effective treatment with naltrexone. Eliminating these in-patient steps sharply reduces the totalcost of treatment. The Coping/Naltrexone group averaged 2.1 naltrexone pills per week during the 20 targetedweeks, 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, andthus not having to start treatment over again. Follow-ups of previous trials prescribing naltrexone for only 12weeks 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 inour 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 OFOPIOID 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 addictionand 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 ofNaltrexone, that can provide a therapeutic blood level for up to one month, insuring compliance with a treatmentplan that includes pharmacotherapy and psychosocial recovery. Such assured compliance will improvetreatment outcome, as well as increasing acceptance of addiction treatment by such diverse bodies as medicalboards 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% gettreatment; in part because of these disciplines questioning treatment because of skepticism over patientcompliance. International exchange of information, as to the role of physician and medication development toimprove 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 wereenrolled in a randomized parallel group study conducted at six A-Clinics in southern Finland. The subjects wereallocated to receive placebo, 10 mg or 40 mg of nalmefene once daily for 16 weeks. The study subjects wereallowed 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) wasthe 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, themonthly number of HDDs decreased during treatment in all groups. The reduction was largest, almost 40 %, innalmefene 40 mg group and was evident already during the first weeks of treatment. The 10 mg dose appearedeffective during the first month in treatment (almost 30 % reduction in HDDs) but the effect was transient, withdrinking levels close to screening period during the two last months in the study. In the placebo group, thenumber 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 thenumber of abstinence days was greatest in 40 mg group, where, on average, one additional day without drinkingper week was achieved during the study. Mean weekly consumption decreased by nearly 40 % reduction with 40mg of nalmefene.

The most frequently encountered adverse events (AEs) that were apparently more frequent for nalmefene thanfor placebo included dizziness, nausea, fatigue, insomnia, decreased appetite, constipation and tinnitus. AEsoccurred predominantly at the beginning of treatment and subsided within a few days, with the exceptions offatigue and nausea. AEs led to discontinuation in only few subjects. Neither the AEs nor clinical laboratory testssuggested any specific organ toxicity.

It is concluded that nalmefene 40 mg once daily is safe and appears effective in the reduction of heavy alcoholconsumption without structured psychosocial treatment. To formally and more unequivocally show a superiorefficacy over placebo, a larger sample size would be needed. The efficacy of 10 mg once daily seems to bemarginal and transient.

FROM RAPID OPIATE DETOXIFICATION TO RAPID ANTAGONIST INDUCTION: CHANGINGCONCEPTS AND TECHNIQUES IN TREATMENT WITH ORAL AND IMPLANTEDNALTREXONE.

Dr Colin Brewer

The Stapleford Centre, 25a Eccleston Street, London SW1W 9NPAs the effectiveness of treatment withproperly supervised oral naltrexone (or the increasingly available depot preparations of naltrexone) is morewidely 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 ofdetoxification but also that they facilitate the initiation of naltrexone treatment. They should therefore beconceptualised 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 dowith the method of detoxification. RAI is much more effective and cost-effective than induction followingtraditional detoxification techniques. It is also clear that naltrexone can be initiated in a variety of settingsranging from the patient's home to an intensive care unit. While deaths associated with ROD remain small innumber, and although hardly any have occurred during the acute detoxification process, it looks as if techniquesinvolving relatively light sedation may have less potential for problems than more invasive procedures. Thispaper will review developments in detoxification methods, long acting naltrexone preparations, treatmentoutcome and the possibility of using pharmacological antagonists to treat other types of drug dependence.

MEDICAL PRESCRIPTION OF HEROIN TO CHRONIC TREATMENT-RESISTANT HEROINADDICTS: 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 AddictsUtrecht, The Netherlands

OBJECTIVE:In the Netherlands approximately 70% of the 25.000 heroin addicts are in contact with addiction treatmentservices. Of these about 70% are in methadone maintenance treatment. A substantial pro-portion of these latterpatients is functioning less than optimal indicated by continued illegal drug use, poor physical and mental healthand lacking social integration. The study aims to investigate the effect of the medical prescription of heroin inchronic 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 arandomized waiting list design with five treatment arms of 125 patients each. A group of 250 patients withpredominantly intravenous illegal heroin use will be randomized in two groups: one that will receive 12 monthsheroin immediately following randomization and another receiving heroin only after 12 months. A secondcohort of 375 patients who predominantly inhale their illegal heroin will be randomized in three groups: one thatwill receive 12 months of heroine immediately following randomization, one that will receive heroin for 6months only starting 6 months after randomization and finally one group receiving heroin only 12 months afterrandomization. Primary outcome variables include physical health (MAP-OTI), psychological well being (SCL-90), and social integration (ASI)

RESULTS:Currently all patients are enrolled in the study. No major medical or public order complications wereencountered 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 millionhard-core users.

Although many compounds have been evaluated for the treatment of cocaine dependence, none has beenapproved 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 offinding 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 nervoussystem homeostasis, 3) reducing craving, 4) treating underlying/co morbid conditions that may predisposesubpopulations 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 newmolecular entities that are being developed specifically for cocaine addiction (bottom up approach). Someexamples of medications that are currently in development are monoamines uptake inhibitors (GBR12909, andNS 2359) antidepressants (sertraline, venlafaxine, desipramine), dopamine agonists (cabergoline, amantadine),serotonine antagonists (ondansetron), mood stabilizers/antiepileptic medication (tiagabine, gabapentin), MAOinhibitor (selegiline), COMT inhibitor (tolcapone), and disulfiram.

Promising positive signals of efficacy have been shown in early phase II clinical trials for Selegiline (NIDAselegiline study report), and Disulfiram (Carroll et al, 1998; Petrakis et al, 1999; George et al, 2000). Screeningpilot 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 inpress) showed medication related reduction in cocaine use. Data from phase I safety trial of a cocaine vaccineare also promising.

New interest has arisen in biological markers of addiction to identify subtypes of patients who may responddifferently to specific medications. This approach may be promising in maximizing medication effect, orpredicting relapse. To explore this further, NIDA is implementing specific neuroendocrine, electrophysiologicalor 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 withthe focus on data from selective medications with positive signals.

COMPARISON OF RAPID OPIATE DETOXIFICATION AND NALTREXONE THERAPY WITHMETHADONE 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 andAlcohol Studies, Department of Psychiatry, University of Queensland, and the Alcohol and Drug Service, RoyalBrisbane Hospital, Queensland Health, Herston, Queensland, Australia)

Despite the claims and counterclaims for the benefits of naltrexone treatment and agonist maintenance, there hasnot been a controlled trial that has directly compared these treatments with patients randomly assigned to one orother 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 trialcomprised persons who were dependent on heroin, had attempted to detoxify several times previously, withoutsuccess, and were not on agonist maintenance. They were randomly assigned to (1) rapid opiate detoxificationunder anaesthetic followed by naltrexone treatment for a year, (2) rapid opiate detoxification under sedationfollowed by naltrexone, or (3) commencement on methadone maintenance. The second trial comprised patientswith 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 methadonemaintenance. Six months after randomisation, those allocated to methadone maintenance had the option ofundergoing 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 monthsafter 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 withmethadone maintenance will be summarised. The findings will be discussed in relation to the current debateabout the role of antagonist, abstinence-orientated treatment and agonist maintenance.

TRAMADOL ABUSE AND DEPENDENCE:AN ADDICTION MEDICINE PERSPECTIVE

Greg Skipper, MD, FASAMMedical Director, Alabama Physician Health Program, Montgomery, Alabama, USA 36104

David Smith, MD, FASAMMedical Director, Haight Ashbury Free Clinic, Past President, American Society of Addiction Medicine, SanFrancisco, CA, USA

Jim Tracy, DMDVice 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 prescriptionanalgesic since 1995. During the evaluation process prior to approval of Tramadol the Food and DrugAdministration, 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, whereTramadol had been available for years (2) its mode of analgesic action involving the stimulation of opiate mureceptors 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 subsequentscheduling (e.g. Darvon, Stadol, Talwin, and others). However, despite these concerns, because the abusepotential 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 healthprofessionals, 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 thenumber of potential subjects involved this represents a far higher incidence than would be expected from thepost-marketing surveillance data. The purpose of this paper is to highlight an Addiction Medicine perspectiveregarding Tramadol and its abuse and dependence potential. We suggest that health professional are the “pointmen” who demonstrate abuse and dependence with new prescription drugs prior to problems in the generalpublic. This is particularly true when the potentially addictive drug is released as an uncontrolled drug as iteasily finds its way into physicians sample shelves and is readily available to them. It is suggested that theAmerican Society of Addiction Medicine consider developing its own committee to assess the addictivepotential of drugs.

MEDICATIONS FOR THE TREATMENT OF OPIATE DEPENDENCE: CURRENT THERAPIESAND NEW DEVELOPMENTS

Frank Vocci

Division of Treatment Research and Development, National Institute on Drug Abuse, National Institutes ofHealth, Bethesda, Maryland, USA, 20892

Methadone is the primary medication used in the treatment of opiate dependence in the USA. TheAmerican Methadone Treatment Association estimates that 179,000 patients are being treated with opiateagonists, primarily methadone. Methadone was identified in the early 1960s by Dole, Nyswander, and Kreek asan 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 oreliminate illicit opiate use and improve treatment retention. The beneficial effects of methadone on reduction ofopiate use and treatment retention are dose-related. These effects result in a fourfold reduction in mortality riskand a seven fold reduction in HIV risk.

Levomethadyl Acetate (LAAM) is a methadone congener that is converted to active metabolites, nor-LAAM and dinor-LAAM. LAAM is administered on a three times per week or an every other day basis. Theeffects of LAAM are similar to methadone; reductions in opiate use are dose-related. LAAM was approved bythe US Food and Drug Administration (FDA) in 1993. Recently, LAAM has been relegated to second linestatus and a “black box” warning was placed in the LAAM product labeling, warning of QT prolongation andthe possibility of toursade de pointes.

Naltrexone is an orally active opiate antagonist that is approved for use in detoxified opiate addictedpersons. Naltrexone has been demonstrated to reduce relapse and recidivism in formerly opiate dependentprobationers. Problems with adherence to naltrexone therapy have resulted in the development of injectabledosage forms of naltrexone. Clinical pharmacology studies have documented significant opiate blockade for atleast one month with a depot naltrexone dosage form. These dosage forms are currently in Phase II clinicaltesting.

Buprenorphine is a mu opiate partial agonist that is currently marketed in several countries for the treatmentof opiate dependence. Sublingual dosage forms of buprenorphine and buprenorphine/naloxone combinationtablets are currently in development in the USA, having reached “approvable” status at the FDA. Evidence forthe efficacy in the treatment of opiate dependence will be reviewed. NIDA is sponsoring a multicenter “bestpractices” trial of buprenorphine/naloxone in non-clinic settings to determine guidelines for patient visitationand buprenorphine/ naloxone prescribing practices.

Lofexidine is an alpha 2 adrenergic agonist that is currently under evaluation for its effect to ameliorate theopiate withdrawal syndrome.

New medications for the treatment of opiate dependence will be developed from an increased understandingof the neurobiology of opiate addiction. For example, there is evidence that the stress (corticotrophin releasingfactor 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 opiateintake.

CRAVING BY IMAGERY CUE REACTIVITY IN OPIATE DEPENDENCE FOLLOWINGDETOXIFICATION

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 markedwith 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 authorshave postulated that exposure to various internal and external stimuli associated with drug use (drug cues), maytrigger conditioned reactions, which in turn increases the drug taking behaviour in them. Aim: The present studywas aimed at exploring the effects of imagery cue exposure on measures of craving and autonomic arousal inopiate addicts following detoxification. Material and methods: Opiate dependent subjects (N=38) followingdetoxification underwent imagery cue reactivity trials. In this procedure subjects were asked to describe verballyand then imagine their craving experiences. Craving was measured subjectively by using heroin cravingquestionnaire and autonomic parameters of galvanic skin resistance (GSR), systolic blood pressure (SBP), heartrate (HR), and skin temperature (ST) was taken during drug related cue imagery. Spearman’s r and Wilcoxonsigned ranks test where employed in analysis. Multivariate repeated measurement analysis (wilk’s Lambda) wasemployed wherever appropriate. Results: significant increase in subjective ratings on the measures of cravingand 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 toneutral cues. Conclusion: The results supports the earlier evidence that cue imagery is a powerful tool ineliciting 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

1Centre for Prevention and Treatment of Illegal Drug Dependence, Koper, Slovenia2University Psychiatric Hospital, Ljubljana – Polje, Slovenia3Regional Institute of Public Health, Koper, Slovenia

The aim of the study was to find out clinical and sociodemographic differences between heroin addicts withoutand with comorbidity (substance abuse and mental illness - SAMI) who seek help in outpatient methadoneclinic. Fortyseven patients (32 males, 15 females) from outpatient methadone program in Koper, Slovenia wereincluded (23 SAMI and 24 addicts without comorbidity (AWC)). AbSo questionnaire was used. Diagnoses weremade 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 ofthe whole group were as follows: mean age 25.2 years, age at first contact with an illegal drug 18.5 years, age atcontinuos 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. Meandose of methadone in SAMI patients was 63.4 mg and in AWC 43.7 mg daily (p=0.10). Physical relatedproblems were similary distributed in both groups. Only 15% of patients had insight. The following differncesbetween 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 beforeinclusion in treatment programme (56.5% vs. 29.2%), pre-inclusion amphetamine abuse (30.4% vs. 8.3%). Priorto inclusion in programme all SAMI patients used heroin more than once daily. Drugs as automedication used39.1% of SAMI patients. Due to multiple problems, SAMI patients need intensive treatment approach directedtowards 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 andWestmead Hospitals, Sydney, Australia, Et al

Background:Experimentation with smoking and alcohol is common amongst adolescents. Of this group some may engage ina 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 expulsionfor those students whose behaviour has reached unacceptable limits. These students may have multidimensionalproblems 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 useand smoking.

Aims:To explore whether suspended school students presenting to our medical service have smoking and alcohol userates which are higher than their peers.

Methods:Those teenagers (aged over 14 years) referred to the Outpatient Department of Adolescent Medicine, WestmeadHospital were asked whether they had ever been suspended from school. Those who had were asked to completethe Health Behaviours of School Students questionnaire. This study looks at the responses to the smoking andalcohol use questions. These results were compared with the most recent statewide data from the 1996 NSWHealth Behaviours of School Students survey.

Results:The findings from this survey to date indicate that these suspended students have higher rates of smoking anddrinking compared with the NSW sample. The suspended students were more than 5 times more likely to smokemore 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 athigher 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 studywere 56, all males, age between 25 and 50 y., income 10,000-18,000 US dollars; education: high school. 20subjects were alcoholics, 20 were social drinkers, according to WHO classification, 16 were abstinent. Theaggressive 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) aggressivenesslevel was significantly (P<0.05) increased in social drinkers and alcoholics, while intropunitive (I) andimpunities (M) behavior levels were significantly (P<0.05) increased in abstinent subjects than in social drinkersand alcoholics. The dominant reaction for the alcoholics was Ego-defense (E-D), instead of obstacle-dominance(O-D) and need-persistence (N-P).Moreover, the amount of alcohol intake seems relevant for the impaired situation control, as a significantdifference was found between social drinkers and alcoholics for Ego-defense levels. Indeed, coping skills forfrustration was normal in social drinkers, like in abstinent subjects.

NALTREXONE (NTX) THERAPY FOR THE CONTROL OF CRAVING IN ALCOHOLICS:RESULTS IN FAMILY HISTORY-POSITIVE SUBJECTS

Ceccanti M., Attilia M.L., Sebastiani G, Berretta F., Coriale G., Silli L.,Ioni M.F., Ulanio F, Balducci G.*

Alcohol Liver Disease Unit, Dep. Clin. Medicine, University La Sapienza, Rome(*) National Institute of Health – Rome, Italy

In 1992, Volpicelli et al. performed a randomized, double-blind, clinical trial to investigate if NTX was effectivein the prevention of relapse in alcoholics when abstinent. Their results showed a good effect with respect toplacebo in the control of craving for alcohol, thus suggesting the involvement of opioid system in alcoholdependence. A different endorphine pattern was also reported in alcoholics from families with a high density ofalcohol-dependent subjects.A series of 55 male alcoholics, abstinent from alcohol for more than 3 weeks, was enrolled in this study, andwas split into 2 subset, according to positive or negative family history. A family history-positive subject wasone whose biological father and at least one additional relative was alcohol-dependent. The patients were treatedwith NTX, 50 mg/day and psychological support. Dropout and relapse patients (subjects reporting drinking 5 ormore days within 1 week or reporting 5 or more drinks per drinking occasion) were evaluated at 4 weeks (T4)and 12 weeks (T12)

DROPOUT AND RELAPSE (%)Assessment time T4 T12

Treatment NTX Placebo NTX Placebo

Family-positive 0 35,0 0* 58.5*

Family-negative 25.0 16.8 56.0 25.0

*Fisher exact test: P< 0,04.

According to our results (if confirmed by further research), NTX treatment, at the dose used in this study, shouldbe restricted to alcoholics with positive family history. In fact, among family history-negative subjects, thedropout and relapse values were greater (but not at significance level) in NTX-patients than in placebo-patients,with a Risk Ratio (RR) increase by a 2.5 factor for relapse.

ASSESSMENT OF READINESS TO CHANGE QUESTIONNAIRE (RTCQ) TEST IN AN ITALIANPOPULATION OF ALCOHOLICS. PRELIMINARY REPORT

Ceccanti M., D’arista F., Lucidi F.*, Berretta F., Giaccio S., Mauri B.,Fiorentino D., Attilia M.L., Balducci G. §

Alcohol Liver Disease Unit, Dep. Clin. Medicine, (*) Dep. Psychology, University “La Sapienza”, (§) NationalInstitute of Health, Rome, Italy.

An Italian translation of the 12-items “Readiness To Change Questionnaire” (RTCQ) was made by our researchgroup for a clinical application in an Italian population of alcoholics. The purpose of this study was theevaluation of RTCQ as screening test for the assessment of the motivation to stop drinking, using the results asguidelines for the following treatment: motivational interview, coping skills therapy, cognitive behavioraltreatment. According to the Prochaska and Di Clemente model, an unselected population of chronic alcoholics(n=174), according to DSM-IV definition of alcohol dependence, hospitalized (day-hospital) in our AlcoholUnit, was split into three subsets: pre-contemplation (7.4%), contemplation (36.2%), action (56.4%). RTCQ testwas administered by a trained psychologist. According to factor analysis, the 3 factors (pre-contemplation,contemplation, action) explained the 58 % of variance, fairly close to reported data. Internal consistency(Crombach’s _) was significant for action (0.80), at significance limits for contemplation (0.66) andprecontemplation (0.63).Thus, according to our results, RTCQ test, in our Italian translation, seems useful for the assessment of themotivation stage. The significance of internal consistency for precontemplation and contemplation subsets willincrease probably as the number of subjects on study will be increased.Further research is performed at present in our Unit to assess the RTCQ predictive value of changes in drinkingbehavior.

CHARACTERISTICS OF DRUG-ABUSERS IN THE EARLY TREATMENT

Jadranko Gali _ , Sanja Jeli_, Snje_ana _alamon, Ksenija Butorac, Luca Sablji_, Andreja Rogar, Andrea SilviaHotujac

City Drug Abuse Prevention Center, Psychiatric Hospital Vrap_e, Park prijateljstva 1, HR-10000 Zagreb,Croatia

City Drug Abuse Prevention Center in Zagreb provides an early treatment of the drug-abusers with the maingoal to prevent fully developed addicton disorders. Clients have an opportunity to get information, counseling,education and psychotherapy, including raising the awareness about adaptive and behavioral difficulties andsupporting drug-free life adaptive mechanisms. The paper will present characteristics of the drug-abusersundergone early treatment in the Center in one year period (2000).Total number of clients that had asked for the intervention is 1066; 491 ( 46%) of them were included in the fulltreatment programs. Family or institutional initiative (social services, District Attorney or school services)triggered most of clients' coming to the Center. Only 9% of the clients came on their own initiative. Mean age is19,9 years, the common population are high-school students. Male to female ratio is 4:1, without agedifferences. Most of them (71,9%) have whole families, no previous treatment for drug-abuse (78,4%) and havenot been previously prosecuted for criminal actions (85,4%). The most commonly abused substance ismarijuana, then ecstasy, heroin, LSD, etc. Dominant motivation declared by drug-abusers is curiosity,entertainment and peer influence. The group evaluated in this paper consists of mostly "weekend consumers" ofpsychoactive substances, without severe signs of psycho-physical and social deterioration. Presented data pointout some specifics of the target group that are important in creating drug-abuse prevention programs.

PSYCHOSOCIAL ISSUES IN FEMALE OPIOID DEPENDENCE –AN INDIAN SCENARIO

Dr. Udayan Khastgir, Dr. Utpal Goswami, Dr. Unnati Kumar and Dr. Debakanta Behera

Department of Psychiatry, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India 110001

Background: Till recently substance use disorder was considered to be primarily a male problem, but now thegender difference in various aspects of substance use disorders has received increasing attention. Aim: To studythe various social, demographic, and psychiatric aspects of opioid dependence in females; and then comparingthem with males having opioid dependence disorder. Method: The various sociodemographic factors and drugtaking behavior of 37 females with Opioid Dependence Disorder (DSM-IIIR) were compared with 35 maleopioid dependence disorder patients. The psychiatric comorbidity of both the groups was also studied. Results:The average age of the females (31.2+ 4.9) with opioid dependence was more as compared to the males(30.4+9.7). Most of them were housewives (96.8%), either illiterate or educated till primary level (86.5%),married (73.9%), belonging to a nuclear family (67.5%) and having lower socioeconomic status (81.0%). Theduration of dependence and the daily amount of drug consumed were significantly less when compared to themales (p<0.01). 81% of the females had one or more previous attempts to abstain and had good motivation.Most of the patients (83.8%) had been initiated to this habit by their husbands, who themselves were opioiddependence. Benzodiazepines were the commonest drug abused along with opoids by these patients. 56.7% ofthe women had a co-morbid diagnosis of depression. Conclusion: Females begin using the substance at a laterage, generally take lower dose, are introduced to the drug by their husbands, more motivated than the males andso come for the treatment earlier; and also have a higher prevalence of a co morbid psychiatric illness. So thesefindings will improve the treatment outcome of opioid dependence in females.

MODE OF PREVIOUS HEROIN USE AND METHADONE DOSE IN MAINTENANCE

Okruhlica, L., Rakova, M., Klempova, D.

Centre for Treatment of Drug Dependencies, Hranicna 2, 821 05 Bratislava, Slovak Republic

The main objective was to study association between the mode of heroin use before beginning with methadonemaintenance, and the amount of daily methadone dose while in methadone maintenance program in Bratislava.There were 76 patients, 15 females and 61 males, with mean age of 30 years (SD + 6.3) in this pilot studysample. The mean daily methadone dose was 138 mg (SD + 5.3) in the group of former i. v. heroin users (n=68),which was statistically significantly higher (p<0.01) in comparison with mean methadone dose 75 mg (SD +5.3) in the group of former non i. v. heroin users (n=8). Consistently, the difference was found between groupsin plasma methadone concentrations (394 vs. 189 ng/ml, respectively). Conclusion: The mode of heroin usecould be useful predictor of the level of daily methadone dose (higher or lower), which is needed forstabilization of patient in methadone maintenance program. The limitations are discussed, such as small numberof subjects, and also hypothetical interpretation of the findings, in this paper.

ALCOHOL – RELATED NEUROMUSCOLAR DEMAGE IN YOUNG PATIENTS

G. Tamaro, R. Simeone, S. Renier, GB. Modonutti

Istituto per l’infanzia, Trieste, Italy

Alcohol has a direct toxic effect on liver and muscle cells in chronic alcoholics, but alcohol consumption is alsothe most important cause of acute poisoning in teenagers and represents a public health problem also in youngpopulation.Many biochemical parameters are usually employed for the evaluation of alcohol liver toxicity (ALT, AST,GGT, CDT); different tests are useful markers for acute or chronic abuse. The aim of this study was theevaluation of neuromuscular damage through determination of creatine kinase and its isoenzymes (CPK – MM,MB, BB) in 45 young patients admitted in hospital for acute and occasional heavy alcohol intake.The following parameters were tested: ALT, AST, GGT and its isoenzymes, CPK and isoenzymes, CDT andMCV. High levels of alcohol (150 – 200 mg/dl) were found in all patients without evidence of liver damage: alltests were within normal values. On the contrary, variations of neuromuscular markers showed a commonpathological pattern for the appearance of CPK – B subunit and CPK – MB and CPK – BB isoenzymes.Alterated ratio of CPK – MB is probably related to alcohol cardiotoxicity and alcoholic myopathy alsoconfirmed by total CPK increase, while the appearance of CPK – BB in serum is considered a marker ofcentral and peripheral nervous system toxicity. Pathological variations of CPK isoenzymes have clinicalrelevance even when the total CPK activity is not elevated.Our data showed a close correlation between these biochemical abnormalities and clinical symptoms duringacute alcohol intake and we believe that alcohol can trigger muscle and nervous damage in young subjects evenduring occasional consumption outside of chronic abuse; we suggest the determination of serum enzymeactivities for the evaluation of specific organ diagnosis toxicity.

Helping to find a way out

sage across the blood brain barrier. Acamprosate may act by stimu-lating GABAergic inhibitory neurotransmission and antagonisingexcitatory amino-acids, particularly glutamate. Animal experimentalstudies have demonstrated that acamprosate affects alcohol depen-dence in rats, decreasing the voluntary intake of alcohol withoutaffecting food and total fluid intake. Pharmacokinetic properties:Acamprosate absorption across the gastrointestinal tract is moder-ate, slow and sustained and varies substantially from person to per-son. Food reduces the oral absorption of acamprosate. Steady-statelevels of acamprosate are achieved by the seventh day of dosing.Acamprosate is not protein-bound. Oral absorption shows consid-erable variability and is usually less than 10% of the ingested drug inthe first 24 hours. The drug is excreted in the urine and is notmetabolised significantly. There is a linear relationship between cre-atinine clearance values and total apparent plasma clearance, renal

clearance and plasma half-life of acamprosate. The pharmacokinetics of acamprosate are not altered by hepatic dys-function. Preclinical safety data: In the preclinical studies, signs of toxicity are related to the excessive intake of calciumand not to acetylhomotaurine. Disorders of phosphorus/calcium metabolism have been observed including diarrhoea,soft tissue calcification, renal and cardiac lesions. Acamprosate had no mutagenic or carcinogenic effect, nor any tera-togenic or adverse effects on the male or female reproductive systems of animals. Detailed in vitro and in vivo researchon acamprosate to detect genetic and chromosomal mutations has not produced any evidence of potential genetic tox-icity. Pharmaceutical particulars: List of excipients: Each tablet contains Acamprosate 333.0 mg as the active ingredient.Crospovidone (KOLLIDON CL). Microcrystalline cellulose (AVICEL PH 101). Magnesium silicate (COMPRESSIL). Sodiumstarch glycolate (EXPLOTAB). Anhydrous colloidal silica (AEROSIL 200). Magnesium stearate. Anionic copolymer ofmethacrylic acid and acrylic acid ethyl ester (EUDRAGIT L 30 D). Talc. Propylene glycol. Incompatibilities: None known.Shelf life: 3 years. Special precautions for storage: None. Nature and contents of container: Aluminium/PVC sheets of blis-ters containing 12 or 20 tablets. Sheets of blisters are presented in cartons of 48, 60, 84 or 200 tablets. Polypropylene bot-tles of 125 ml capacity, closed with a tamper-evident polypropylene cap, containing 180 tablets. Instructions for use/handl-ing: Not applicable. Name and address of holder of marketingauthorisation: LIPHA S.A. • 34 rue Saint Romain • 69379 LYONCedex 08 • FRANCE Marketing authorisation number. Date offirst authorisation/renewal of authorisation. Date of revision ofthe text: July 1995.

Name of medicinal product: Campral 333 mg coated gastro-resistanttablets. Qualitative and quantitative composition: Each tablet con-tains acamprosate (I.N.N.) calcium 333.0 mg as the active ingredient.Pharmaceutical form: Enterocoated tablets. Clinical particulars:Therapeutic indications: Acamprosate is indicated as therapy to“maintain abstinence in alcohol dependent patients”. It should becombined with counselling. Posology and method of administration:Adults: • 2 tablets of acamprosate taken three times daily with meals(2 tablets morning, noon and night) in subjects weighing 60 kg ormore. • In subjects weighing less than 60 kg, 4 tablets divided intothree daily doses with meals (2 tablets in the morning, 1 at noon and1 in at night). Children and the Elderly: acamprosate should not beadministered to children and the elderly. The recommended periodof the treatment is 1 year. Treatment with acamprosate should be initiated as soon as possible after the withdrawal period and shouldbe maintained if the patient relapses. Contraindications: Acamprosate is contraindicated: • in patients with a knownhypersensitivity to the drug • in pregnant women and lactating women • in cases of renal insufficiency (serum creati-nine>120 micromol/L) • in cases with severe hepatic failure (Childs-Pugh Classification C). Special warnings and special pre-cautions for use: Acamprosate does not constitute treatment for the withdrawal period. Interaction with other medica-ments and other forms of interaction: The concomitant intake of alcohol and acamprosate does not affect the pharma-cokinetics of either alcohol or acamprosate. Administering acamprosate with food diminishes the bioavailability of thedrug compared with its administration in the fasting state. Pharmacokinetic studies have been completed and show nointeraction between acamprosate and diazepam, disulfiram or imipramine. Pregnancy and lactation: Although animalstudies have not shown any evidence of foetotoxicity or teratogenicity, the safety of acamprosate has not been estab-lished in pregnant women. Acamprosate should not be administered to pregnant women. Acamprosate is excreted in themilk of lactating animals, safe use of acamprosate has not been demonstrated in lactating women. Acamprosate shouldnot be administered to breast feeding women. Effects on ability to drive and use machines: Acamprosate should notimpair the patients ability to drive or operate machinery. Side-effects: Adverse events associated with acamprosate tendto be mild and transient in nature. The adverse events are predominantly gastrointestinal or dermatological. Diarrhoea,and less frequently nausea, vomiting and abdominal pain are the gastrointestinal adverse events. Pruritus is the pre-dominant dermatological adverse event. An occasional maculopapular rash and rare cases of bullous skin reactions havebeen reported. Fluctuation in libido have been reported by patients receiving acamprosate as well as by patients receiv-ing the placebo. Overdose: Five cases of overdose associated with acamprosate therapy have been reported in humans,including one patient who ingested 43 g of acamprosate. After gastric lavage all patients had an uneventful recovery.Diarrhoea was observed in two cases. No case of hypercalcaemia was reported in the course of these overdoses. However,should this occur, the patients should be treated for acute hypercalcaemia. Pharmacological properties:Pharmacodynamic properties: Acamprosate (calcium acetylhomotaurinate) has a chemical structure similar to that ofamino-acid neuromediators, such as taurine or gamma-amino-butyric acid (GABA), including an acetylation to permit pas-

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