Mexico final congresso

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  • Photos include: (left to right; top to bottom)
    Parliament
    Caribanna festival
    Diwali festival
    Hockey
    Banff National Park
  • Diversos proyectos terapeuticos en Brazil Argentiea Peru
    en Peru patrimonio cultural de la nacion
    Inspiracion
    Takiwais reconocida por OMS...centro para rehabilitacion d edrogadiccion y investigacion d emedicina tradicional amazonica
    Dieta
    Purgas
    Ayahuasca
    Comunidad terapeutica, ergoterapia, Laboratoria de plantas medicinales
    y pr DEVIDA Comision nacional para el desarollo y vida sin drogas ( oranismo peruano equivalente al conadic
    IMCA
  • Mexico final congresso

    1. 1. Assessing the effectiveness of ayahuasca for the treatment of addictions: What is the “right” research paradigm? Dr. Brian Rush Professor University of Toronto, Dept. of Psychiatry Scientist Emeritus, Centre for Addiction and Mental Health Health Systems and Health Equity Research Group Toronto, Canada
    2. 2. Canada and the importance of cultural context
    3. 3. Objectives Today  Situate today’s presentation in the current research literature on the treatment of addictions and therapeutic effectiveness of ayahuasca  Describe potential research paradigms that can be used to make further progress in this important area  Briefly describe the Ayahuasca Treatment Outcome Project (ATOP), it’s mixed model approach and next steps
    4. 4. The reality of addictions treatment on a global scale  Need in the community is much greater than our current capacity to respond – especially indigenous people - it truly is a global challenge and a very expensive one  The majority of people who need help do not seek help, even when good services are available (only about 20% or less)
    5. 5. Realities …..  Many people get better on their own but its not ideal – a lot of people, families and communities get hurt along the way – we have a responsibility to help  Treatment DOES WORK but it usually takes several attempts and we need a lot more options – severe addiction is very difficult to resolve, especially in combination with major mental health challenges such as depression and trauma
    6. 6. Mental Disorders Co-morbidity of Mental Health and Addiction Challenges in Treatment Populations Substance Use Disorders 70- 80%
    7. 7. Realities …..  Some common elements of treatment success include:  Therapeutic relationship and trust  Tolerance and respect  Belief and expectancies  Culturally appropriate  To summarize: we have a moral and therapeutic imperative to continue searching for more treatment options that are appropriate for more people
    8. 8. The reality in many parts of North, Central and South America as well as Australia and NZ Justice Street services Schools Social Assistance Housing Workplace Traditional Healing Why would we NOT want to study and learn from these traditions? (moral and therapeutic imperative) Hospitals Addiction Services Mental Health Primary Care
    9. 9. Our Vision  Traditional healing is recognized as a legitimate part of the community treatment system – we must extend our services to where the people are at in their own cultural context  Treatment centres and professionals using traditional healing approaches need to be linked with larger system of services and not working in isolation - and they need to be recognized as partners in the network
    10. 10. The importance of “evidence” in going forward  Research evidence plays an important role in gaining acceptance of other professionals, funders and the community as a whole  Research evidence plays an important role in being sure people are being treated safely and respectfully  Current challenge – there are many kinds of research and many ways of knowing something
    11. 11. What is the current evidence base (for addictions)?  Very strong cultural/community knowledge base within indigenous communities and the Brazilian churches  Studies of long-term users show very low toxicity, zero addiction potential and often better health on several indicators  Retrospective studies of long term users show strong evidence of recovery from alcohol and drug dependence  Prospective follow up studies have been limited in their design (Takiwasi, Canada) but results in the right direction  Qualitative research on subjective experience – reasons for use, personal benefits, assessment of therapeutic mechanisms
    12. 12. A continuum of “knowing” in relation to healing  The pyramid of current Evidence-Based Medicine (EBM)  Indigenous evaluation paradigm  Common territory being explored in ATOP
    13. 13. The “Evidence Pyramid” Behind Current Medical Practice Meta-Analysis Systematic Reviews Randomized Control Trials Cohort Studies Case Control Studies Case Reports Animal Research
    14. 14. Adaptation of the “Evidence Pyramid” for Public Health Practice Experimental Studies (I-Low, II- Moderate, III-High) Quasi- Experimental Studies (I-Low, II- Moderate, III-High) Analytic Observational Studies (I-Low, II- Moderate, III-High)
    15. 15. Adaptation of the Pyramid For Qualitative Evidence I - Generalizable conceptual studies II- Descriptive Studies III- Single Case Studies (I-Low, II- Moderate, III-High)
    16. 16. But this is the Pyramid that Rules today for Modern Medicine Meta-Analysis Systematic Reviews Randomized Control Trials Cohort Studies Case Control Studies Case Reports Animal Research
    17. 17. Evolving models of research evidence  More recognition now for “practice-based evidence as opposed to evidence-based practice  More recognition of ”community-defined,” culture-based evidence  More recognition of the limitations of RCT’s  Who is actually is in the studies?  Does it really work for highly complex interventions?
    18. 18. So what about ayahuasca in all and its tremendous complexity?
    19. 19. Banisteriopsis caaba
    20. 20. In what context is it used for healing?  Indigenous Amazonian context (Peru, Equador, Columbia, Venezuela.. some aspects remain in Brazil) – local healers/curanderos, shamanic practice – ritual, icaros, dietas, many variations  Neo-shamanic centres – some specific to addictions and/or mental health (Peru, Argentina) – many others for mental wellness and spiritual growth – various practices integrated  Syncretic churches in Brazil – used as a ceremonial sacrament - Santo Daime, UDV, Barqinha
    21. 21. Alternative healing contexts
    22. 22. Dimensions of the Complexity  Cultural and community context (e.g., belief, values)  Production context (e.g., plant mix, training)  Context of use (e.g., shamanic/church, curandero, icaros, other plant mix, group/dieta, light/dark, etc.)  Personal context (e.g., physical/mental health, diet, abstinence, previous experience, intention,motivation)  Neuro-biological context (e.g., absorption rate, neuroplasticity, serotonin uptake)  Energetic context (e.g., invasion/bad intention, darts, location)
    23. 23. The purpose of an experimental design is to REMOVE all of this context and isolate the “active ingredient” of interest to the researcher If we really think about this what are the chances of success? Is it really appropriate to try?
    24. 24. What is the current evidence base (for addictions)?  Very strong cultural/community knowledge base within indigenous communities and the Brazilian churches  Studies of long-term users show very low toxicity, zero addiction potential and often better health on several indicators  Retrospective studies of long term users show strong evidence of recovery from alcohol and drug dependence  Prospective follow up studies have been limited in their design (Takiwasi, Canada) but results in the right direction  Qualitative research on subjective experience – reasons for use, personal benefits, assessment of therapeutic mechanisms
    25. 25. Do we need to do more?
    26. 26. Part of the Globalization of Ayahuasca  What are “safe” practices?  What practices can be better informed by evidence (however that is interpreted)?  What can these practices (plant medicines) teach us about healing and therapeutics?  What traditional and “modern” practices can be combined to benefit people seeking help?  What can the study of traditional medicine teach us about “evidence-based medicine”?
    27. 27. An Indigenous Evaluation Paradigm  All things are living, spiritual entities and relational – including knowledge itself  as such has moral purpose) -what is the good to come  nothing can be isolated from its context – all views are wholistic  Knowledge has meaning only in a place/community context and through direct experience  Outcomes (and risks) relate to family/community  Evaluator must have relationship with program representatives
    28. 28. Key principles of indigenous evaluation practice (con’t)  Meaningful involvement  Respect for culture in defining questions and gathering information  Using metaphor and stories to guide the evaluation process  Capacity building  Interpretation in indigenous context/cosmology  Sharing of results respectfully and with premission
    29. 29. Reconciling these Research Paradigms
    30. 30. Reconciling these Research Paradigms
    31. 31. Realist Evaluation Model Complexity-rich  Intervention + context = outcome  Indigenous engagement  Realist research synthesis and contribution analysis  Mixed methods: qualitative and quantitative  Assess effectiveness in naturalistic settings (not assessing efficacy in tightly controlled conditions)
    32. 32. What is ATOP? Ayahuasca Treatment Outcome Project ATOP Umbrella - Core team members -Project sites/partners: • ATOP-Peru • ATOP-Mexico • ATOP- Brazil • Argentina/Uruguay - early stages - consensus on core features
    33. 33. Under the ATOP umbrella:  Core focus and objectives (e.g. addictions and related co-morbidity)  Core design  integration of traditional practices and modern therapeutics  inclusion/exclusion criteria  baseline and at least one year follow up  comparison/control conditions as local situation allows
    34. 34. Under the umbrella….  Core descriptive, process and modifying measures  Demographics  Diagnostic profile  Wellness- Severity profile  Previous healing/treatment experiences  Family history  Expectancies/beliefs  Level of participation  Motivation (level and source)
    35. 35. Under the umbrella…  Core outcome measures  Substance use (ASI) plus substance use measures from the GAIN  Mental health (Beck depression/anxiety)  Quality of life (WHO)  Spirituality (WHO)  Satisfaction with services (CSQ-8)
    36. 36. Under the Umbrella...  Core ethical principles (e.g., consents, locator processes for follow up, training/credentials of the curanderos, use of other plant medicines such as tobacco)  Core interest in the neuroscience aspects but questions and protocol yet to be defined and as local conditions allow
    37. 37. Staged approach to implementation…  Start up funding by crowdfunding, DEVIDA in Peru, and other donations for initial planning meeting in Tarapoto Peru – umbrella defined
    38. 38. Current status of ATOP sub-projects  ATOP-Peru – Funding application to Canada Grand Challenges (meeting was yesterday!!) - decision announced in May  Letter of support from DEVIDA– national anti- drug agency  Takiwasi, and several other Peruvian centres have committed to join  Independent third party follow up team  Two-year time frame – may need additional resources to extend the follow-up to one year post discharge
    39. 39. Takiwasi
    40. 40. ATOP-Mexico  Controlled randomized study – ayahuasca- assisted psychotherapy following detox  Control conditions – placebo or retreat without ayahuasca  18-month follow-up  ATOP baseline and outcome measures  Proposal is under review
    41. 41. ATOP-Brazil  Proposal under development for submission to SENAD – Brazilian gov’t anti-drug agency  Three potential centres identified at this point  Common measures –some challenges with infrastructure to be overcome but  Additional cross-sectional descriptive component – nation-wide  Anticipated submission date: fall of 2014
    42. 42. What is ATOP? Ayahuasca Treatment Outcome Project ATOP Umbrella - consensus on core features -Core team members -Project sites/partners: ATOP-Peru ATOP-Mexico ATOP- Brazil Argentina/Uruguay - early stages - Advisory structure – curanderos, leaders
    43. 43. Reconciling these Research Paradigms
    44. 44. Reconciling these Research Paradigms
    45. 45. Reconciling these Research Paradigms
    46. 46. Muchas gracias y buena suerte en su trabajo personal y profesional!!!

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