Monday, August 3, 2009
The UCSD Center for Criminality & Addiction Research, Training & Application (CCARTA) is holding its annual Summer Clinical Institute in Addiction Studies. The conference is open to the public and of interest to anyone interested in discovering the latest in addiction science, treatment, and social impacts.
MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh. You're listening to These Days on KPBS. We all know that it's very difficult for people addicted to substances from heroin to nicotine to kick the habit. The rate of successful treatment of addiction is usually low and many people who do quit, have at least one or more relapses into addictive behavior. This situation is heartbreaking for addicts and their families, but it is also frustrating for the people whose life's work is treating addicts. Doctors and researchers in addiction studies are constantly evaluating methods to treat addiction and help people internationally avoid getting addicted in the first place. UCSD is holding its 38th Annual Summer Clinical Institute in Addiction Studies. And two of the prominent participants in that event are my guests this morning. I’d like to welcome Phaedon Kaloterakis, who is Director of KETHEA in Greece. It is the largest institute for prevention and treatment of addiction in Europe, and welcome.
DR. PHAEDON KALOTERAKIS (Director, KETHEA): Thank you. Thank you very much.
CAVANAUGH: And Dr. Igor Koutsenok is Assistant Professor of Psychiatry at the UCSD School of Medicine and Director of the Center for Criminality and Addiction Research Training and Application. And, Dr. Koutsenok, thank you for joining us.
DR. IGOR KOUTSENOK (Physician, Director of the Center for Criminality and Addiction Research Training and Application): Thank you. Good morning.
CAVANAUGH: I would like to start in asking you some questions about this event that’s taking place this week. It’s the 38th Annual Addiction Conference being held by UCSD. Who attends and what are they looking for from the conference?
DR. KOUTSENOK: We have a very large range of students and attendees from Ph.D. psychologists to substance abuse counselors, social workers, criminal justice professionals, physicians, nurses. It’s really a very across the board professionals from all kinds of disciplines, people who are trying to help in addiction treatment and addiction prevention. And I guess their rationale to come is not just to come to La Jolla, to visit San Diego, which is beautiful.
DR. KALOTERAKIS: That’s not a bad rationale, by the way.
DR. KOUTSENOK: Yes, it’s not a bad idea. I think the – what really attracts them is the level of the presenters and teachers and faculty. These are people who – people from all over the world and these are people who bring the best, the most recent science, not just academic science but the science that can be implemented practically, so that’s why these people are there. We will teach them. We will help them to implement the scientific findings—and we have a lot—into their real practice.
CAVANAUGH: Now what is addiction as you define it in this conference? Are there a wide range of substances and behaviors that people can get addicted to or do you specify certain addictive behaviors?
DR. KOUTSENOK: Well, this conference is about the substance use disorders, and substances use, abuse and dependence of psychoactive substances. In terms of the definition of addiction, addiction is a repetitive, maladaptive behavior, despite obvious psychological behavior or biological problems or psychosocial problems. So as you see, in the definition of addiction, there is no – there is not even a word about substances.
DR. KOUTSENOK: It’s a behavior that is problematic. So whether the person is addicted to substances or gambling, some of the basic mechanisms are – they are not the same but there is a lot of similarities there.
CAVANAUGH: Exactly. And, Dr. Kaloterakis, as you practice in Greece, are – do you know a comparison between the United States and Greece in the sense of do you think the addictive behavior, the addictive people that you see are basically the same as here in the United States?
DR. KALOTERAKIS: Of course. Of course. There are many similarities. The social conducts might be different because the culture is different, the cultures, I should say. But addiction, as a behavior, because that’s what we’re talking about, it is the same. So there are not that many differences from here in U.S. to Europe to Greece, most specifically. It is the same thing. And that’s why this exchange of experiences, of the know how, of all the scientific data is very important, not only for the people who will attend this summer institute but for us who came from Europe to speak. So…
DR. KALOTERAKIS: …it’s an opportunity for them.
CAVANAUGH: It is an opportunity for everyone…
DR. KALOTERAKIS: Yeah, exactly.
CAVANAUGH: …who’s going to be attending. I wonder, if there are new substances coming up that you notice that more and more people are addicted to? Or is it just sort of the same things that we generally know? Alcohol and the heroin and, in some cases, cocaine? Is it – are there new things…?
DR. KALOTERAKIS: Yes, the biggest of these, at least in Europe…
DR. KALOTERAKIS: …is heroin, alcohol and cocaine but the new trend is methamphetamines. The Ecstasy is a big thing. And one of the reasons is because it is – it can be produced at home. I mean, it’s easy produced so you don’t have to move it from country to country and then we have the problem of policing and all this. So methamphetamines in Europe are becoming big. The use of methamphetamines is becoming quite problematic. But heroin and alcohol are still the two big ones, except for Spain, for example, that has this connection with Latin America, I mean, all the flags that go fly in America from Europe go through Spain, so there we have a lot of cocaine. I mean, as I said, the cultural thing is important but still an addiction is an addiction.
CAVANAUGH: And Dr. Koutsenok, when it comes to rates of addiction, are there some countries that have a very high rate of addiction? Like I’ve heard that alcoholism is especially a problem in Russia. Or is it basically similar throughout – internationally in various countries?
DR. KOUTSENOK: You know, it goes in cycles. There are cultures that they’re more permissive to alcohol use than to drug use, for instance some of the Scandinavian countries. In Russia, it’s a part of the culture. It’s a part of many different things including local legislation. But the important thing for me to say is, first, I don’t think there is anything dramatically new in terms of the substances. I mean, there’s some variations right now but we need to remember that the development of dependence, the development of addiction is a combination of at least three players: the substance, the chemical, the individual who’s using the chemical, and the environment in which this process unfolds. So when we talk just about the chemical, forgetting about two other participants in this process, I don’t think we’ll go any – we’re going anywhere. So, right, substances change but not something drastically, dramatically. Yes, there are some cultures, as I said, with more emphasized use of some type of chemicals versus other types and there’s some genetic reasons for that. There’s some environmental reasons for that as well, cultural, traditional.
CAVANAUGH: I’m speaking with Dr. Igor Koutsenok and Dr. Phaedon Kaloterakis, and we are talking about the 38th Annual Summer Clinical Institute in Addiction Studies that’s taking place this week at UCSD. You know, in preparing for this segment, I read a little bit about what the president of the U.N.’s International Drug Control Board said in his statement this year, and it was sort of surprising to me because we usually think of problems with substances and painkillers and that people become addicted to them and we want to stamp them out. But what he was addressing is that there are millions of people around the world who are suffering because they do not have access to controlled painkillers. One of the reasons is that doctors and the medical hierarchy are afraid of people becoming addicted. I wonder if either of you would like to comment on that?
DR. KALOTERAKIS: Well, I would like to follow on what Dr. Koutsenok said. There are no bad substances or good substances. You cannot attribute, let’s say, a moral adjective to substances. The substances are substances. It is us humans who get into a relationship with the substance. We use a substance and it makes a difference. So it’s the same with the painkillers or with the prescription drugs, it’s how we use them. And it can be problematic, of course, but it can also be helpful. So it’s how you deal with it that makes a difference. And it takes the user, the person who needs it, and also the physician, the doctor, to regulate this. That’s all. It’s not – it’s not really sky rocket science, if you think about it.
DR. KOUTSENOK: And we…
CAVANAUGH: And will you be talking about how to balance those two? That fear of addiction with the relief of suffering?
DR. KOUTSENOK: Yes, and one of the ways to reduce the anxiety and the fear in professionals, including in physicians, is by improving their education and their training.
DR. KALOTERAKIS: Right.
DR. KOUTSENOK: Because, in fact, the addictive disorders and treatment of addictions and substance use disorders really have very little place in physicians’ training. And this is probably one of the reasons why many physicians are afraid of prescribing or prefer – they avoid prescribing different types of substances is because they have never been trained properly how to do it, so this is one of the things that we need to emphasize.
CAVANAUGH: We have a caller on the line. Jim is calling from La Mesa. And good morning, Jim, and welcome to These Days.
JIM (Caller, La Mesa): Good morning. It’s really a very interesting topic. Listen, California’s beginning the drive, it may not actually come to fruition but to legalize the use of marijuana. I’m kind of curious what your clinical opinions are of that possible initiative.
CAVANAUGH: Thank you, Jim.
DR. KOUTSENOK: Well, if you have at least two hours more to talk about it, I would love – In – Very briefly, if I may. I’m against it, first. Secondly, when we talk about these kind of things, we need to make it sure – we need to make sure that we understand the difference between crimin – legalization and decriminalization. I’m definitely – I would consider decriminalization. I think it’s a good idea. I don’t think the legalization will give us any better situation than it is now simply because I don’t have any evidence. This kind of – this issue is – has always been filled with emotions and attitudes. I think the decisions of that magnitude must be based on science, on data, not emotions. So I understand the emotional attitude but I would not base my decision on the emotions.
CAVANAUGH: And let me ask, you know…
DR. KALOTERAKIS: I would like to say…
CAVANAUGH: Yes, please.
DR. KALOTERAKIS: …to add something to this. I cannot speak about California. I can speak about Greece or Europe. In Greece, for example, the marijuana use is decriminalized. Marijuana is not legalized but marijuana use is decriminalized, and I think this is the right way to go. And I agree with Dr. Koutsenok that we shouldn’t go on legalizing and let me give you one aspect of this. It’s what they call the educational aspect. It’s different for an adult to think about using it or not using it, you know, for recreational purposes. But with the younger – the younger generation, the adolescents or the teenagers, then you have a problem because they learn certain behavior and they learn by using one drug to escape, which is not done with alcohol all of the time. You can drink some alcohol just for the taste of it. But with marijuana, you always do it to get the high, right? So you learn a behavior which might lead – might open a door for more severe and problematic behavior as well, so we should be very careful with that.
CAVANAUGH: And I know, Dr. Koutsenok, that you deal a great deal with the subject of addicts in prison. And if you could, what is the difference between decriminalization and legalization?
DR. KOUTSENOK: Well, decriminalization means that the use itself, the possession of the drug and the use itself, should not be prosecuted. This is a public health problem. People need to receive appropriate treatment but they should not be prosecuted or sent to prison. But that’s pretty much what it is now because there are very few people right now in prisons or doing time because they had some marijuana or they smoked a joint.
DR. KALOTERAKIS: But…
DR. KOUTSENOK: Very few are there for that. So this is decriminalization. Legalization means you can go and buy it from a store exactly like alcohol. Well, listen, we already have so many problems with alcohol and tobacco, I don’t see any reason to create another one.
DR. KALOTERAKIS: May I?
DR. KALOTERAKIS: That would be a naïve way to deal with it. For example, in Greece, 70% of the people incarcerated or the people in prison are because of the drug law, which is wrong. I mean, you know, you shouldn’t be punished for using something for yourself, so you need to change that. But to legalize it, it’s a different matter. And I think it’s very naïve of us to think that if you legalize it this will solve many problems. I – Well, it’s a long – it’s a big discussion as Dr. Koutsenok said before.
DR. KALOTERAKIS: But I think we should be more wise.
CAVANAUGH: One last question about this, I wonder, do you think there is a certain consensus among people who work in addiction studies that incarcerating people who are addicted to substances just for their addiction, just for using the substance, is a bad idea?
DR. KOUTSENOK: I don’t know about consensus.
DR. KALOTERAKIS: No.
DR. KOUTSENOK: I mean, consensus in the addiction field is a difficult thing in any area. I would – I wouldn’t say we have consensus but there – the – most people who are professionals in this field, not just professionals in addiction treatment, but even criminal justice professionals, they understand that sending people to prison just for use doesn’t make much sense from multiple perspectives. Even think about it, substance dependence is a chronic and relapsing condition. Unfortunately, it will stay for a long time. It’s not like appendicitis; you operate, it’s over. People who are doing time in prison and they have addictive disorders, most of them don’t do life. They will go out. When they go out, the chance – and if they don’t get any treatment, the chances are they will get worse very soon. So if we keep sending them over and over to a prison, it doesn’t really solve any problem. It creates multiple other problems. So I don’t think it’s a good idea to incarcerate people just for use. They need to be treated, they need to be treated professionally, they need to be treated carefully by trained professionals.
CAVANAUGH: I am speaking with Dr. Igor Koutsenok and Dr. Phaedon Kaloterakis, and they are both participants in this week’s Summer Clinical Institute in Addiction Studies at UCSD. And I wanted to move on and – Dr. Koutsenok, and ask you, I know that one of the conference topics is the link between post traumatic stress disorder and addiction. And since you’re here at UCSD, can you tell us if members of the military returning from Iraq and Afghanistan are at more of risk of developing addictions?
DR. KOUTSENOK: Well, anybody with traumatic experience in the past, with or without post traumatic stress disorder, is at higher risk to start using substances and eventually develop problematic behavior and problems with drugs. The guys who are coming back from – from the war, many of them have lots of traumatic experiences. Quite a few of them have post traumatic stress disorder, quite a few of them have traumatic brain injury. The department that I work for, the Department of Psychiatry, is very sensitive to their needs and we have the Center for Stress and Mental Health within our department. I don’t work at the center but people who do work, I know them well and they’re really doing a fabulous job trying to address this issue and help veterans with PTSD or traumatic histories. Definitely, the addiction treatment for this population has some specifics, definitely these people do need treatment and probably a long term treatment. And definitely, they need a lot of support in multiple areas to – just to help and to readjust.
CAVANAUGH: Would addiction in that case be a form of what they call self-medication?
DR. KOUTSENOK: Yes, this is one of the few cases of real self-medication. The self-medication idea is very common although it’s by far less common than people think. The PT – self-medication means people who are mentally ill, they use substances to reduce the intensity of unpleasant symptoms. Well, most of the mentally ill don’t use substances for that reason because those substances make mental health symptoms worse, not better. In case of PTSD, this is exactly one of the few examples of a real self-medication. People use all kinds of substances, alcohol, and legal, illegal drugs to avoid the flashbacks, to be able to sleep, to be able to concentrate. Yes, you are right. This is a case of self-medication.
CAVANAUGH: It’s interesting. And Dr. Kaloterakis, in your work in Greece, do – have you run across any really promising new therapies or new anti-addiction drugs or anything like that to help people wean themselves off from addiction?
DR. KALOTERAKIS: Right. They’re not new.
DR. KALOTERAKIS: I can speak about promising therapies, yes, but they’re…
DR. KALOTERAKIS: …not that new. And let me say that I think we, in Europe, owe a lot to our American colleagues here and, a parenthesis, for me it’s an honor to be here and to be able to have a dialogue with my American colleagues. Therapeutical communities, for example, that’s one method that really works…
CAVANAUGH: I’m sorry. Say that again. I’m sorry.
DR. KALOTERAKIS: Therapeutic communities.
CAVANAUGH: Okay. Thank you.
DR. KALOTERAKIS: That’s a method that really works, that really has results. Because for me, I think, the best harm reduction is rehabilitation, is to help people quit and because it’s a social – the psycho-social element is very dominant in drug addiction, the community method is really, I would say, one of the best and it comes from here, from California actually. By the way, yesterday I was with my family at the animal…
DR. KOUTSENOK: At the…
CAVANAUGH: At the Wild Animal…
DR. KALOTERAKIS: Wild Animal Park.
DR. KALOTERAKIS: Thank you. And I saw flags from different nations that really collaborated with the San Diego Zoo, you know, and I think UCSD should have a Greek flag as well because of this, because UCSD, with KETHEA, with my organization, which is, as you said, is the largest in Europe, here’s a program for over 12 years now in Greece, training addiction professionals. So I think it’s just gratitude that I want to express here and, really, you should be proud of this. That’s why I’m saying about this…
CAVANAUGH: Well, that’s…
DR. KALOTERAKIS: …big flag there.
CAVANAUGH: …fabulous to hear. Dr. Koutsenok, is California on the cutting edge of addiction treatment and therapies?
DR. KOUTSENOK: I wouldn’t say about California. I can talk about the department that I work for, the Department of Psychiatry at UCSD, one of the best Departments of Psychiatry actually in the world. And we have a large group of really world-best professionals, and I’m not among them. World best professionals, researching in addiction field, offering trainings, offering all kinds of support in the United States and abroad. So this department is one of the best in terms of addiction research and treatment and services.
CAVANAUGH: And I think it’s important to add, too, because this institute is not just for doctors and researchers.
DR. KOUTSENOK: No.
CAVANAUGH: But it’s for people who work in the addiction field and I know that, as I said, that your – a lot of your research has to do with people who are addicts in prison. What do you think that the legal system needs to learn about addiction and treatment in order to really help people come out of prison, as you were saying, in a better state than they went in.
DR. KOUTSENOK: Well, the legal system and the prison system – Oh, they need to learn that if you do nothing, it’s very expensive. Right now, in the fiscal crisis, drug abuse and substance abuse treatment programs in prisons are usually first to go. And this is exactly what is happening. A huge mistake that will cost a lot of money to the state and to legislature this year. But people up there, they rarely think this way. Doing nothing is by far more expensive than doing something.
CAVANAUGH: Now when you say up there, I assume you’re talking about Sacramento?
DR. KOUTSENOK: I’m talking about people who make important decisions, yes, I’m talking about Sacramento and I’m talking about the state senate, I’m talking about the governor and everybody who’s involved in the policy. Right now, reducing or cutting programs available for offenders in prisons and in the community will cost much more than they will save. I don’t think they realize it.
DR. KALOTERAKIS: As I said before, I cannot speak about California but about Greece and Europe, it’s the same thing and the oxymoron in this is that when you have a financial crisis, an economic crisis, a social crisis follows. And because of this, people will use more substances, will use more drugs, let’s say, and the oxymoron is that although the problem is getting bigger, the first thing to cut off is money for services like this, which really doesn’t make sense.
CAVANAUGH: Really doesn’t make sense.
DR. KALOTERAKIS: It doesn’t make sense.
CAVANAUGH: I have to end it here. We’re out of time. I want to thank you both so much, Dr. Igor…
DR. KOUTSENOK: Thank you.
CAVANAUGH: …Koutsenok, and Dr. Phaedon Kaloterakis.
DR. KALOTERAKIS: Thank you very much.
CAVANAUGH: I hope I haven’t massacred your names too much.
DR. KALOTERAKIS: No, no, no.
DR. KOUTSENOK: You’ve been just – just great.
DR. KALOTERAKIS: You’ve been great. Thank you.
CAVANAUGH: I want to let everybody know that there is the Addiction Conference. It’s August 4th through 6th at UCSD’s Price Center Ballroom. And that’s the UCSD Center for Criminality and Addiction Research Training and Application. It’s a summer clinical institute. Thank you both very much for being here.
DR. KOUTSENOK: Thank you.
DR. KALOTERAKIS: Thank you.
CAVANAUGH: And you’ve been listening to These Days on KPBS.