Wednesday, February 11, 2009
MESSAGE FROM YOUR PRESIDENT:
Painless Choices: Cocaine Cowboys Version 2.0
“Cocaine Cowboys” is a 2006 documentary film, which chronicles the development of the illegal drug trade in Miami during the 1970s and 1980s with interviews of both law enforcement and organized crime leaders. The film reveals that much of the economic growth, which took place in Miami during this time period, was a benefit of the drug trade. As members of the drug trade made immense amounts of money, this money flowed in large amounts into legitimate businesses. As a result, drug money indirectly financed the construction of many of the modern high-rise buildings in southern Florida. Later, when law enforcement pressure drove many major players out of the picture, many high-end stores and businesses closed because of plummeting sales.
But drug dealers and their cronies do have learned their lessons and refined their approach. Their basic premise: why going underground if one can deal narcotics legally. What ingredients do you need? A medical office, a doctor’s license,a DEA number, on-site drug dispensing and plenty of advertisement space. All of the above results in a booming cash business in our midst, attracting clients from as far away as Alabama, Kentucky and Georgia. One street newspaper features a “Health & Wellness” section brimming with almost fifty (50) pain clinic ads strategically following the “adult business” section.
In those ads “renowned” pain “doctors” want you to “ get back the life you once knew”, to help you to “ break free from pain” and suggest that “in all this madness good doctors matter.” Naturally, most of those clinics are happy to provide you with any narcotics of your choice if you provide the “proof” to be in pain. An MRI indicating an abnormality suffices to qualify you as a legitimate pain patients. From then on one can receive a variety of narcotics of choice from their menu, dispensed on-site, and with an almost guaranteed refill option, otherwise their business model would suffer. In many cases these unscrupulous modern narco cowboys make millions of dollars a year in CASH!
I have had the “pleasure” encountering several of those “colleagues” who in many cases have no formal training in pain medicine, are semi-retired, had licensure problems, and appear to be board certified in predatory medicine.
The unprecedented concentration of those “pain clinics” in midst our community contributes to out-of-control opioid abuse, narcotic drug dealing and endangers the public health. In my opinion, several of those pain clinics are financed and operated by criminal gangs and the proceeds of their activities are being invested in local businesses, including real estate.It requires the concerted efforts of law-enforcement, political leadership and the medical community to root out his problem. Several steps can be taken right now:
1) Impose a moratorium of dispensing narcotics in physician’s offices, unless the prescribing physician is board-certified in anesthesiology and pain medicine and operates within a licensed and certified facility to be approved by a designated agency. This will immediately reduce the phenomenon of “ pill shoppers” who are pretending to suffer from pain, receive narcotics in numerous pain clinics and then sell those for a huge profit on the street.
2) Mandatory monthly inspection of all pain clinics in South Florida. Skilled inspectors can be trained to randomly audit charts, on-site pharmacies and monitor the patient flow at so-called pain clinics.
3) Criminal background checks of all operators and their financial backers to be reviewed and updated on a quarterly basis.
4) Implementation of a prescription drug monitoring system as a tool to identify drug-seekers and doctor-shoppers.
5) Requiring the Board of Medicine to suspend the license of any physician who violates the standards of care as it pertains to inappropriate prescription of narcotics.
I want to emphasize that the above proposed sanction DO NOT APPLY to most physicians in private practice who in almost all cases legitimately prescribe narcotics for pain. The “physicians” in questions in those pain clinics prescribe hundreds of powerful narcotics at a time to anyone pretending to be in pain! Their “standard of practice” does NOT equate our high standards of care. Les act together to rid our community from these narco cowboys. Lets protect our families, friends and patients from those predators.
Don’t be afraid to call them by their name: drug dealers in a white coat.
Tuesday, February 17, 2009
Pain Treatment Guidelines
Dear Friends and Colleagues:
Attached a very interesting article which I received from two of our FSAM board members.
Thanks John and Michelle.
Looking forward to your comments.
Yours
Bernd
============================================================================
Two professional societies released guidelines last week on opioid therapy to treat chronic, noncancer pain.
The American Pain Society and the American Academy of Pain Medicine convened a multidisciplinary panel of 21 experts to review evidence and compose 25 recommendations. The recommendations, published in the February Journal of Pain, advise providers to:
=Do a history, physical exam and appropriate testing—including a risk assessment of substance abuse—before starting a patient on chronic opioid therapy (COT);
=Consider a COT trial for patients whose pain is moderate or severe and for whom it has an adverse impact on function or quality of life;
=Reassess patients on COT periodically, with monitoring to include documenting pain and functioning levels, adherence, and presence of adverse events;
=Use COT on patients with a history of drug abuse or psychiatric issues only if they can be monitored more frequently and strictly;
=Do periodic urine drug screens on patients at high risk or who engaged in drug-related behavior in the past, and possibly on patients who aren't high-risk, too; and
=Evaluate health status, adherence and side effects on an ongoing basis in patients on high doses of COT, and consider more follow-up visits.
On a related note, FDA last week sent letters to opioid manufacturers asking them to develop plans to reduce the misuse of their drugs, the Feb. 9 Washington Post reported. The plans, which are meant to help reduce the rising incidence of overdose and abuse, might include enhanced warnings on labels or restricting the kinds of patients who can use the drugs, the Post said. A list of affected drugs, most of which are high dose and/or extended release, is online.
============================================================================
Article Abstract
The Journal of Pain, Volume 10, Issue 2, Pages 113-130.e22 (February 2009)
Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain
Roger Chou1, Gilbert J. Fanciullo2, Perry G. Fine3, Jeremy A. Adler4, Jane C. Ballantyne5, Pamela Davies6, Marilee I. Donovan7, David A. Fishbain8, Kathy M. Foley9, Jeffrey Fudin10, Aaron M. Gilson11, Alexander Kelter12, Alexander Mauskop13, Patrick G. O'Connor14, Steven D. Passik15, Gavril W. Pasternak16, Russell K. Portenoy17, Ben A. Rich18, Richard G. Roberts19, Knox H. Todd20, Christine Miaskowski21, American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel
Abstract
Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices.
Perspective
Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.
Link to full article: http://www.jpain.org/article/PIIS1526590008008316/fulltext
Attached a very interesting article which I received from two of our FSAM board members.
Thanks John and Michelle.
Looking forward to your comments.
Yours
Bernd
============================================================================
Two professional societies released guidelines last week on opioid therapy to treat chronic, noncancer pain.
The American Pain Society and the American Academy of Pain Medicine convened a multidisciplinary panel of 21 experts to review evidence and compose 25 recommendations. The recommendations, published in the February Journal of Pain, advise providers to:
=Do a history, physical exam and appropriate testing—including a risk assessment of substance abuse—before starting a patient on chronic opioid therapy (COT);
=Consider a COT trial for patients whose pain is moderate or severe and for whom it has an adverse impact on function or quality of life;
=Reassess patients on COT periodically, with monitoring to include documenting pain and functioning levels, adherence, and presence of adverse events;
=Use COT on patients with a history of drug abuse or psychiatric issues only if they can be monitored more frequently and strictly;
=Do periodic urine drug screens on patients at high risk or who engaged in drug-related behavior in the past, and possibly on patients who aren't high-risk, too; and
=Evaluate health status, adherence and side effects on an ongoing basis in patients on high doses of COT, and consider more follow-up visits.
On a related note, FDA last week sent letters to opioid manufacturers asking them to develop plans to reduce the misuse of their drugs, the Feb. 9 Washington Post reported. The plans, which are meant to help reduce the rising incidence of overdose and abuse, might include enhanced warnings on labels or restricting the kinds of patients who can use the drugs, the Post said. A list of affected drugs, most of which are high dose and/or extended release, is online.
============================================================================
Article Abstract
The Journal of Pain, Volume 10, Issue 2, Pages 113-130.e22 (February 2009)
Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain
Roger Chou1, Gilbert J. Fanciullo2, Perry G. Fine3, Jeremy A. Adler4, Jane C. Ballantyne5, Pamela Davies6, Marilee I. Donovan7, David A. Fishbain8, Kathy M. Foley9, Jeffrey Fudin10, Aaron M. Gilson11, Alexander Kelter12, Alexander Mauskop13, Patrick G. O'Connor14, Steven D. Passik15, Gavril W. Pasternak16, Russell K. Portenoy17, Ben A. Rich18, Richard G. Roberts19, Knox H. Todd20, Christine Miaskowski21, American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel
Abstract
Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices.
Perspective
Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.
Link to full article: http://www.jpain.org/article/PIIS1526590008008316/fulltext
Monday, February 16, 2009
Interesting articles
Dear Friends and Colleagues:
By reviewing several journals I found the attached articles which may help you to manage patients in your office:
1) Realistic Approaches to Counseling in the Office Setting,
H. RUSSELL SEARIGHT, PhD, MPH, Department of Psychology, Lake Superior State University, Sault Sainte Marie, Michigan
Although it is often unrecognized, family physicians provide a significant amount of mental health care in the United States. Time is one of the major obstacles to providing counseling in primary care. Counseling approaches developed specifically for ambulatory patients and traditional psychotherapies modified for primary care are efficient first-line treatments. For some clinical conditions, providing individualized feedback alone leads to improvement. The five A's (ask, advise, assess, assist, arrange) and FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy) techniques are stepwise protocols that are effective for smoking cessation and reducing excessive alcohol consumption. These models can be adapted to address other problems, such as treatment nonadherence. Although both approaches are helpful to patients who are ready to change, they are less likely to be successful in patients who are ambivalent or who have broader psychosocial problems. For patients who are less committed to changing health risk behavior or increasing healthy behavior, the stages-of-change approach and motivational interviewing address barriers. Patients with psychiatric conditions and acute psychosocial stressors will likely respond to problem-solving therapy or the BATHE (background, affect, troubles, handling, empathy) technique. Although brief primary care counseling has been effective, patients who do not fully respond to the initial intervention should receive multimodal therapy or be referred to a mental health professional. (Am Fam Physician. 2009;79(4):277-284. Copyright © 2009 American Academy of Family Physicians.)
http://www.aafp.org/afp/20090215/277.html
2) Reducing Tobacco Use in Adolescents
IRENE M. ROSEN, LTC, MC, USA, Madigan Army Medical Center, Fort Lewis, Washington
DOUGLAS M. MAURER, MAJ, MC, USA, Carl R. Darnall Army Medical Center, Fort Hood, Texas
After steadily decreasing since the late 1990s, adolescent smoking rates have stabilized at levels well above national goals. Experts recommend screening for tobacco use and exposure at every patient visit, although evidence of improved outcomes in adolescents is lacking. Counseling should be provided using the 5-A method (ask, advise, assess, assist, and arrange). All smokers should be offered smoking cessation assistance, including counseling, nicotine replacement therapy, bupropion therapy, or combination therapy. Pharmacotherapy of any kind doubles the likelihood of successful smoking cessation in adults; however, nicotine replacement therapy is the only pharmacologic intervention that has been extensively studied in children. Community interventions such as smoking bans and educational programs have been effective at reducing smoking rates in children and adolescents. Antismoking advertising and tobacco sales taxes also help deter new smokers and motivate current smokers to attempt to quit. (Am Fam Physician. 2008;77(4):483-490, 491-492. Copyright © 2008 American Academy of Family Physicians.)
http://www.aafp.org/afp/20080215/483.html
3) Adolescent Substance Use and Abuse: Recognition and Management
KIM S. GRISWOLD, MD, MPH; HELEN ARONOFF, MD, MAT; JOAN B. KERNAN, BS; and LINDA S. KAHN, PhD State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York
Substance abuse in adolescents is undertreated in the United States. Family physicians are well positioned to recognize substance use in their patients and to take steps to address the issue before use escalates. Comorbid mental disorders among adolescents with substance abuse include depression, anxiety, conduct disorder, and attention-deficit/hyperactivity disorder. Office-, home-, and school-based drug testing is not routinely recommended. Screening tools for adolescent substance abuse include the CRAFFT questionnaire. Family therapy is crucial in the management of adolescent substance use disorders. Although family physicians may be able to treat adolescents with substance use disorders in the office setting, it is often necessary and prudent to refer patients to one or more appropriate consultants who specialize specifically in substance use disorders, psychology, or psychiatry. Treatment options include anticipatory guidance, brief therapeutic counseling, school-based drug-counseling programs, outpatient substance abuse clinics, day treatment programs, and inpatient and residential programs. Working within community and family contexts, family physicians can activate and oversee the system of professionals and treatment components necessary for optimal management of substance misuse in adolescents. (Am Fam Physician. 2008;77(3):331-336. Copyright © 2008 American Academy of Family Physicians.)
http://www.aafp.org/afp/20080201/331.html
I look forward to your feedback.
Yours
Bernd Wollschlaeger,MD,FAAFP,FASAM
President, Florida Society of Addiction Medicine
By reviewing several journals I found the attached articles which may help you to manage patients in your office:
1) Realistic Approaches to Counseling in the Office Setting,
H. RUSSELL SEARIGHT, PhD, MPH, Department of Psychology, Lake Superior State University, Sault Sainte Marie, Michigan
Although it is often unrecognized, family physicians provide a significant amount of mental health care in the United States. Time is one of the major obstacles to providing counseling in primary care. Counseling approaches developed specifically for ambulatory patients and traditional psychotherapies modified for primary care are efficient first-line treatments. For some clinical conditions, providing individualized feedback alone leads to improvement. The five A's (ask, advise, assess, assist, arrange) and FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy) techniques are stepwise protocols that are effective for smoking cessation and reducing excessive alcohol consumption. These models can be adapted to address other problems, such as treatment nonadherence. Although both approaches are helpful to patients who are ready to change, they are less likely to be successful in patients who are ambivalent or who have broader psychosocial problems. For patients who are less committed to changing health risk behavior or increasing healthy behavior, the stages-of-change approach and motivational interviewing address barriers. Patients with psychiatric conditions and acute psychosocial stressors will likely respond to problem-solving therapy or the BATHE (background, affect, troubles, handling, empathy) technique. Although brief primary care counseling has been effective, patients who do not fully respond to the initial intervention should receive multimodal therapy or be referred to a mental health professional. (Am Fam Physician. 2009;79(4):277-284. Copyright © 2009 American Academy of Family Physicians.)
http://www.aafp.org/afp/20090215/277.html
2) Reducing Tobacco Use in Adolescents
IRENE M. ROSEN, LTC, MC, USA, Madigan Army Medical Center, Fort Lewis, Washington
DOUGLAS M. MAURER, MAJ, MC, USA, Carl R. Darnall Army Medical Center, Fort Hood, Texas
After steadily decreasing since the late 1990s, adolescent smoking rates have stabilized at levels well above national goals. Experts recommend screening for tobacco use and exposure at every patient visit, although evidence of improved outcomes in adolescents is lacking. Counseling should be provided using the 5-A method (ask, advise, assess, assist, and arrange). All smokers should be offered smoking cessation assistance, including counseling, nicotine replacement therapy, bupropion therapy, or combination therapy. Pharmacotherapy of any kind doubles the likelihood of successful smoking cessation in adults; however, nicotine replacement therapy is the only pharmacologic intervention that has been extensively studied in children. Community interventions such as smoking bans and educational programs have been effective at reducing smoking rates in children and adolescents. Antismoking advertising and tobacco sales taxes also help deter new smokers and motivate current smokers to attempt to quit. (Am Fam Physician. 2008;77(4):483-490, 491-492. Copyright © 2008 American Academy of Family Physicians.)
http://www.aafp.org/afp/20080215/483.html
3) Adolescent Substance Use and Abuse: Recognition and Management
KIM S. GRISWOLD, MD, MPH; HELEN ARONOFF, MD, MAT; JOAN B. KERNAN, BS; and LINDA S. KAHN, PhD State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York
Substance abuse in adolescents is undertreated in the United States. Family physicians are well positioned to recognize substance use in their patients and to take steps to address the issue before use escalates. Comorbid mental disorders among adolescents with substance abuse include depression, anxiety, conduct disorder, and attention-deficit/hyperactivity disorder. Office-, home-, and school-based drug testing is not routinely recommended. Screening tools for adolescent substance abuse include the CRAFFT questionnaire. Family therapy is crucial in the management of adolescent substance use disorders. Although family physicians may be able to treat adolescents with substance use disorders in the office setting, it is often necessary and prudent to refer patients to one or more appropriate consultants who specialize specifically in substance use disorders, psychology, or psychiatry. Treatment options include anticipatory guidance, brief therapeutic counseling, school-based drug-counseling programs, outpatient substance abuse clinics, day treatment programs, and inpatient and residential programs. Working within community and family contexts, family physicians can activate and oversee the system of professionals and treatment components necessary for optimal management of substance misuse in adolescents. (Am Fam Physician. 2008;77(3):331-336. Copyright © 2008 American Academy of Family Physicians.)
http://www.aafp.org/afp/20080201/331.html
I look forward to your feedback.
Yours
Bernd Wollschlaeger,MD,FAAFP,FASAM
President, Florida Society of Addiction Medicine
Saturday, February 7, 2009
Addiction Treatment and the Criminal Justice System
Attached a very interesting an timely article summarizing relevant neuroscientific findings and evidence-based principles of addiction treatment that, if implemented in the criminal justice system, could help improve public heath and reduce criminal behavior.
The basic premise of the article is that not treating a drug-abusing offender is a missed opportunity to simultaneously improve both public health and safety. Integrating treatment into the criminal justice system would provide treatment to individuals who otherwise would not receive it, improving their medical outcomes and decreasing their rates of reincarceration.
Research over the last 2 decades has consistently reported the beneficial effects of treatment for the drug abuser in the criminal justice system.These interventions include therapeutic alternatives to incarceration, treatment merged with judicial oversight in drug courts, prison- and jail-based treatments, and reentry programs intended to help offenders transition from incarceration back into the community.Through monitoring, supervision, and threat of legal sanctions, the justice system can provide leverage to encourage drug abusers to enter and remain in treatment.
Effective interventions depend on a coordinated response between criminal justice agencies, drug abuse treatment providers, mental health and physical health care organizations, and social service agencies. Each type of criminal justice agency (eg, jail, drug court, probation, prison) has its own role in sanctioning and supervision and lends itself to specific intervention opportunities.
Effective integration of drug treatment interventions into criminal justice settings requires matching the intervention to the organization. For example, since jail stays are usually brief, the interventions best suited to jails may be screening for drug and alcohol abuse, other mental illnesses, and medical conditions (eg, HIV, hepatitis B or C), with referral to community-based treatment providers. Implementing these principles throughout the criminal justice and drug abuse treatment systems also requires that these systems work together to address the addicted individual's drug use, comorbid mental disorders and medical conditions, if present, and criminal behavior. Treatment professionals should understand the criminal justice process and the supervision requirements of their patients. In addition to addressing drug use behaviors, treatment outcomes improve when antisocial and criminal behaviors are targets of clinical intervention.Criminal justice professionals must develop an understanding of addiction—signs and symptoms, treatment, and relapse—and their role in facilitating recovery.
The challenge of delivering treatment in a criminal setting requires the cooperation and coordination of 2 disparate cultures: the criminal justice system organized to punish the offender and protect society and the drug abuse treatment systems organized to help the addicted individual. Addressing addiction as a disease does not remove the responsibility of the individual, which is the argument frequently used to resist recognizing and treating addiction as an illness. Rather it highlights the personal responsibility of the addicted person to seek and adhere to drug treatment and that of society to ensure that such treatment is available and based on scientific evidence. Only a small percentage of those requiring treatment for drug addiction seek help voluntarily; in light of this, the criminal justice system provides a unique opportunity to intervene and disrupt the cycle of drug use and crime in a cost-effective manner.
For those interested I can e-mail a PDF version of the complete article.
See you soon in Tampa for our Annual Scientific Conference
Yours
Bernd Wollschlaeger,MD,FAAFp,FASAM
President,Florida Society of Addiction Medicine
==========================================================================================================================
Treating Drug Abuse and Addiction in the Criminal Justice System: Improving Public Health and Safety
Redonna K. Chandler, PhD; Bennett W. Fletcher, PhD; Nora D. Volkow, MD
JAMA. 2009;301(2):183-190.
ABSTRACT
Despite increasing evidence that addiction is a treatable disease of the brain, most individuals do not receive treatment. Involvement in the criminal justice system often results from illegal drug-seeking behavior and participation in illegal activities that reflect, in part, disrupted behavior ensuing from brain changes triggered by repeated drug use. Treating drug-involved offenders provides a unique opportunity to decrease substance abuse and reduce associated criminal behavior. Emerging neuroscience has the potential to transform traditional sanction-oriented public safety approaches by providing new therapeutic strategies against addiction that could be used in the criminal justice system. We summarize relevant neuroscientific findings and evidence-based principles of addiction treatment that, if implemented in the criminal justice system, could help improve public heath and reduce criminal behavior.
INTRODUCTION
The past 20 years have seen significant increases in the numbers of individuals incarcerated or under other forms of criminal justice supervision in the United States. These numbers are staggering—approximately 7.1 million adults in the United States are under some form of criminal justice supervision.1 The large increase in the criminal justice population reflects in part tougher laws and penalties for drug offenses.2 An estimated one-half of all prisoners (including some sentenced for other than drug offenses) meet the criteria for diagnosis of drug abuse or dependence (Table 1).3-4
During the past 20 years, fundamental advances in the neurobiology of addiction have been made. Molecular and imaging studies have revealed addiction as a brain disorder with a strong genetic component, and this has galvanized research on new pharmacological treatments. However, a large disconnect remains between addiction research and the treatment of addiction in general, particularly within the criminal justice system. This is evidenced in that most prisoners (80%-85%) who could benefit from drug abuse treatment do not receive it.3-4 In addition, drug-using offenders are at high risk for infectious diseases such as human immunodeficiency virus (HIV) and hepatitis C5 and frequently have comorbid psychiatric disorders,6-7 which further highlights the dire treatment needs of this population.
Not treating a drug-abusing offender is a missed opportunity to simultaneously improve both public health and safety. Integrating treatment into the criminal justice system would provide treatment to individuals who otherwise would not receive it, improving their medical outcomes and decreasing their rates of reincarceration.8
Recidivism in the Drug-Abusing Offender
The inadequacy of incarceration by itself in addressing drug abuse or addiction is evident in the statistics. A review of recidivism in 15 states found that one-quarter of individuals released returned to prison within 3 years for technical violations that included, among other things, testing positive for drug use.9 Illicit drugs are used in jails and prisons despite their highly structured, controlled environments,10 but even enforced abstinence can mislead criminal justice professionals as well as addicted persons to underestimate the vulnerability to relapse postincarceration. On release from prison or jail, addicted persons will experience challenges to their sobriety through multiple stressors that increase their risk of relapsing to drug use. These include the stigma associated with being labeled an ex-offender, the need for housing and legitimate employment, stresses in reunifying with family, and multiple requirements for criminal justice supervision.11-12
Returning to neighborhoods associated with preincarceration drug use places the addicted individual in an environment rich in drug cues. As discussed below, these conditioned cues automatically activate the reward/motivational neurocircuitry and can trigger an intense desire to consume drugs (craving).13 The molecular and neurobiological adaptations resulting from chronic drug use persist for months after drug discontinuation,14 and evidence exists that compulsive seeking of drugs when addicted individuals are reexposed to drug cues progressively increases after drug withdrawal.15 This could explain why many drug-addicted individuals rapidly return to drug use following long periods of abstinence during incarceration and highlights the need for ongoing treatment following release.
Drug Abuse Treatment Effectiveness in the Criminal Justice System
Research over the last 2 decades has consistently reported the beneficial effects of treatment for the drug abuser in the criminal justice system.16-17 These interventions include therapeutic alternatives to incarceration, treatment merged with judicial oversight in drug courts, prison- and jail-based treatments, and reentry programs intended to help offenders transition from incarceration back into the community.8, 18 Through monitoring, supervision, and threat of legal sanctions, the justice system can provide leverage to encourage drug abusers to enter and remain in treatment.
Behavioral treatments are the most commonly used interventions for addressing substance use disorders. Evidence-based behavioral interventions include cognitive therapies that teach coping and decision-making skills, contingency management therapies that reinforce behavioral changes associated with abstinence, and motivational therapies that enhance the motivation to participate in treatment and in non–drug-related activities.19-20 Many residential treatment programs rely on the creation of a "therapeutic community" based on a social learning model.21 Medications such as methadone, buprenorphine, and naltrexone are beneficial for the treatment of heroin addiction and naltrexone and topiramate for the treatment of alcoholism.22-24 Self-help programs such as Alcoholics Anonymous or SMART Recovery can be valuable adjuncts to formal drug treatment.25
Research has consistently shown that community-based drug abuse treatment can reduce drug use and drug-related criminal behavior.26 A meta-analysis of 78 comparison-group community-based drug treatment studies found treatment to be up to 1.8 times better in reducing drug use than the usual alternatives.20 In a meta-analysis of 66 incarceration-based treatment evaluations, therapeutic community and counseling approaches were respectively 1.4 and 1.5 times more likely to reduce reoffending.27 Drug courts combine judicial supervision with drug treatment as an alternative to incarceration; their graduates have rearrest rates about half those of matched comparison samples and much lower than those of drug court dropouts.28 Individuals who participated in prison-based treatment followed by a community-based program postincarceration were 7 times more likely to be drug free and 3 times less likely to be arrested for criminal behavior than those not receiving treatment.29-30
The benefits of medications for drug treatment were shown in a recent randomized trial in which heroin-dependent inmates began methadone treatment in prison prior to release and continued in the community postrelease. At 1-, 3-, and 6-month follow-up, patients who received methadone plus counseling were significantly less likely to use heroin or engage in criminal activity than those who received only counseling.31-33 The potential exists for immediate adoption of methadone maintenance for incarcerated persons with opioid addictions, but most prison systems have not been receptive to this approach.34
Economic analyses highlight the cost-effectiveness of treating drug-involved offenders.35 On average, incarceration in the United States costs approximately $22 000 per month,36 and there is little evidence that this strategy reduces drug use or drug-related reincarceration rates for nonviolent drug offenders. By contrast, the average cost of methadone is $4000 per month,37 and treatment with methadone has demonstrated effectiveness in reducing drug use and criminal activity following release.31 Alternatives to incarceration can also defray job productivity losses and the separation from family and social support systems.
The cost of integrating volunteer-led self-help organizations such as Alcoholics Anonymous and Narcotics Anonymous into criminal justice settings is nominal and could provide support to the recovery efforts of addicted persons in the criminal justice system. One dollar spent on drug courts is estimated to save approximately $4 in avoided costs of incarceration and health care,38 and prison-based treatment saves between $2 to $6.39 These economic benefits in part reflect reductions in criminal behavior.40-41
Access to Treatment
Drug education—not drug treatment—is the most common service provided to prisoners with drug abuse or addiction problems.4, 42 More than one-quarter of state inmates and 1 in 5 federal inmates meeting abuse/dependence criteria participate in self-help groups such as Alcoholics Anonymous while in prison.4 However, though treatment during and after incarceration has been shown to significantly reduce drug use and drug-related crime, less than 20% of inmates with drug abuse or dependence receive formal treatment (Table 1).3-4
In a recent survey of correctional programs and organizations across the United States,42 most correctional agencies reported providing some type of drug abuse treatment services; however, the median percentage of offenders who had access to those services at any given time was low, usually less than 10% (Table 2).42 Even if a correctional institution does provide treatment, the continuity of treatment postincarceration, which is essential to recovery,16 is often lacking when the drug-involved offender transitions from incarceration to community supervision.43 Failure to receive treatment on release increases the risk not only of relapse but also of mortality from drug overdose and other causes.44
Infectious diseases such as HIV and hepatitis C are associated with illicit drug use and occur at higher rates in correctional populations than in the general population,5 but treatment for these conditions appears to fall short of need.45-46 It is feasible to implement screening and treatment in correctional settings for HIV47-48 and hepatitis C.49-50 Continuity of treatment for released offenders with infectious disease is crucial not only for the individual's health51-52 but also for the health of the community.45, 53
There are many barriers to treatment for the drug-involved offender, including lack of the resources, infrastructure, and treatment staff (including physicians knowledgeable about addiction medicine) required to meet the drug treatment needs of individuals under their supervision. Addiction remains a stigmatized disease not often regarded by the criminal justice system as a medical condition; as a consequence, treatment is not constitutionally guaranteed as is the treatment of other medical conditions.
Neurobiology of Addiction
Addiction is a chronic brain disease for which genetic factors are believed to contribute 40% to 60% of the vulnerability.54 Repeated drug exposure in individuals who are vulnerable (because of genetics, or developmental or environmental factors) trigger neuroadaptations in the brain that result in the compulsive drug use and loss of control over drug-related behaviors that characterizes addiction. Molecular and neuroimaging studies have helped illuminate how genes may affect vulnerability to addiction and how repeated use of addictive drugs causes long-lasting disruptions to the structure and function of the brain.55 Among the genes identified to contribute to the vulnerability for addiction are those that participate in the neuroplastic changes associated with learning.56 Imaging studies have identified multiple brain circuits that are disrupted in addicted persons57; these include circuits involved in reward and motivation, learning and memory, cognitive control, mood, and interoception (awareness of physiological body signals) (Figure). Disruption of these circuits impairs the addicted person's ability to inhibit intentional actions or to control strong emotions and desires and also increases the likelihood that the individual will have difficulties making adaptive decisions.60-61
Circuits work together and change with experience. Each is linked to an important concept: reward (saliency), motivation (drive), memory (learning associations), inhibitory control (conflict resolution), mood (well-being),58 and interoception (internal awareness).59 Size of circuit ovals indicates influence in determining behavioral outcomes. Thicker line weights indicate greater influence on regulation of the circuit. A, In a nonaddicted person the decision to consume a drug (same process pertains for natural rewards) is a function of the balance between the expected pleasure (based on past experience or memory), alternative stimuli (this includes internal states such as mood and interoception but also alternative external rewards), and potential negative outcomes that oppose the motivation to take the drug (inhibitory control exerted by prefrontal cortex) and stop the drug use. B, During addiction, the enhanced value of the drug in the reward, motivation, and memory circuits overcomes the inhibitory control exerted by the prefrontal cortex, thereby favoring a positive feedback loop initiated by the consumption of the drug and perpetuated by enhanced activation of the motivation/drive and memory circuits. Decreased sensitivity to rewards also raises the hedonic threshold, disrupting mood and increasing the saliency values of drugs and behaviors temporarily associated with relief from the dysphoria. Learning and conditioning result in an enhanced interoceptive awareness of discomfort and the associated desire for the drug (craving). Absence of lines from inhibitory control circuit to reward and motivation circuits indicates loss of regulation.
Addiction also decreases sensitivity in the reward and the motivational circuits, which modulate response to positive as well as negative reinforcers. Practically, this suggests that an addicted individual may experience less motivation to pursue activities likely to result in beneficial outcomes and to avoid those that could result in punishment. One can also predict that dysfunction in this neurocircuitry would reduce an addicted person's motivation to abstain from drug use because alternative reinforcers (natural stimuli) are comparatively weaker and negative consequences (eg, incarceration) are less salient.62
In parallel, the repeated use of drugs leads to the formation of new linked memories that condition the addicted individual to expect pleasurable responses—not only when exposed to a drug but also when exposed to stimuli associated with the drug. These stimuli trigger automatic responses that frequently drive relapse, even in individuals motivated to stop taking drugs.63 The enhanced sensitivity to drugs as rewards and the conditioning to associated drug cues increase the interoceptive awareness of discomfort (anxiety and tension) that occurs when the individual is exposed to drug cues and increase the desire to consume the drug.64 Additionally, repeated drug use also affects brain regions implicated in mood and anxiety, which could explain the high rate of addiction comorbid with dysphoria, depression, or both and the vulnerability of the addicted person to relapse when exposed to social stressors.65-66
Impairment of the neural substrates affected by addiction—particularly those concerned with behavioral inhibition, control of emotions and desires, and decision-making—increase the likelihood that addicted individuals will make choices that appear impulsive.67-68 This idea is supported by research in the emerging area of behavioral economics, which has found that addicted individuals differ from those who do not use drugs in how they make decisions. Addicted individuals tend to have higher levels of temporal discounting than those who do not use drugs; ie, they tend to choose immediate, smaller rewards over future, larger rewards.69 High temporal discounting is also associated with impulsivity—the inability to delay immediate gratification and to recognize the potential for negative consequences.70
Many of the neurobiological changes associated with repeated drug use persist for long periods after drug discontinuation.71 This helps explain why addicted individuals who have ceased drug use are at high risk of relapse and provides neurobiological support for the recognition of addiction as a chronic relapsing disease.72
What are the implications of neuroscience research for how society and clinicians might regard the addicted offender? There are at least 3 implications for how this emerging knowledge about the neurologic basis of addictive behavior is important.
First, of most importance, neuroscience's uncovering of new molecular targets implicated in the responses to drugs and of new knowledge on the function of the human brain provides new targets for medication development and behavioral interventions in addiction. Although many of the neurobiological changes associated with repeated drug use persist for long periods after drug discontinuation,71 research suggests that the impaired brain can regain some of the functions damaged by use of illicit drugs over time.73
Second, neuroscience establishes a biological framework for understanding aspects of addictive behavior that otherwise seem to defy rational explanation. In the absence of known biological determinants, these behaviors often have been attributed to "moral weakness."74 Identifying the neurologic factors underlying addictive behavior can place these moral arguments into a more reasoned context. Addiction does not absolve one of responsibility for use of illicit drugs or for criminal behavior, but understanding how addictive drugs affect behavior through brain mechanisms can inform decisions to provide treatment to addicted individuals. For example, mandated treatment may be useful for drug-involved offenders who would otherwise not engage in the treatment process or make progress toward recovery. The persistence of neurologic deficits provides support for the recognition of addiction as a chronic disease and highlights the need for the same continuity of care so important in treatment of other chronic diseases (eg, asthma, hypertension).72 It also suggests that agonist medications such as methadone are important treatments for addiction, even for individuals who have been under enforced abstinence during incarceration.
Third, neuroscience may help addicted individuals to better understand their own addiction. Such individuals may become frustrated when their efforts to control their own drug use are unsuccessful, and even with treatment many become frustrated with what is often a slow and tenuous recovery process. The neurobiology of the brain can help the addicted individual put this disease into a more understandable context and thereby facilitate effective treatment. Little research has been conducted in the field of addiction on whether knowing more about the substance use disorder is useful in helping to sustain recovery, and more research is needed. However, the concept of the "expert patient" who serves as his or her own best health advocate in a recovery management paradigm has been promoted for chronic disorders. As with these other illnesses, addiction must be managed by the individual over time to sustain recovery.
Principles of Drug Abuse Treatment for Offenders
Principles of Drug Abuse Treatment for Criminal Justice Populations,75 published by the National Institute on Drug Abuse, synthesizes research on drug abuse treatment for drug abusers in the criminal justice system. It is intended as a resource for criminal justice professionals and the treatment community working with drug abusers involved with the system. The publication summarizes 20 years of research to provide guidance on evidence-based practices and identifies general principles on how to effectively address the drug abuse problems of populations involved with the criminal justice system (Box).75
Implementing the Principles
Effective interventions depend on a coordinated response between criminal justice agencies, drug abuse treatment providers, mental health and physical health care organizations, and social service agencies. Each type of criminal justice agency (eg, jail, drug court, probation, prison) has its own role in sanctioning and supervision and lends itself to specific intervention opportunities. Table 3 provides a simplified overview of the criminal justice system and identifies the points at which intervention is possible.
Effective integration of drug treatment interventions into criminal justice settings requires matching the intervention to the organization. For example, since jail stays are usually brief, the interventions best suited to jails may be screening for drug and alcohol abuse, other mental illnesses, and medical conditions (eg, HIV, hepatitis B or C), with referral to community-based treatment providers. Implementing these principles throughout the criminal justice and drug abuse treatment systems also requires that these systems work together to address the addicted individual's drug use, comorbid mental disorders and medical conditions, if present, and criminal behavior. Treatment professionals should understand the criminal justice process and the supervision requirements of their patients. In addition to addressing drug use behaviors, treatment outcomes improve when antisocial and criminal behaviors are targets of clinical intervention.76 Criminal justice professionals must develop an understanding of addiction—signs and symptoms, treatment, and relapse—and their role in facilitating recovery.
Substance Abuse Treatment Research in Criminal Justice Settings
Prison environments are inherently coercive,77 and special safeguards have been developed to ensure that prisoners can choose freely whether to participate in biomedical research without fear of consequence. Beyond mere equipoise, clinical trials must be designed so the research is of benefit to the prisoner participant regardless of the assigned study group. Within these constraints, it is important to conduct research to help improve substance abuse treatment and to assist in the successful transition of the substance abuser to the community. To facilitate research in this area, the National Institute on Drug Abuse created the Criminal Justice Drug Abuse Treatment Studies research cooperative,78 a network of correctional agencies linked with treatment research centers and community treatment programs.
Opiate agonist medications used for the treatment of heroin addiction such as methadone and buprenorphine are underused in correctional populations. Naltrexone, an opiate antagonist, was developed to treat heroin addiction but also has been approved for treating alcoholism. Naltrexone is likely to be more acceptable in the criminal justice setting than agonist medications. However, the poor compliance with naltrexone has limited its use in the treatment of heroin addiction. The recent development of a long-lasting depot formulation for naltrexone79-80 obviates this limitation, and a multisite clinical trial (NCT00781898) is currently evaluating its effectiveness in heroin-addicted probationers. Another area of research intended to reduce relapse in addicted offenders is the development of vaccines against cocaine, methamphetamine, or heroin.
Several avenues currently exist for providing drug abuse treatment as an alternative to incarceration. Drug courts were intended to provide a bridge between drug treatment and adjudication; from the first drug court established in Miami in 1989, drug courts have increased in number to nearly 2000 today. States such as Arizona, California, and New York have created treatment alternatives to incarceration for first-time drug offenders, juvenile offenders, and others. Many states are coming under political pressure to reduce the costs associated with incarceration by diverting nonviolent drug offenders to treatment.
Conclusions
Punishment alone is a futile and ineffective response to drug abuse,2 failing as a public safety intervention for offenders whose criminal behavior is directly related to drug use.81 Addiction is a chronic brain disease with a strong genetic component that in most instances requires treatment. The increase in the number of drug-abusing offenders highlights the urgency to institute treatments for populations involved in the criminal justice system. It also provides a unique opportunity to intervene for individuals who would otherwise not seek treatment.
The challenge of delivering treatment in a criminal setting requires the cooperation and coordination of 2 disparate cultures: the criminal justice system organized to punish the offender and protect society and the drug abuse treatment systems organized to help the addicted individual. Addressing addiction as a disease does not remove the responsibility of the individual, which is the argument frequently used to resist recognizing and treating addiction as an illness. Rather it highlights the personal responsibility of the addicted person to seek and adhere to drug treatment and that of society to ensure that such treatment is available and based on scientific evidence. Only a small percentage of those requiring treatment for drug addiction seek help voluntarily; in light of this, the criminal justice system provides a unique opportunity to intervene and disrupt the cycle of drug use and crime in a cost-effective manner.
AUTHOR INFORMATION
Corresponding Author: Nora D. Volkow, MD, National Institute on Drug Abuse, 6001 Executive Blvd, Room 5274, Bethesda, MD 20892 (nvolkow@nida.nih.gov).
Author Contributions: Study concept and design: Chandler, Fletcher, Volkow.
Analysis and interpretation of data: Fletcher.
Drafting of the manuscript: Chandler, Fletcher.
Critical revision of the manuscript for important intellectual content: Chandler, Fletcher, Volkow.
Administrative, technical, or material support: Chandler, Fletcher, Volkow.
Financial Disclosures: None reported.
Funding/Support: This article was written by staff from the National Institute on Drug Abuse and there was no external funding for this work.
Disclaimer: The statements in this article are those of the authors and not necessarily those of the National Institute on Drug Abuse.
Additional Contributions: We thank Faye S. Taxman, PhD, and Matthew Perdoni, MS, both of George Mason University, for data on physical/medical, mental health, and substance use services (Table 2) from the NIDA National Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) National Criminal Justice Treatment Practices Survey. Neither of these individuals received compensation for their contributions.
Author Affiliations: Services Research Branch, National Institute on Drug Abuse (Drs Chandler and Fletcher); and National Institute on Drug Abuse (Dr Volkow), Bethesda, Maryland.
REFERENCES
1. Glaze LE, Bonczar TP. Probation and Parole in the United States, 2005. Washington, DC: Office of Justice Programs, Bureau of Justice Statistics; 2006. Dept of Justice publication NCJ 215091.
2. Jensen EL, Gerber J, Mosher C. Social consequences of the War on Drugs: the legacy of failed policy. Criminal Justice Policy Review. 2004;15(1):100-121.
3. Karberg JC, James DJ. Substance Dependence, Abuse, and Treatment of Jail Inmates, 2002. Washington, DC: Office of Justice Programs, Bureau of Justice Statistics; 2005. Dept of Justice publication NCJ 209588.
4. Mumola CJ, Karberg JC. Drug Use and Dependence, State and Federal Prisoners, 2004. Washington, DC: Office of Justice Programs, Bureau of Justice Statistics; 2006. Dept of Justice publication NCJ 213530.
5. Weinbaum CM, Sabin KM, Santibanez SS. Hepatitis B, hepatitis C, and HIV in correctional populations: a review of epidemiology and prevention. AIDS. 2005;19(suppl 3):S41-S46. PUBMED
6. Abram KM, Teplin LA. Co-occurring disorders among mentally ill jail detainees: implications for public policy. Am Psychol. 1991;46(10):1036-1045. FULL TEXT | PUBMED
7. Chandler RK, Peters RH, Field G, Juliano-Bult D. Challenges in implementing evidence-based treatment practices for co-occurring disorders in the criminal justice system. Behav Sci Law. 2004;22(4):431-448. PUBMED
8. Knight K, ed, Farabee D, ed. Treating Addicted Offenders: A Continuum of Effective Practices. Kingston, NJ: Civic Research Institute; 2004.
9. Langan PA, Levin DJ. Recidivism of Prisoners Released in 1994. Washington, DC: Office of Justice Programs, Bureau of Justice Statistics; 2002. Dept of Justice publication NCJ 193427.
10. Simpler AH, Langhinrichsen-Rohling J. Substance use in prison: how much occurs and is it associated with psychopathology? Addict Res Theory. 2005;13(5):503-511.
11. Field G. Continuity of offender treatment: from the institution to the community. In: Knight K, Farabee D, eds. Treating Addicted Offenders: A Continuum of Effective Practices. Kingston, NJ: Civic Research Institute; 2004:33-1–33-9.
12. Shivy VA, Wu JJ, Moon AE, Mann SC, Holland JG, Eacho C. Ex-offenders reentering the workforce. J Couns Psychol. 2007;54(4):466-473.
13. Volkow ND, Wang GJ, Telang F; et al. Cocaine cues and dopamine in dorsal striatum: mechanism of craving in cocaine addiction. J Neurosci. 2006;26(24):6583-6588. FREE FULL TEXT
14. Nestler EJ. Review: transcriptional mechanisms of addiction: role of Delta FosB. Philos Trans R Soc Lond B Biol Sci. 2008;363(1507):3245-3255. FULL TEXT | PUBMED
15. Grimm JW, Hope BT, Wise RA, Shaham Y. Neuroadaptation: incubation of cocaine craving after withdrawal. Nature. 2001;412(6843):141-142. FULL TEXT | PUBMED
16. Inciardi JA, Martin SS, Butzin CA, Hooper RM, Harrison LD. An effective model of prison-based treatment for drug-involved offenders. J Drug Issues. 1997;27(2):261-278. ISI
17. Pearson FS, Lipton DS. A meta-analytic review of the effectiveness of corrections-based treatments for drug abuse. Prison J. 1999;79(4):384-410.
18. Leukefeld CG, ed, Tims F, ed, Farabee D, ed. Treatment of Drug Offenders: Policies and Issues. New York, NY: Springer; 2002.
19. Wormith JS, Althouse R, Simpson M, Reitzel LR, Fagan TJ, Morgan RD. The rehabilitation and reintegration of offenders—the current landscape and some future directions for correctional psychology. Crim Justice Behav. 2007;34(7):879-892. FREE FULL TEXT
20. Prendergast ML, Podus D, Chang E, Urada D. The effectiveness of drug abuse treatment: a meta-analysis of comparison group studies. Drug Alcohol Depend. 2002;67(1):53-72. FULL TEXT | ISI | PUBMED
21. De Leon G. Therapeutic communities: is there an essential model? In: De Leon G, ed. Community as Method: Therapeutic Communities for Special Populations and Special Settings. Westport, CT: Praeger; 1997:3-18.
22. Volkow ND, Li TK. Drugs and alcohol: treating and preventing abuse, addiction and their medical consequences. Pharmacol Ther. 2005;108(1):3-17. FULL TEXT | ISI | PUBMED
23. Johnson BA, Rosenthal N, Capece JA; et al, Topiramate for Alcoholism Advisory Board; Topiramate for Alcoholism Study Group. Topiramate for treating alcohol dependence: a randomized controlled trial. JAMA. 2007;298(14):1641-1651. FREE FULL TEXT
24. Cropsey KL, Villalobos GC, St Clair CL. Pharmacotherapy treatment in substance-dependent correctional populations: a review. Subst Use Misuse. 2005;40(13-14):1983-1999. PUBMED
25. Humphreys K, Wing S, McCarty D; et al. Self-help organizations for alcohol and drug problems: toward evidence-based practice and policy. J Subst Abuse Treat. 2004;26(3):151-158. FULL TEXT | PUBMED
26. Lurigio AJ. Drug treatment availability and effectiveness—studies of the general and criminal justice populations. Crim Justice Behav. 2000;27(4):495-528. FREE FULL TEXT
27. Mitchell O, Wilson DB, MacKenzie DL. Does incarceration-based drug treatment reduce recidivism? a meta-analytic synthesis of the research. J Exp Criminol. 2007;3(4):353-375.
28. Peters RH, Murrin MR. Effectiveness of treatment-based drug courts in reducing recidivism. Crim Justice Behav. 2000;27(1):72-96. FREE FULL TEXT
29. Butzin CA, O’Connell DJ, Martin SS, Inciardi JA. Effect of drug treatment during work release on new arrests and incarcerations. J Crim Justice. 2006;34(5):557-565.
30. Martin SS, Butzin CA, Saum CA, Inciardi JA. Three-year outcomes of therapeutic community treatment for drug-involved offenders in Delaware: from prison to work release to aftercare. Prison J. 1999;79(3):294-320.
31. Gordon MS, Kinlock TW, Schwartz RP, O’Grady KE. A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release. Addiction. 2008;103(8):1333-1342. PUBMED
32. Kinlock TW, Gordon MS, Schwartz RP, O’Grady KE. A study of methadone maintenance for male prisoners. Crim Justice Behav. 2008;35(1):34-47. FREE FULL TEXT
33. Kinlock TW, Gordon MS, Schwartz RP, O’Grady K, Fitzgerald TT, Wilson M. A randomized clinical trial of methadone maintenance for prisoners: results at 1-month post-release. Drug Alcohol Depend. 2007;91(2-3):220-227. PUBMED
34. Rich JD, Boutwell AE, Shield DC; et al. Attitudes and practices regarding the use of methadone in US state and federal prisons. J Urban Health. 2005;82(3):411-419. ISI | PUBMED
35. McCollister KE, French MT, Prendergast ML, Hall E, Sacks S. Long-term cost effectiveness of addiction treatment for criminal offenders. Justice Q. 2004;21(3):659-679.
36. Stephan JJ. State Prison Expenditures, 2001. Washington, DC: Office of Justice Programs, Bureau of Justice Statistics; 2004. Dept of Justice publication NCJ 202949.
37. Rich JD, McKenzie M, Shield DC; et al. Linkage with methadone treatment upon release from incarceration: a promising opportunity. J Addict Dis. 2005;24(3):49-59. ISI | PUBMED
38. Logan TK, Hoyt WH, McCollister KE, French MT, Leukefeld C, Minton L. Economic evaluation of drug court: methodology, results, and policy implications. Eval Program Plann. 2004;27(4):381-396. FULL TEXT | ISI
39. Daley M, Love CT, Shepard DS, Petersen CB, White KL, Hall FB. Cost-effectiveness of Connecticut's in-prison substance abuse treatment. J Offender Rehabil. 2004;39(3):69-92.
40. Flynn PM, Kristiansen PL, Porto JV, Hubbard RL. Costs and benefits of treatment for cocaine addiction in DATOS. Drug Alcohol Depend. 1999;57(2):167-174. FULL TEXT | PUBMED
41. Zarkin GA, Dunlap LJ, Hicks KA, Mamo D. Benefits and costs of methadone treatment: results from a lifetime simulation model. Health Econ. 2005;14(11):1133-1150. FULL TEXT | ISI | PUBMED
42. Taxman FS, Perdoni ML, Harrison LD. Drug treatment services for adult offenders: the state of the state. J Subst Abuse Treat. 2007;32(3):239-254. FULL TEXT | ISI | PUBMED
43. Hammett TM, Roberts C, Kennedy S. Health-related issues in prisoner reentry. Crime Delinq. 2001;47(3):390-409. FREE FULL TEXT
44. Binswanger IA, Stern MF, Deyo RA; et al. Release from prison—a high risk of death for former inmates [published correction appears in N Engl J Med. 2007;356(5):536]. N Engl J Med. 2007;356(2):157-165. FREE FULL TEXT
45. Boutwell AE, Allen SA, Rich JD. Opportunities to address the hepatitis C epidemic in the correctional setting. Clin Infect Dis. 2005;40(suppl 5):S367-S372. FULL TEXT | ISI | PUBMED
46. Zaller N, Thurmond P, Rich JD. Limited spending: an analysis of correctional expenditures on antiretrovirals for HIV-infected prisoners. Public Health Rep. 2007;122(1):49-54. PUBMED
47. Desai AA, Latta ET, Spaulding A, Rich JD, Flanigan TP. The importance of routine HIV testing in the incarcerated population: the Rhode Island experience. AIDS Educ Prev. 2002;14(5)(suppl B):45-52. FULL TEXT | ISI | PUBMED
48. Sabin KM, Frey RL Jr, Horsley R, Greby SM. Characteristics and trends of newly identified HIV infections among incarcerated populations: CDC HIV voluntary counseling testing and referral system 1992-1998. J Urban Health. 2001;78(2):241-255. ISI | PUBMED
49. Allen SA, Spaulding AC, Osei AM, Taylor LE, Cabral AM, Rich JD. Treatment of chronic hepatitis C in a state correctional facility. Ann Intern Med. 2003;138(3):187-190. FREE FULL TEXT
50. Vallabhaneni S, Macalino GE, Reinert SE, Schwartzapfel B, Wolf FA, Rich JD. Prisoners favour hepatitis C testing and treatment. Epidemiol Infect. 2006;134(2):243-248. PUBMED
51. Rich JD, Holmes L, Salas C; et al. Successful linkage of medical care and community services for HIV-positive offenders being released from prison. J Urban Health. 2001;78(2):279-289. ISI | PUBMED
52. Springer SA, Pesanti E, Hodges J, Macura T, Doros G, Altice FL. Effectiveness of antiretroviral therapy among HIV-infected prisoners: reincarceration and the lack of sustained benefit after release to the community. Clin Infect Dis. 2004;38(12):1754-1760. FULL TEXT | ISI | PUBMED
53. Freudenberg N. Jails, prisons, and the health of urban populations: a review of the impact of the correctional system on community health. J Urban Health. 2001;78(2):214-235. ISI | PUBMED
54. Uhl GR, Grow RW. The burden of complex genetics in brain disorders. Arch Gen Psychiatry. 2004;61(3):223-229. FREE FULL TEXT
55. Volkow N, Li TK. The neuroscience of addiction. Nat Neurosci. 2005;8(11):1429-1430. FULL TEXT | ISI | PUBMED
56. Uhl GR. Molecular genetic underpinnings of human substance abuse vulnerability: likely contributions to understanding addiction as a mnemonic process. Neuropharmacology. 2004;47(suppl 1):140-147. FULL TEXT | ISI | PUBMED
57. Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. J Clin Invest. 2003;111(10):1444-1451. FULL TEXT | ISI | PUBMED
58. Koob GF, Le Moal M. Plasticity of reward neurocircuitry and the "dark side" of drug addiction. Nat Neurosci. 2005;8(11):1442-1444. FULL TEXT | ISI | PUBMED
59. Naqvi NH, Rudrauf D, Damasio H, Bechara A. Damage to the insula disrupts addiction to cigarette smoking. Science. 2007;315(5811):531-534. FREE FULL TEXT
60. Hester R, Garavan H. Executive dysfunction in cocaine addiction: evidence for discordant frontal, cingulate, and cerebellar activity. J Neurosci. 2004;24(49):11017-11022. FREE FULL TEXT
61. Fellows LK. The role of orbitofrontal cortex in decision making: a component process account. Ann N Y Acad Sci. 2007;1121:421-430. FULL TEXT | ISI | PUBMED
62. Kalivas PW, Volkow ND. The neural basis of addiction: a pathology of motivation and choice. Am J Psychiatry. 2005;162(8):1403-1413. FREE FULL TEXT
63. Everitt BJ, Robbins TW. Neural systems of reinforcement for drug addiction: from actions to habits to compulsion. Nat Neurosci. 2005;8(11):1481-1489. FULL TEXT | ISI | PUBMED
64. Gray MA, Critchley HD. Interoceptive basis to craving. Neuron. 2007;54(2):183-186. FULL TEXT | PUBMED
65. Kosten TR, Markou A, Koob GF. Depression and stimulant dependence: neurobiology and pharmacotherapy. J Nerv Ment Dis. 1998;186(12):737-745. FULL TEXT | ISI | PUBMED
66. Koob GF, Le Moal M. Drug abuse: hedonic homeostatic dysregulation. Science. 1997;278(5335):52-58. FREE FULL TEXT
67. Winstanley CA. The orbitofrontal cortex, impulsivity, and addiction: probing orbitofrontal dysfunction at the neural, neurochemical, and molecular level. Ann N Y Acad Sci. 2007;1121:639-655. FULL TEXT | ISI | PUBMED
68. Yücel M, Lubman DI, Solowij N, Brewer WJ. Understanding drug addiction: a neuropsychological perspective. Aust N Z J Psychiatry. 2007;41(12):957-968. PUBMED
69. Bickel WK, Miller ML, Yi R, Kowal BP, Lindquist DM, Pitcock JA. Behavioral and neuroeconomics of drug addiction: competing neural systems and temporal discounting processes. Drug Alcohol Depend. 2007;90(suppl 1):S85-S91. ISI | PUBMED
70. Madden GJ, Petry NM, Badger GJ, Bickel WK. Impulsive and self-control choices in opioid-dependent patients and non-drug-using control participants: drug and monetary rewards. Exp Clin Psychopharmacol. 1997;5(3):256-262. FULL TEXT | ISI | PUBMED
71. Shaham Y, Hope BT. The role of neuroadaptations in relapse to drug seeking. Nat Neurosci. 2005;8(11):1437-1439. FULL TEXT | ISI | PUBMED
72. Baler RD, Volkow ND. Drug addiction: the neurobiology of disrupted self-control. Trends Mol Med. 2006;12(12):559-566. FULL TEXT | ISI | PUBMED
73. Ersche KD, Sahakian BJ. The neuropsychology of amphetamine and opiate dependence: implications for treatment. Neuropsychol Rev. 2007;17(3):317-336. PUBMED
74. Kosten TR. Addiction as a brain disease. Am J Psychiatry. 1998;155(6):711-713. PUBMED
75. Fletcher BW, Chandler RK. Principles of Drug Abuse Treatment for Criminal Justice Populations. Washington, DC: National Institute on Drug Abuse; 2006. NIH publication 06-5316.
76. Wilson DB, Bouffard LA, Mackenzie DL. A quantitative review of structured, group-oriented, cognitive-behavioral programs for offenders. Crim Justice Behav. 2005;32(2):172-204. ABSTRACT
77. Gostin LO. Biomedical research involving prisoners: ethical values and legal regulation. JAMA. 2007;297(7):737-740. FREE FULL TEXT
78. Wexler HK, Fletcher BW. National Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) overview. Prison J. 2007;87(1):9-24.
79. Comer SD, Collins ED, Kleber HD, Nuwayser ES, Kerrigan JH, Fischman MW. Depot naltrexone: long-lasting antagonism of the effects of heroin in humans. Psychopharmacology (Berl). 2002;159(4):351-360. FULL TEXT | PUBMED
80. Comer SD, Sullivan MA, Yu E; et al. Injectable, sustained-release naltrexone for the treatment of opioid dependence: a randomized, placebo-controlled trial. Arch Gen Psychiatry. 2006;63(2):210-218. FREE FULL TEXT
81. Dackis C, O’Brien C. Neurobiology of addiction: treatment and public policy ramifications. Nat Neurosci. 2005;8(11):1431-1436. FULL TEXT | ISI | PUBMED
The basic premise of the article is that not treating a drug-abusing offender is a missed opportunity to simultaneously improve both public health and safety. Integrating treatment into the criminal justice system would provide treatment to individuals who otherwise would not receive it, improving their medical outcomes and decreasing their rates of reincarceration.
Research over the last 2 decades has consistently reported the beneficial effects of treatment for the drug abuser in the criminal justice system.These interventions include therapeutic alternatives to incarceration, treatment merged with judicial oversight in drug courts, prison- and jail-based treatments, and reentry programs intended to help offenders transition from incarceration back into the community.Through monitoring, supervision, and threat of legal sanctions, the justice system can provide leverage to encourage drug abusers to enter and remain in treatment.
Effective interventions depend on a coordinated response between criminal justice agencies, drug abuse treatment providers, mental health and physical health care organizations, and social service agencies. Each type of criminal justice agency (eg, jail, drug court, probation, prison) has its own role in sanctioning and supervision and lends itself to specific intervention opportunities.
Effective integration of drug treatment interventions into criminal justice settings requires matching the intervention to the organization. For example, since jail stays are usually brief, the interventions best suited to jails may be screening for drug and alcohol abuse, other mental illnesses, and medical conditions (eg, HIV, hepatitis B or C), with referral to community-based treatment providers. Implementing these principles throughout the criminal justice and drug abuse treatment systems also requires that these systems work together to address the addicted individual's drug use, comorbid mental disorders and medical conditions, if present, and criminal behavior. Treatment professionals should understand the criminal justice process and the supervision requirements of their patients. In addition to addressing drug use behaviors, treatment outcomes improve when antisocial and criminal behaviors are targets of clinical intervention.Criminal justice professionals must develop an understanding of addiction—signs and symptoms, treatment, and relapse—and their role in facilitating recovery.
The challenge of delivering treatment in a criminal setting requires the cooperation and coordination of 2 disparate cultures: the criminal justice system organized to punish the offender and protect society and the drug abuse treatment systems organized to help the addicted individual. Addressing addiction as a disease does not remove the responsibility of the individual, which is the argument frequently used to resist recognizing and treating addiction as an illness. Rather it highlights the personal responsibility of the addicted person to seek and adhere to drug treatment and that of society to ensure that such treatment is available and based on scientific evidence. Only a small percentage of those requiring treatment for drug addiction seek help voluntarily; in light of this, the criminal justice system provides a unique opportunity to intervene and disrupt the cycle of drug use and crime in a cost-effective manner.
For those interested I can e-mail a PDF version of the complete article.
See you soon in Tampa for our Annual Scientific Conference
Yours
Bernd Wollschlaeger,MD,FAAFp,FASAM
President,Florida Society of Addiction Medicine
==========================================================================================================================
Treating Drug Abuse and Addiction in the Criminal Justice System: Improving Public Health and Safety
Redonna K. Chandler, PhD; Bennett W. Fletcher, PhD; Nora D. Volkow, MD
JAMA. 2009;301(2):183-190.
ABSTRACT
Despite increasing evidence that addiction is a treatable disease of the brain, most individuals do not receive treatment. Involvement in the criminal justice system often results from illegal drug-seeking behavior and participation in illegal activities that reflect, in part, disrupted behavior ensuing from brain changes triggered by repeated drug use. Treating drug-involved offenders provides a unique opportunity to decrease substance abuse and reduce associated criminal behavior. Emerging neuroscience has the potential to transform traditional sanction-oriented public safety approaches by providing new therapeutic strategies against addiction that could be used in the criminal justice system. We summarize relevant neuroscientific findings and evidence-based principles of addiction treatment that, if implemented in the criminal justice system, could help improve public heath and reduce criminal behavior.
INTRODUCTION
The past 20 years have seen significant increases in the numbers of individuals incarcerated or under other forms of criminal justice supervision in the United States. These numbers are staggering—approximately 7.1 million adults in the United States are under some form of criminal justice supervision.1 The large increase in the criminal justice population reflects in part tougher laws and penalties for drug offenses.2 An estimated one-half of all prisoners (including some sentenced for other than drug offenses) meet the criteria for diagnosis of drug abuse or dependence (Table 1).3-4
During the past 20 years, fundamental advances in the neurobiology of addiction have been made. Molecular and imaging studies have revealed addiction as a brain disorder with a strong genetic component, and this has galvanized research on new pharmacological treatments. However, a large disconnect remains between addiction research and the treatment of addiction in general, particularly within the criminal justice system. This is evidenced in that most prisoners (80%-85%) who could benefit from drug abuse treatment do not receive it.3-4 In addition, drug-using offenders are at high risk for infectious diseases such as human immunodeficiency virus (HIV) and hepatitis C5 and frequently have comorbid psychiatric disorders,6-7 which further highlights the dire treatment needs of this population.
Not treating a drug-abusing offender is a missed opportunity to simultaneously improve both public health and safety. Integrating treatment into the criminal justice system would provide treatment to individuals who otherwise would not receive it, improving their medical outcomes and decreasing their rates of reincarceration.8
Recidivism in the Drug-Abusing Offender
The inadequacy of incarceration by itself in addressing drug abuse or addiction is evident in the statistics. A review of recidivism in 15 states found that one-quarter of individuals released returned to prison within 3 years for technical violations that included, among other things, testing positive for drug use.9 Illicit drugs are used in jails and prisons despite their highly structured, controlled environments,10 but even enforced abstinence can mislead criminal justice professionals as well as addicted persons to underestimate the vulnerability to relapse postincarceration. On release from prison or jail, addicted persons will experience challenges to their sobriety through multiple stressors that increase their risk of relapsing to drug use. These include the stigma associated with being labeled an ex-offender, the need for housing and legitimate employment, stresses in reunifying with family, and multiple requirements for criminal justice supervision.11-12
Returning to neighborhoods associated with preincarceration drug use places the addicted individual in an environment rich in drug cues. As discussed below, these conditioned cues automatically activate the reward/motivational neurocircuitry and can trigger an intense desire to consume drugs (craving).13 The molecular and neurobiological adaptations resulting from chronic drug use persist for months after drug discontinuation,14 and evidence exists that compulsive seeking of drugs when addicted individuals are reexposed to drug cues progressively increases after drug withdrawal.15 This could explain why many drug-addicted individuals rapidly return to drug use following long periods of abstinence during incarceration and highlights the need for ongoing treatment following release.
Drug Abuse Treatment Effectiveness in the Criminal Justice System
Research over the last 2 decades has consistently reported the beneficial effects of treatment for the drug abuser in the criminal justice system.16-17 These interventions include therapeutic alternatives to incarceration, treatment merged with judicial oversight in drug courts, prison- and jail-based treatments, and reentry programs intended to help offenders transition from incarceration back into the community.8, 18 Through monitoring, supervision, and threat of legal sanctions, the justice system can provide leverage to encourage drug abusers to enter and remain in treatment.
Behavioral treatments are the most commonly used interventions for addressing substance use disorders. Evidence-based behavioral interventions include cognitive therapies that teach coping and decision-making skills, contingency management therapies that reinforce behavioral changes associated with abstinence, and motivational therapies that enhance the motivation to participate in treatment and in non–drug-related activities.19-20 Many residential treatment programs rely on the creation of a "therapeutic community" based on a social learning model.21 Medications such as methadone, buprenorphine, and naltrexone are beneficial for the treatment of heroin addiction and naltrexone and topiramate for the treatment of alcoholism.22-24 Self-help programs such as Alcoholics Anonymous or SMART Recovery can be valuable adjuncts to formal drug treatment.25
Research has consistently shown that community-based drug abuse treatment can reduce drug use and drug-related criminal behavior.26 A meta-analysis of 78 comparison-group community-based drug treatment studies found treatment to be up to 1.8 times better in reducing drug use than the usual alternatives.20 In a meta-analysis of 66 incarceration-based treatment evaluations, therapeutic community and counseling approaches were respectively 1.4 and 1.5 times more likely to reduce reoffending.27 Drug courts combine judicial supervision with drug treatment as an alternative to incarceration; their graduates have rearrest rates about half those of matched comparison samples and much lower than those of drug court dropouts.28 Individuals who participated in prison-based treatment followed by a community-based program postincarceration were 7 times more likely to be drug free and 3 times less likely to be arrested for criminal behavior than those not receiving treatment.29-30
The benefits of medications for drug treatment were shown in a recent randomized trial in which heroin-dependent inmates began methadone treatment in prison prior to release and continued in the community postrelease. At 1-, 3-, and 6-month follow-up, patients who received methadone plus counseling were significantly less likely to use heroin or engage in criminal activity than those who received only counseling.31-33 The potential exists for immediate adoption of methadone maintenance for incarcerated persons with opioid addictions, but most prison systems have not been receptive to this approach.34
Economic analyses highlight the cost-effectiveness of treating drug-involved offenders.35 On average, incarceration in the United States costs approximately $22 000 per month,36 and there is little evidence that this strategy reduces drug use or drug-related reincarceration rates for nonviolent drug offenders. By contrast, the average cost of methadone is $4000 per month,37 and treatment with methadone has demonstrated effectiveness in reducing drug use and criminal activity following release.31 Alternatives to incarceration can also defray job productivity losses and the separation from family and social support systems.
The cost of integrating volunteer-led self-help organizations such as Alcoholics Anonymous and Narcotics Anonymous into criminal justice settings is nominal and could provide support to the recovery efforts of addicted persons in the criminal justice system. One dollar spent on drug courts is estimated to save approximately $4 in avoided costs of incarceration and health care,38 and prison-based treatment saves between $2 to $6.39 These economic benefits in part reflect reductions in criminal behavior.40-41
Access to Treatment
Drug education—not drug treatment—is the most common service provided to prisoners with drug abuse or addiction problems.4, 42 More than one-quarter of state inmates and 1 in 5 federal inmates meeting abuse/dependence criteria participate in self-help groups such as Alcoholics Anonymous while in prison.4 However, though treatment during and after incarceration has been shown to significantly reduce drug use and drug-related crime, less than 20% of inmates with drug abuse or dependence receive formal treatment (Table 1).3-4
In a recent survey of correctional programs and organizations across the United States,42 most correctional agencies reported providing some type of drug abuse treatment services; however, the median percentage of offenders who had access to those services at any given time was low, usually less than 10% (Table 2).42 Even if a correctional institution does provide treatment, the continuity of treatment postincarceration, which is essential to recovery,16 is often lacking when the drug-involved offender transitions from incarceration to community supervision.43 Failure to receive treatment on release increases the risk not only of relapse but also of mortality from drug overdose and other causes.44
Infectious diseases such as HIV and hepatitis C are associated with illicit drug use and occur at higher rates in correctional populations than in the general population,5 but treatment for these conditions appears to fall short of need.45-46 It is feasible to implement screening and treatment in correctional settings for HIV47-48 and hepatitis C.49-50 Continuity of treatment for released offenders with infectious disease is crucial not only for the individual's health51-52 but also for the health of the community.45, 53
There are many barriers to treatment for the drug-involved offender, including lack of the resources, infrastructure, and treatment staff (including physicians knowledgeable about addiction medicine) required to meet the drug treatment needs of individuals under their supervision. Addiction remains a stigmatized disease not often regarded by the criminal justice system as a medical condition; as a consequence, treatment is not constitutionally guaranteed as is the treatment of other medical conditions.
Neurobiology of Addiction
Addiction is a chronic brain disease for which genetic factors are believed to contribute 40% to 60% of the vulnerability.54 Repeated drug exposure in individuals who are vulnerable (because of genetics, or developmental or environmental factors) trigger neuroadaptations in the brain that result in the compulsive drug use and loss of control over drug-related behaviors that characterizes addiction. Molecular and neuroimaging studies have helped illuminate how genes may affect vulnerability to addiction and how repeated use of addictive drugs causes long-lasting disruptions to the structure and function of the brain.55 Among the genes identified to contribute to the vulnerability for addiction are those that participate in the neuroplastic changes associated with learning.56 Imaging studies have identified multiple brain circuits that are disrupted in addicted persons57; these include circuits involved in reward and motivation, learning and memory, cognitive control, mood, and interoception (awareness of physiological body signals) (Figure). Disruption of these circuits impairs the addicted person's ability to inhibit intentional actions or to control strong emotions and desires and also increases the likelihood that the individual will have difficulties making adaptive decisions.60-61
Circuits work together and change with experience. Each is linked to an important concept: reward (saliency), motivation (drive), memory (learning associations), inhibitory control (conflict resolution), mood (well-being),58 and interoception (internal awareness).59 Size of circuit ovals indicates influence in determining behavioral outcomes. Thicker line weights indicate greater influence on regulation of the circuit. A, In a nonaddicted person the decision to consume a drug (same process pertains for natural rewards) is a function of the balance between the expected pleasure (based on past experience or memory), alternative stimuli (this includes internal states such as mood and interoception but also alternative external rewards), and potential negative outcomes that oppose the motivation to take the drug (inhibitory control exerted by prefrontal cortex) and stop the drug use. B, During addiction, the enhanced value of the drug in the reward, motivation, and memory circuits overcomes the inhibitory control exerted by the prefrontal cortex, thereby favoring a positive feedback loop initiated by the consumption of the drug and perpetuated by enhanced activation of the motivation/drive and memory circuits. Decreased sensitivity to rewards also raises the hedonic threshold, disrupting mood and increasing the saliency values of drugs and behaviors temporarily associated with relief from the dysphoria. Learning and conditioning result in an enhanced interoceptive awareness of discomfort and the associated desire for the drug (craving). Absence of lines from inhibitory control circuit to reward and motivation circuits indicates loss of regulation.
Addiction also decreases sensitivity in the reward and the motivational circuits, which modulate response to positive as well as negative reinforcers. Practically, this suggests that an addicted individual may experience less motivation to pursue activities likely to result in beneficial outcomes and to avoid those that could result in punishment. One can also predict that dysfunction in this neurocircuitry would reduce an addicted person's motivation to abstain from drug use because alternative reinforcers (natural stimuli) are comparatively weaker and negative consequences (eg, incarceration) are less salient.62
In parallel, the repeated use of drugs leads to the formation of new linked memories that condition the addicted individual to expect pleasurable responses—not only when exposed to a drug but also when exposed to stimuli associated with the drug. These stimuli trigger automatic responses that frequently drive relapse, even in individuals motivated to stop taking drugs.63 The enhanced sensitivity to drugs as rewards and the conditioning to associated drug cues increase the interoceptive awareness of discomfort (anxiety and tension) that occurs when the individual is exposed to drug cues and increase the desire to consume the drug.64 Additionally, repeated drug use also affects brain regions implicated in mood and anxiety, which could explain the high rate of addiction comorbid with dysphoria, depression, or both and the vulnerability of the addicted person to relapse when exposed to social stressors.65-66
Impairment of the neural substrates affected by addiction—particularly those concerned with behavioral inhibition, control of emotions and desires, and decision-making—increase the likelihood that addicted individuals will make choices that appear impulsive.67-68 This idea is supported by research in the emerging area of behavioral economics, which has found that addicted individuals differ from those who do not use drugs in how they make decisions. Addicted individuals tend to have higher levels of temporal discounting than those who do not use drugs; ie, they tend to choose immediate, smaller rewards over future, larger rewards.69 High temporal discounting is also associated with impulsivity—the inability to delay immediate gratification and to recognize the potential for negative consequences.70
Many of the neurobiological changes associated with repeated drug use persist for long periods after drug discontinuation.71 This helps explain why addicted individuals who have ceased drug use are at high risk of relapse and provides neurobiological support for the recognition of addiction as a chronic relapsing disease.72
What are the implications of neuroscience research for how society and clinicians might regard the addicted offender? There are at least 3 implications for how this emerging knowledge about the neurologic basis of addictive behavior is important.
First, of most importance, neuroscience's uncovering of new molecular targets implicated in the responses to drugs and of new knowledge on the function of the human brain provides new targets for medication development and behavioral interventions in addiction. Although many of the neurobiological changes associated with repeated drug use persist for long periods after drug discontinuation,71 research suggests that the impaired brain can regain some of the functions damaged by use of illicit drugs over time.73
Second, neuroscience establishes a biological framework for understanding aspects of addictive behavior that otherwise seem to defy rational explanation. In the absence of known biological determinants, these behaviors often have been attributed to "moral weakness."74 Identifying the neurologic factors underlying addictive behavior can place these moral arguments into a more reasoned context. Addiction does not absolve one of responsibility for use of illicit drugs or for criminal behavior, but understanding how addictive drugs affect behavior through brain mechanisms can inform decisions to provide treatment to addicted individuals. For example, mandated treatment may be useful for drug-involved offenders who would otherwise not engage in the treatment process or make progress toward recovery. The persistence of neurologic deficits provides support for the recognition of addiction as a chronic disease and highlights the need for the same continuity of care so important in treatment of other chronic diseases (eg, asthma, hypertension).72 It also suggests that agonist medications such as methadone are important treatments for addiction, even for individuals who have been under enforced abstinence during incarceration.
Third, neuroscience may help addicted individuals to better understand their own addiction. Such individuals may become frustrated when their efforts to control their own drug use are unsuccessful, and even with treatment many become frustrated with what is often a slow and tenuous recovery process. The neurobiology of the brain can help the addicted individual put this disease into a more understandable context and thereby facilitate effective treatment. Little research has been conducted in the field of addiction on whether knowing more about the substance use disorder is useful in helping to sustain recovery, and more research is needed. However, the concept of the "expert patient" who serves as his or her own best health advocate in a recovery management paradigm has been promoted for chronic disorders. As with these other illnesses, addiction must be managed by the individual over time to sustain recovery.
Principles of Drug Abuse Treatment for Offenders
Principles of Drug Abuse Treatment for Criminal Justice Populations,75 published by the National Institute on Drug Abuse, synthesizes research on drug abuse treatment for drug abusers in the criminal justice system. It is intended as a resource for criminal justice professionals and the treatment community working with drug abusers involved with the system. The publication summarizes 20 years of research to provide guidance on evidence-based practices and identifies general principles on how to effectively address the drug abuse problems of populations involved with the criminal justice system (Box).75
Implementing the Principles
Effective interventions depend on a coordinated response between criminal justice agencies, drug abuse treatment providers, mental health and physical health care organizations, and social service agencies. Each type of criminal justice agency (eg, jail, drug court, probation, prison) has its own role in sanctioning and supervision and lends itself to specific intervention opportunities. Table 3 provides a simplified overview of the criminal justice system and identifies the points at which intervention is possible.
Effective integration of drug treatment interventions into criminal justice settings requires matching the intervention to the organization. For example, since jail stays are usually brief, the interventions best suited to jails may be screening for drug and alcohol abuse, other mental illnesses, and medical conditions (eg, HIV, hepatitis B or C), with referral to community-based treatment providers. Implementing these principles throughout the criminal justice and drug abuse treatment systems also requires that these systems work together to address the addicted individual's drug use, comorbid mental disorders and medical conditions, if present, and criminal behavior. Treatment professionals should understand the criminal justice process and the supervision requirements of their patients. In addition to addressing drug use behaviors, treatment outcomes improve when antisocial and criminal behaviors are targets of clinical intervention.76 Criminal justice professionals must develop an understanding of addiction—signs and symptoms, treatment, and relapse—and their role in facilitating recovery.
Substance Abuse Treatment Research in Criminal Justice Settings
Prison environments are inherently coercive,77 and special safeguards have been developed to ensure that prisoners can choose freely whether to participate in biomedical research without fear of consequence. Beyond mere equipoise, clinical trials must be designed so the research is of benefit to the prisoner participant regardless of the assigned study group. Within these constraints, it is important to conduct research to help improve substance abuse treatment and to assist in the successful transition of the substance abuser to the community. To facilitate research in this area, the National Institute on Drug Abuse created the Criminal Justice Drug Abuse Treatment Studies research cooperative,78 a network of correctional agencies linked with treatment research centers and community treatment programs.
Opiate agonist medications used for the treatment of heroin addiction such as methadone and buprenorphine are underused in correctional populations. Naltrexone, an opiate antagonist, was developed to treat heroin addiction but also has been approved for treating alcoholism. Naltrexone is likely to be more acceptable in the criminal justice setting than agonist medications. However, the poor compliance with naltrexone has limited its use in the treatment of heroin addiction. The recent development of a long-lasting depot formulation for naltrexone79-80 obviates this limitation, and a multisite clinical trial (NCT00781898) is currently evaluating its effectiveness in heroin-addicted probationers. Another area of research intended to reduce relapse in addicted offenders is the development of vaccines against cocaine, methamphetamine, or heroin.
Several avenues currently exist for providing drug abuse treatment as an alternative to incarceration. Drug courts were intended to provide a bridge between drug treatment and adjudication; from the first drug court established in Miami in 1989, drug courts have increased in number to nearly 2000 today. States such as Arizona, California, and New York have created treatment alternatives to incarceration for first-time drug offenders, juvenile offenders, and others. Many states are coming under political pressure to reduce the costs associated with incarceration by diverting nonviolent drug offenders to treatment.
Conclusions
Punishment alone is a futile and ineffective response to drug abuse,2 failing as a public safety intervention for offenders whose criminal behavior is directly related to drug use.81 Addiction is a chronic brain disease with a strong genetic component that in most instances requires treatment. The increase in the number of drug-abusing offenders highlights the urgency to institute treatments for populations involved in the criminal justice system. It also provides a unique opportunity to intervene for individuals who would otherwise not seek treatment.
The challenge of delivering treatment in a criminal setting requires the cooperation and coordination of 2 disparate cultures: the criminal justice system organized to punish the offender and protect society and the drug abuse treatment systems organized to help the addicted individual. Addressing addiction as a disease does not remove the responsibility of the individual, which is the argument frequently used to resist recognizing and treating addiction as an illness. Rather it highlights the personal responsibility of the addicted person to seek and adhere to drug treatment and that of society to ensure that such treatment is available and based on scientific evidence. Only a small percentage of those requiring treatment for drug addiction seek help voluntarily; in light of this, the criminal justice system provides a unique opportunity to intervene and disrupt the cycle of drug use and crime in a cost-effective manner.
AUTHOR INFORMATION
Corresponding Author: Nora D. Volkow, MD, National Institute on Drug Abuse, 6001 Executive Blvd, Room 5274, Bethesda, MD 20892 (nvolkow@nida.nih.gov).
Author Contributions: Study concept and design: Chandler, Fletcher, Volkow.
Analysis and interpretation of data: Fletcher.
Drafting of the manuscript: Chandler, Fletcher.
Critical revision of the manuscript for important intellectual content: Chandler, Fletcher, Volkow.
Administrative, technical, or material support: Chandler, Fletcher, Volkow.
Financial Disclosures: None reported.
Funding/Support: This article was written by staff from the National Institute on Drug Abuse and there was no external funding for this work.
Disclaimer: The statements in this article are those of the authors and not necessarily those of the National Institute on Drug Abuse.
Additional Contributions: We thank Faye S. Taxman, PhD, and Matthew Perdoni, MS, both of George Mason University, for data on physical/medical, mental health, and substance use services (Table 2) from the NIDA National Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) National Criminal Justice Treatment Practices Survey. Neither of these individuals received compensation for their contributions.
Author Affiliations: Services Research Branch, National Institute on Drug Abuse (Drs Chandler and Fletcher); and National Institute on Drug Abuse (Dr Volkow), Bethesda, Maryland.
REFERENCES
1. Glaze LE, Bonczar TP. Probation and Parole in the United States, 2005. Washington, DC: Office of Justice Programs, Bureau of Justice Statistics; 2006. Dept of Justice publication NCJ 215091.
2. Jensen EL, Gerber J, Mosher C. Social consequences of the War on Drugs: the legacy of failed policy. Criminal Justice Policy Review. 2004;15(1):100-121.
3. Karberg JC, James DJ. Substance Dependence, Abuse, and Treatment of Jail Inmates, 2002. Washington, DC: Office of Justice Programs, Bureau of Justice Statistics; 2005. Dept of Justice publication NCJ 209588.
4. Mumola CJ, Karberg JC. Drug Use and Dependence, State and Federal Prisoners, 2004. Washington, DC: Office of Justice Programs, Bureau of Justice Statistics; 2006. Dept of Justice publication NCJ 213530.
5. Weinbaum CM, Sabin KM, Santibanez SS. Hepatitis B, hepatitis C, and HIV in correctional populations: a review of epidemiology and prevention. AIDS. 2005;19(suppl 3):S41-S46. PUBMED
6. Abram KM, Teplin LA. Co-occurring disorders among mentally ill jail detainees: implications for public policy. Am Psychol. 1991;46(10):1036-1045. FULL TEXT | PUBMED
7. Chandler RK, Peters RH, Field G, Juliano-Bult D. Challenges in implementing evidence-based treatment practices for co-occurring disorders in the criminal justice system. Behav Sci Law. 2004;22(4):431-448. PUBMED
8. Knight K, ed, Farabee D, ed. Treating Addicted Offenders: A Continuum of Effective Practices. Kingston, NJ: Civic Research Institute; 2004.
9. Langan PA, Levin DJ. Recidivism of Prisoners Released in 1994. Washington, DC: Office of Justice Programs, Bureau of Justice Statistics; 2002. Dept of Justice publication NCJ 193427.
10. Simpler AH, Langhinrichsen-Rohling J. Substance use in prison: how much occurs and is it associated with psychopathology? Addict Res Theory. 2005;13(5):503-511.
11. Field G. Continuity of offender treatment: from the institution to the community. In: Knight K, Farabee D, eds. Treating Addicted Offenders: A Continuum of Effective Practices. Kingston, NJ: Civic Research Institute; 2004:33-1–33-9.
12. Shivy VA, Wu JJ, Moon AE, Mann SC, Holland JG, Eacho C. Ex-offenders reentering the workforce. J Couns Psychol. 2007;54(4):466-473.
13. Volkow ND, Wang GJ, Telang F; et al. Cocaine cues and dopamine in dorsal striatum: mechanism of craving in cocaine addiction. J Neurosci. 2006;26(24):6583-6588. FREE FULL TEXT
14. Nestler EJ. Review: transcriptional mechanisms of addiction: role of Delta FosB. Philos Trans R Soc Lond B Biol Sci. 2008;363(1507):3245-3255. FULL TEXT | PUBMED
15. Grimm JW, Hope BT, Wise RA, Shaham Y. Neuroadaptation: incubation of cocaine craving after withdrawal. Nature. 2001;412(6843):141-142. FULL TEXT | PUBMED
16. Inciardi JA, Martin SS, Butzin CA, Hooper RM, Harrison LD. An effective model of prison-based treatment for drug-involved offenders. J Drug Issues. 1997;27(2):261-278. ISI
17. Pearson FS, Lipton DS. A meta-analytic review of the effectiveness of corrections-based treatments for drug abuse. Prison J. 1999;79(4):384-410.
18. Leukefeld CG, ed, Tims F, ed, Farabee D, ed. Treatment of Drug Offenders: Policies and Issues. New York, NY: Springer; 2002.
19. Wormith JS, Althouse R, Simpson M, Reitzel LR, Fagan TJ, Morgan RD. The rehabilitation and reintegration of offenders—the current landscape and some future directions for correctional psychology. Crim Justice Behav. 2007;34(7):879-892. FREE FULL TEXT
20. Prendergast ML, Podus D, Chang E, Urada D. The effectiveness of drug abuse treatment: a meta-analysis of comparison group studies. Drug Alcohol Depend. 2002;67(1):53-72. FULL TEXT | ISI | PUBMED
21. De Leon G. Therapeutic communities: is there an essential model? In: De Leon G, ed. Community as Method: Therapeutic Communities for Special Populations and Special Settings. Westport, CT: Praeger; 1997:3-18.
22. Volkow ND, Li TK. Drugs and alcohol: treating and preventing abuse, addiction and their medical consequences. Pharmacol Ther. 2005;108(1):3-17. FULL TEXT | ISI | PUBMED
23. Johnson BA, Rosenthal N, Capece JA; et al, Topiramate for Alcoholism Advisory Board; Topiramate for Alcoholism Study Group. Topiramate for treating alcohol dependence: a randomized controlled trial. JAMA. 2007;298(14):1641-1651. FREE FULL TEXT
24. Cropsey KL, Villalobos GC, St Clair CL. Pharmacotherapy treatment in substance-dependent correctional populations: a review. Subst Use Misuse. 2005;40(13-14):1983-1999. PUBMED
25. Humphreys K, Wing S, McCarty D; et al. Self-help organizations for alcohol and drug problems: toward evidence-based practice and policy. J Subst Abuse Treat. 2004;26(3):151-158. FULL TEXT | PUBMED
26. Lurigio AJ. Drug treatment availability and effectiveness—studies of the general and criminal justice populations. Crim Justice Behav. 2000;27(4):495-528. FREE FULL TEXT
27. Mitchell O, Wilson DB, MacKenzie DL. Does incarceration-based drug treatment reduce recidivism? a meta-analytic synthesis of the research. J Exp Criminol. 2007;3(4):353-375.
28. Peters RH, Murrin MR. Effectiveness of treatment-based drug courts in reducing recidivism. Crim Justice Behav. 2000;27(1):72-96. FREE FULL TEXT
29. Butzin CA, O’Connell DJ, Martin SS, Inciardi JA. Effect of drug treatment during work release on new arrests and incarcerations. J Crim Justice. 2006;34(5):557-565.
30. Martin SS, Butzin CA, Saum CA, Inciardi JA. Three-year outcomes of therapeutic community treatment for drug-involved offenders in Delaware: from prison to work release to aftercare. Prison J. 1999;79(3):294-320.
31. Gordon MS, Kinlock TW, Schwartz RP, O’Grady KE. A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release. Addiction. 2008;103(8):1333-1342. PUBMED
32. Kinlock TW, Gordon MS, Schwartz RP, O’Grady KE. A study of methadone maintenance for male prisoners. Crim Justice Behav. 2008;35(1):34-47. FREE FULL TEXT
33. Kinlock TW, Gordon MS, Schwartz RP, O’Grady K, Fitzgerald TT, Wilson M. A randomized clinical trial of methadone maintenance for prisoners: results at 1-month post-release. Drug Alcohol Depend. 2007;91(2-3):220-227. PUBMED
34. Rich JD, Boutwell AE, Shield DC; et al. Attitudes and practices regarding the use of methadone in US state and federal prisons. J Urban Health. 2005;82(3):411-419. ISI | PUBMED
35. McCollister KE, French MT, Prendergast ML, Hall E, Sacks S. Long-term cost effectiveness of addiction treatment for criminal offenders. Justice Q. 2004;21(3):659-679.
36. Stephan JJ. State Prison Expenditures, 2001. Washington, DC: Office of Justice Programs, Bureau of Justice Statistics; 2004. Dept of Justice publication NCJ 202949.
37. Rich JD, McKenzie M, Shield DC; et al. Linkage with methadone treatment upon release from incarceration: a promising opportunity. J Addict Dis. 2005;24(3):49-59. ISI | PUBMED
38. Logan TK, Hoyt WH, McCollister KE, French MT, Leukefeld C, Minton L. Economic evaluation of drug court: methodology, results, and policy implications. Eval Program Plann. 2004;27(4):381-396. FULL TEXT | ISI
39. Daley M, Love CT, Shepard DS, Petersen CB, White KL, Hall FB. Cost-effectiveness of Connecticut's in-prison substance abuse treatment. J Offender Rehabil. 2004;39(3):69-92.
40. Flynn PM, Kristiansen PL, Porto JV, Hubbard RL. Costs and benefits of treatment for cocaine addiction in DATOS. Drug Alcohol Depend. 1999;57(2):167-174. FULL TEXT | PUBMED
41. Zarkin GA, Dunlap LJ, Hicks KA, Mamo D. Benefits and costs of methadone treatment: results from a lifetime simulation model. Health Econ. 2005;14(11):1133-1150. FULL TEXT | ISI | PUBMED
42. Taxman FS, Perdoni ML, Harrison LD. Drug treatment services for adult offenders: the state of the state. J Subst Abuse Treat. 2007;32(3):239-254. FULL TEXT | ISI | PUBMED
43. Hammett TM, Roberts C, Kennedy S. Health-related issues in prisoner reentry. Crime Delinq. 2001;47(3):390-409. FREE FULL TEXT
44. Binswanger IA, Stern MF, Deyo RA; et al. Release from prison—a high risk of death for former inmates [published correction appears in N Engl J Med. 2007;356(5):536]. N Engl J Med. 2007;356(2):157-165. FREE FULL TEXT
45. Boutwell AE, Allen SA, Rich JD. Opportunities to address the hepatitis C epidemic in the correctional setting. Clin Infect Dis. 2005;40(suppl 5):S367-S372. FULL TEXT | ISI | PUBMED
46. Zaller N, Thurmond P, Rich JD. Limited spending: an analysis of correctional expenditures on antiretrovirals for HIV-infected prisoners. Public Health Rep. 2007;122(1):49-54. PUBMED
47. Desai AA, Latta ET, Spaulding A, Rich JD, Flanigan TP. The importance of routine HIV testing in the incarcerated population: the Rhode Island experience. AIDS Educ Prev. 2002;14(5)(suppl B):45-52. FULL TEXT | ISI | PUBMED
48. Sabin KM, Frey RL Jr, Horsley R, Greby SM. Characteristics and trends of newly identified HIV infections among incarcerated populations: CDC HIV voluntary counseling testing and referral system 1992-1998. J Urban Health. 2001;78(2):241-255. ISI | PUBMED
49. Allen SA, Spaulding AC, Osei AM, Taylor LE, Cabral AM, Rich JD. Treatment of chronic hepatitis C in a state correctional facility. Ann Intern Med. 2003;138(3):187-190. FREE FULL TEXT
50. Vallabhaneni S, Macalino GE, Reinert SE, Schwartzapfel B, Wolf FA, Rich JD. Prisoners favour hepatitis C testing and treatment. Epidemiol Infect. 2006;134(2):243-248. PUBMED
51. Rich JD, Holmes L, Salas C; et al. Successful linkage of medical care and community services for HIV-positive offenders being released from prison. J Urban Health. 2001;78(2):279-289. ISI | PUBMED
52. Springer SA, Pesanti E, Hodges J, Macura T, Doros G, Altice FL. Effectiveness of antiretroviral therapy among HIV-infected prisoners: reincarceration and the lack of sustained benefit after release to the community. Clin Infect Dis. 2004;38(12):1754-1760. FULL TEXT | ISI | PUBMED
53. Freudenberg N. Jails, prisons, and the health of urban populations: a review of the impact of the correctional system on community health. J Urban Health. 2001;78(2):214-235. ISI | PUBMED
54. Uhl GR, Grow RW. The burden of complex genetics in brain disorders. Arch Gen Psychiatry. 2004;61(3):223-229. FREE FULL TEXT
55. Volkow N, Li TK. The neuroscience of addiction. Nat Neurosci. 2005;8(11):1429-1430. FULL TEXT | ISI | PUBMED
56. Uhl GR. Molecular genetic underpinnings of human substance abuse vulnerability: likely contributions to understanding addiction as a mnemonic process. Neuropharmacology. 2004;47(suppl 1):140-147. FULL TEXT | ISI | PUBMED
57. Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. J Clin Invest. 2003;111(10):1444-1451. FULL TEXT | ISI | PUBMED
58. Koob GF, Le Moal M. Plasticity of reward neurocircuitry and the "dark side" of drug addiction. Nat Neurosci. 2005;8(11):1442-1444. FULL TEXT | ISI | PUBMED
59. Naqvi NH, Rudrauf D, Damasio H, Bechara A. Damage to the insula disrupts addiction to cigarette smoking. Science. 2007;315(5811):531-534. FREE FULL TEXT
60. Hester R, Garavan H. Executive dysfunction in cocaine addiction: evidence for discordant frontal, cingulate, and cerebellar activity. J Neurosci. 2004;24(49):11017-11022. FREE FULL TEXT
61. Fellows LK. The role of orbitofrontal cortex in decision making: a component process account. Ann N Y Acad Sci. 2007;1121:421-430. FULL TEXT | ISI | PUBMED
62. Kalivas PW, Volkow ND. The neural basis of addiction: a pathology of motivation and choice. Am J Psychiatry. 2005;162(8):1403-1413. FREE FULL TEXT
63. Everitt BJ, Robbins TW. Neural systems of reinforcement for drug addiction: from actions to habits to compulsion. Nat Neurosci. 2005;8(11):1481-1489. FULL TEXT | ISI | PUBMED
64. Gray MA, Critchley HD. Interoceptive basis to craving. Neuron. 2007;54(2):183-186. FULL TEXT | PUBMED
65. Kosten TR, Markou A, Koob GF. Depression and stimulant dependence: neurobiology and pharmacotherapy. J Nerv Ment Dis. 1998;186(12):737-745. FULL TEXT | ISI | PUBMED
66. Koob GF, Le Moal M. Drug abuse: hedonic homeostatic dysregulation. Science. 1997;278(5335):52-58. FREE FULL TEXT
67. Winstanley CA. The orbitofrontal cortex, impulsivity, and addiction: probing orbitofrontal dysfunction at the neural, neurochemical, and molecular level. Ann N Y Acad Sci. 2007;1121:639-655. FULL TEXT | ISI | PUBMED
68. Yücel M, Lubman DI, Solowij N, Brewer WJ. Understanding drug addiction: a neuropsychological perspective. Aust N Z J Psychiatry. 2007;41(12):957-968. PUBMED
69. Bickel WK, Miller ML, Yi R, Kowal BP, Lindquist DM, Pitcock JA. Behavioral and neuroeconomics of drug addiction: competing neural systems and temporal discounting processes. Drug Alcohol Depend. 2007;90(suppl 1):S85-S91. ISI | PUBMED
70. Madden GJ, Petry NM, Badger GJ, Bickel WK. Impulsive and self-control choices in opioid-dependent patients and non-drug-using control participants: drug and monetary rewards. Exp Clin Psychopharmacol. 1997;5(3):256-262. FULL TEXT | ISI | PUBMED
71. Shaham Y, Hope BT. The role of neuroadaptations in relapse to drug seeking. Nat Neurosci. 2005;8(11):1437-1439. FULL TEXT | ISI | PUBMED
72. Baler RD, Volkow ND. Drug addiction: the neurobiology of disrupted self-control. Trends Mol Med. 2006;12(12):559-566. FULL TEXT | ISI | PUBMED
73. Ersche KD, Sahakian BJ. The neuropsychology of amphetamine and opiate dependence: implications for treatment. Neuropsychol Rev. 2007;17(3):317-336. PUBMED
74. Kosten TR. Addiction as a brain disease. Am J Psychiatry. 1998;155(6):711-713. PUBMED
75. Fletcher BW, Chandler RK. Principles of Drug Abuse Treatment for Criminal Justice Populations. Washington, DC: National Institute on Drug Abuse; 2006. NIH publication 06-5316.
76. Wilson DB, Bouffard LA, Mackenzie DL. A quantitative review of structured, group-oriented, cognitive-behavioral programs for offenders. Crim Justice Behav. 2005;32(2):172-204. ABSTRACT
77. Gostin LO. Biomedical research involving prisoners: ethical values and legal regulation. JAMA. 2007;297(7):737-740. FREE FULL TEXT
78. Wexler HK, Fletcher BW. National Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) overview. Prison J. 2007;87(1):9-24.
79. Comer SD, Collins ED, Kleber HD, Nuwayser ES, Kerrigan JH, Fischman MW. Depot naltrexone: long-lasting antagonism of the effects of heroin in humans. Psychopharmacology (Berl). 2002;159(4):351-360. FULL TEXT | PUBMED
80. Comer SD, Sullivan MA, Yu E; et al. Injectable, sustained-release naltrexone for the treatment of opioid dependence: a randomized, placebo-controlled trial. Arch Gen Psychiatry. 2006;63(2):210-218. FREE FULL TEXT
81. Dackis C, O’Brien C. Neurobiology of addiction: treatment and public policy ramifications. Nat Neurosci. 2005;8(11):1431-1436. FULL TEXT | ISI | PUBMED
Alcoholism:Screening and Brief Interventions
Attached several articles highlighting the urgency to diagnose and treat Alcoholism and to implement screening and brief intervention tools.
Clinicians should routinely screen for alcohol disorders, using clinical interviews, questionnaires, blood tests, or a combination of these methods.
Its important to stress that:
"To a large extent the burden attributable to alcohol is preventable and there are proven and effective strategies and interventions to reduce alcohol-related harm. The challenge is getting governments to implement effective alcohol policies in the face of strong industry opposition and widespread public sentiment that alcohol-related harm is a problem confined to a few very heavy drinkers."
I hope that this information can be of value for your clinical practice and I look forward to your feedback.
Yours
Bernd Wollschlaeger,MD,FAAFP,FASAM
President, Florida Society of Addiction Medicine
=======================================================================================
The Lancet, Volume 373, Issue 9662, Pages 492 - 501, 7 February 2009
Alcohol-use disorders
Dr Marc A Schuckit MD a b
Summary
Alcohol dependence and alcohol abuse or harmful use cause substantial morbidity and mortality. Alcohol-use disorders are associated with depressive episodes, severe anxiety, insomnia, suicide, and abuse of other drugs. Continued heavy alcohol use also shortens the onset of heart disease, stroke, cancers, and liver cirrhosis, by affecting the cardiovascular, gastrointestinal, and immune systems. Heavy drinking can also cause mild anterograde amnesias, temporary cognitive deficits, sleep problems, and peripheral neuropathy; cause gastrointestinal problems; decrease bone density and production of blood cells; and cause fetal alcohol syndrome. Alcohol-use disorders complicate assessment and treatment of other medical and psychiatric problems. Standard criteria for alcohol dependence—the more severe disorder—can be used to reliably identify people for whom drinking causes major physiological consequences and persistent impairment of quality of life and ability to function. Clinicians should routinely screen for alcohol disorders, using clinical interviews, questionnaires, blood tests, or a combination of these methods. Causes include environmental factors and specific genes that affect the risk of alcohol-use disorders, including genes for enzymes that metabolise alcohol, such as alcohol dehydrogenase and aldehyde dehydrogenase; those associated with disinhibition; and those that confer a low sensitivity to alcohol. Treatment can include motivational interviewing to help people to evaluate their situations, brief interventions to facilitate more healthy behaviours, detoxification to address withdrawal symptoms, cognitive-behavioural therapies to avoid relapses, and judicious use of drugs to diminish cravings or
discourage relapses.
--------------------------------------------------------------------------------------
The Lancet, Volume 373, Issue 9662, Page 433, 7 February 2009
Alcohol misuse needs a global response
The Lancet
Around 2 billion people worldwide consume alcoholic beverages and over 76 million people have alcohol-use disorders. In most parts of the world the burden related to alcohol consumption in terms of morbidity, mortality, and disability is substantial. WHO estimates that the harmful use of alcohol causes about 2·3 million premature deaths per year worldwide (3·7% of global mortality) and is responsible for 4·4% of the global burden of disease. Although there are regional and national differences in levels, patterns, and context of drinking, current trends suggest availability and alcohol consumption will continue to rise.
The health effects of alcohol are diverse. The highest alcohol-attributable burdens are neuropsychiatric disorders, which are described in a Seminar by Marc A Schuckit in The Lancet today. Alcohol use increases the risk of cardiovascular diseases and various cancers, as well as injuries and accidents. It increases the transmission of sexually transmitted diseases and HIV infection through association with unsafe sexual practices. The harmful effects of alcohol are associated with many adverse consequences such as crime, violence, unemployment, and workplace absenteeism. Rising levels of consumption are most pronounced in women and young people, with the latter more prone to heavy binge drinking. There is no doubt that tackling alcohol-related harm is an urgent public-health imperative.
To a large extent the burden attributable to alcohol is preventable and there are proven and effective strategies and interventions to reduce alcohol-related harm. The challenge is getting governments to implement effective alcohol policies in the face of strong industry opposition and widespread public sentiment that alcohol-related harm is a problem confined to a few very heavy drinkers. The Scandinavian countries have traditionally had some of the best-developed policies to control hazardous drinking: government monopolies on alcohol sales, higher taxes on high-alcohol beverages, restrictions on promotion and sale, and tough policies combatting drinking and driving. But these policies have been eroded as a result of deregulation imposed as a condition of European Union membership, and global pressures to allow free trade in all commodities, including alcohol.
Last week, the UK Government released guidance re-commending that young people up to the age of 15 years should avoid alcohol altogether. Similarly, in Australia the National Health and Medical Research Council will be issuing guidelines in late February, recommending that people under the age of 18 years should not consume any alcohol. Certainly, it is desirable to delay the onset age of drinking. US experience showed that raising the minimum legal drinking age to 21 years (with minimum enforcement) substantially reduced deaths from alcohol-related causes. However, education and persuasion are the least effective intervention and so advice by itself in England and Australia will likely make little difference unless it is complemented by policies that focus on price, availability, and affordability at the population level. The UK is often cited as a country that (because of industry influence and the possible political unpopularity of having a drinking age limit) has had an absence of effective alcohol policies, preferring soft measures like education campaigns on issues such as underage drinking, rather than tackling the root of the problem. It is no surprise then that the UK has some of the worst indicators of alcohol-related harm in young people in Europe.
Patterns of global alcohol consumption are changing. The recent increase in consumption in low-income and middle-income countries in southeast Asia and the western Pacific regions are particularly worrying. And the alcohol industry is rapidly infiltrating the markets of Brazil, India, China, and Russia. Last week, news reports of the closure of 800 liquor stores in Rajasthan, India, to curb alcohol-related harm, together with the South African Government shutting down 30 000 illegal shabeens (drinking dens), show positive moves by governments to tackle the problem.
Addressing the harms of alcohol as part of a global-health agenda is gathering momentum. WHO is in the midst of developing a strategy to reduce harmful use of alcohol in consultation and collaboration with member states. That work will be presented to the World Health Assembly in 2010. A Framework Convention on Alcohol Control (a legally binding international treaty) is under discussion. And a forthcoming Lancet Series on alcohol will explore the dimensions of an effective response required to tackle this global-health threat. But countries should not wait. They need to act now to develop comprehensive and effective policies to make a difference.
--------------------------------------------------------------------------------------
Resources:
1. Alcohol Screeing and Brief Intervention http://pubs.niaaa.nih.gov/publications/Practitioner/pocketguide/pocket_guide.htm
2. Alcohol SBI for Trauma Patients http://sbirt.samhsa.gov/documents/SBIRT_guide_Sep07.pdf
3. Screening and Brief Intervention for High-Risk College Student Drinkers http://homepage.psy.utexas.edu/homepage/class/Psy394Q/Behavior%20Therapy%20Class/Assigned%20Readings/Substance%20Abuse/Marlatt98.pdf
Clinicians should routinely screen for alcohol disorders, using clinical interviews, questionnaires, blood tests, or a combination of these methods.
Its important to stress that:
"To a large extent the burden attributable to alcohol is preventable and there are proven and effective strategies and interventions to reduce alcohol-related harm. The challenge is getting governments to implement effective alcohol policies in the face of strong industry opposition and widespread public sentiment that alcohol-related harm is a problem confined to a few very heavy drinkers."
I hope that this information can be of value for your clinical practice and I look forward to your feedback.
Yours
Bernd Wollschlaeger,MD,FAAFP,FASAM
President, Florida Society of Addiction Medicine
=======================================================================================
The Lancet, Volume 373, Issue 9662, Pages 492 - 501, 7 February 2009
Alcohol-use disorders
Dr Marc A Schuckit MD a b
Summary
Alcohol dependence and alcohol abuse or harmful use cause substantial morbidity and mortality. Alcohol-use disorders are associated with depressive episodes, severe anxiety, insomnia, suicide, and abuse of other drugs. Continued heavy alcohol use also shortens the onset of heart disease, stroke, cancers, and liver cirrhosis, by affecting the cardiovascular, gastrointestinal, and immune systems. Heavy drinking can also cause mild anterograde amnesias, temporary cognitive deficits, sleep problems, and peripheral neuropathy; cause gastrointestinal problems; decrease bone density and production of blood cells; and cause fetal alcohol syndrome. Alcohol-use disorders complicate assessment and treatment of other medical and psychiatric problems. Standard criteria for alcohol dependence—the more severe disorder—can be used to reliably identify people for whom drinking causes major physiological consequences and persistent impairment of quality of life and ability to function. Clinicians should routinely screen for alcohol disorders, using clinical interviews, questionnaires, blood tests, or a combination of these methods. Causes include environmental factors and specific genes that affect the risk of alcohol-use disorders, including genes for enzymes that metabolise alcohol, such as alcohol dehydrogenase and aldehyde dehydrogenase; those associated with disinhibition; and those that confer a low sensitivity to alcohol. Treatment can include motivational interviewing to help people to evaluate their situations, brief interventions to facilitate more healthy behaviours, detoxification to address withdrawal symptoms, cognitive-behavioural therapies to avoid relapses, and judicious use of drugs to diminish cravings or
discourage relapses.
--------------------------------------------------------------------------------------
The Lancet, Volume 373, Issue 9662, Page 433, 7 February 2009
Alcohol misuse needs a global response
The Lancet
Around 2 billion people worldwide consume alcoholic beverages and over 76 million people have alcohol-use disorders. In most parts of the world the burden related to alcohol consumption in terms of morbidity, mortality, and disability is substantial. WHO estimates that the harmful use of alcohol causes about 2·3 million premature deaths per year worldwide (3·7% of global mortality) and is responsible for 4·4% of the global burden of disease. Although there are regional and national differences in levels, patterns, and context of drinking, current trends suggest availability and alcohol consumption will continue to rise.
The health effects of alcohol are diverse. The highest alcohol-attributable burdens are neuropsychiatric disorders, which are described in a Seminar by Marc A Schuckit in The Lancet today. Alcohol use increases the risk of cardiovascular diseases and various cancers, as well as injuries and accidents. It increases the transmission of sexually transmitted diseases and HIV infection through association with unsafe sexual practices. The harmful effects of alcohol are associated with many adverse consequences such as crime, violence, unemployment, and workplace absenteeism. Rising levels of consumption are most pronounced in women and young people, with the latter more prone to heavy binge drinking. There is no doubt that tackling alcohol-related harm is an urgent public-health imperative.
To a large extent the burden attributable to alcohol is preventable and there are proven and effective strategies and interventions to reduce alcohol-related harm. The challenge is getting governments to implement effective alcohol policies in the face of strong industry opposition and widespread public sentiment that alcohol-related harm is a problem confined to a few very heavy drinkers. The Scandinavian countries have traditionally had some of the best-developed policies to control hazardous drinking: government monopolies on alcohol sales, higher taxes on high-alcohol beverages, restrictions on promotion and sale, and tough policies combatting drinking and driving. But these policies have been eroded as a result of deregulation imposed as a condition of European Union membership, and global pressures to allow free trade in all commodities, including alcohol.
Last week, the UK Government released guidance re-commending that young people up to the age of 15 years should avoid alcohol altogether. Similarly, in Australia the National Health and Medical Research Council will be issuing guidelines in late February, recommending that people under the age of 18 years should not consume any alcohol. Certainly, it is desirable to delay the onset age of drinking. US experience showed that raising the minimum legal drinking age to 21 years (with minimum enforcement) substantially reduced deaths from alcohol-related causes. However, education and persuasion are the least effective intervention and so advice by itself in England and Australia will likely make little difference unless it is complemented by policies that focus on price, availability, and affordability at the population level. The UK is often cited as a country that (because of industry influence and the possible political unpopularity of having a drinking age limit) has had an absence of effective alcohol policies, preferring soft measures like education campaigns on issues such as underage drinking, rather than tackling the root of the problem. It is no surprise then that the UK has some of the worst indicators of alcohol-related harm in young people in Europe.
Patterns of global alcohol consumption are changing. The recent increase in consumption in low-income and middle-income countries in southeast Asia and the western Pacific regions are particularly worrying. And the alcohol industry is rapidly infiltrating the markets of Brazil, India, China, and Russia. Last week, news reports of the closure of 800 liquor stores in Rajasthan, India, to curb alcohol-related harm, together with the South African Government shutting down 30 000 illegal shabeens (drinking dens), show positive moves by governments to tackle the problem.
Addressing the harms of alcohol as part of a global-health agenda is gathering momentum. WHO is in the midst of developing a strategy to reduce harmful use of alcohol in consultation and collaboration with member states. That work will be presented to the World Health Assembly in 2010. A Framework Convention on Alcohol Control (a legally binding international treaty) is under discussion. And a forthcoming Lancet Series on alcohol will explore the dimensions of an effective response required to tackle this global-health threat. But countries should not wait. They need to act now to develop comprehensive and effective policies to make a difference.
--------------------------------------------------------------------------------------
Resources:
1. Alcohol Screeing and Brief Intervention http://pubs.niaaa.nih.gov/publications/Practitioner/pocketguide/pocket_guide.htm
2. Alcohol SBI for Trauma Patients http://sbirt.samhsa.gov/documents/SBIRT_guide_Sep07.pdf
3. Screening and Brief Intervention for High-Risk College Student Drinkers http://homepage.psy.utexas.edu/homepage/class/Psy394Q/Behavior%20Therapy%20Class/Assigned%20Readings/Substance%20Abuse/Marlatt98.pdf
Subscribe to:
Posts (Atom)