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Nora D. Volkow , M.D. Director National Institute on Drug Abuse

DRUGS & CRIME. Effectively Breaking the Cycle of. RESEARCH and TREATMENT Provide the Answers. Nora D. Volkow , M.D. Director National Institute on Drug Abuse. Decreased Brain Metabolism in Drug Abuse Patient. High. Control Cocaine Abuser. Low.

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Nora D. Volkow , M.D. Director National Institute on Drug Abuse

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  1. DRUGS & CRIME Effectively Breaking the Cycle of RESEARCH and TREATMENT Provide the Answers Nora D. Volkow, M.D. Director National Institute on Drug Abuse

  2. Decreased Brain Metabolism in Drug Abuse Patient High Control Cocaine Abuser Low ADDICTION IS A DISEASE OF THE BRAIN As other diseases, it affects tissue function Decreased Heart Metabolism inHeart Disease Patient Healthy Heart Diseased Heart Sources: From the laboratories of Drs. N. Volkow and H. Schelbert

  3. 50 to 70% 50 to 70% 40 to 60% 30 to 50% Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses Addiction Treatment Does Work 100 90 80 70 60 Percent of Patients Who Relapse 50 40 30 20 10 0 Drug Dependence Type I Diabetes Hypertension Asthma Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

  4. Evaluation of A Hypothetical Treatment HYPERTENSION During Pre - - Post Symptom Severity Just Like Hypertension, Addiction Is A Chronic Disease That Requires Continued Care ADDICTION Pre - - - - - - - - - - - - Post Symptom Severity Stage of Treatment Source: McLellan, AT, Addiction 97, 249-252, 2002.

  5. Time in Treatment (Retention) Is the Most Reliable Predictor of Post-Discharge Outcomes… Legal Pressure Was the Strongest Predictor Of Remaining in Treatment 80 Treatment Works Even If It’s Not Voluntary Low Pressure 70 Moderate-to-High Pressure 60 55 52 50 40 39 % Retained 90 Days 40 28 25 30 20 10 0 Program A (42%) Program B (69%) Program C (88%) Three Programs (with % of Caseload CJ Supervised) Source: Hiller, et al., Legal Pressure and Treatment Retention in DATOS (ASC Meeting, San Diego, Nov 1997)

  6. In 2003, An Estimated 21.6 Million Americans Were Dependent On or Abused Any Illicit Drugs or Alcohol But…Only 3.3 Million (15%) of These Individuals Had Received Some Type of Treatment In the Past Year

  7. Drug Use Connected to Criminal Activity In 2003, the combined federal, state, and local adult correctional population reached a new record of almost 6.9 million(Bureau of Justice Statistics, 2004). • 64% jail, state/federal inmates report regular drug use (BJS, 1997) • Drug use involved > 50% of violent crimes and 60-80% of child • abuse/neglect (NIJ, 1999)

  8. Minorities are Disproportionately Impacted by Incarceration and HIV/AIDS 6 4 3 1 100% 12 15 18 23 80% 11 16 Other 60% 43 Hispanic 50 Black 40% 70 White 65 20% 35 26 0% Prisoners Population IDUs w/ HIV-AIDS Abuse/Dependent

  9. Addressing Drugs and Crime Integrated PUBLIC HEALTH PUBLIC SAFETY Strategy ` Community-based treatment Close supervision INTEGRATED STRATEGY Public Safety Approach Public Health Approach Blends functions of criminal justice & treatment systems to optimize outcomes - illegal behavior - punishment - disease - treatment High Attrition High Recidivism Opportunity to avoid incarceration or criminal record Consequences for noncompliance are certain & immediate

  10. NIDA Response • Research Portfolio Integrating Treatment into CJ Settings Drug Courts Prisons/Jails Probation/Parole HIV/AIDS Re-entry • Translating Research Principles of Effective Treatment with Drug Abusing Offenders Judicial Training

  11. Research Centers Coordinating Center Criminal Justice Drug Abuse Treatment Studies(CJ-DATS) To improve outcomes for offenders with substance use disorders by improving the integration of drug abuse treatment with other public health & public safety systems

  12. CREST Completers + Aftercare CREST Completers + Aftercare No Treatment No Treatment CREST Dropouts CREST Dropouts CREST Completers CREST Completers Delaware Work Release TC (Crest) + Aftercare Drug-Free an Arrest-Free 3 Years After Release (N=448) AFTERCARE is Indispensable Arrest-Free Drug-Free * * * * * Martin, Butzin, Saum, & Inciardi (1999), The Prison Journal * p < .05 from Comparison

  13. Amity Prison TC 3-Year OutcomesReincarceration Rates (N=478) AFTERCARE is Indispensable Percent Reincarcerated Wexler et al., Three-year reincarceration outcomes for Amity…, Prison Journal 79:321-336, 1999.

  14. Components of Comprehensive Drug Abuse Treatment Intake Processing / Assessment Treatment Plan Detoxification Self-Help / Peer Support Groups A Variety of Ancillary Services are Key to Successful Transition into the Community Child Care Services Vocational Services Family Services Housing / Transportation Services Mental Health Services Behavioral Therapy and Counseling Substance Use Monitoring Clinical and Case Management Medical Services Financial Services Pharmacotherapy Continuing Care Legal Services Educational Services AIDS / HIV Services NIDA Principles of Drug Addiction Treatment: A Research-Based Guide (2000)

  15. What Are the ROADBLOCKS ? • Lack of Methadone Treatment Access Availability of BUPRENORPHINE may facilitate more widespread use of pharmacological treatments • Changing the Culture Education of judges Secondary CJ-DATS goal – to help change the culture by embedding research into existing settings • Infrastructure to Support Transition to the Community Ancillary services are critical to successful transition

  16. and to… and to… Erase theSTIGMA Erase theSTIGMA Where Do We Need to Go From Here? We Need to… Advance theSCIENCE

  17. Dopamine Neurotransmission 1100 AMPHETAMINE 1000 900 800 700 600 500 % of Basal Release 400 300 200 frontal cortex 100 0 0 1 2 3 4 5 hr Time After Amphetamine FOOD 200 nucleus accumbens VTA/SN 150 % of Basal Release 100 Empty 50 Box Feeding 0 0 60 120 180 Time (min) Di Chiara et al.

  18. Brain Dopamine System DA Transporters DA Receptors DA Anatomy DA DA DA DA DA DA signal Dopamine Cell Metabolism

  19. Dopamine D2 Receptors are Lower in Addiction Cocaine DA DA DA DA DA DA DA DA DA DA DA DA Meth Reward Circuits Non-Drug Abuser DA D2 Receptor Availability Alcohol DA DA DA DA DA DA Heroin Reward Circuits Drug Abuser control addicted

  20. Effects of a Social Stressor on Brain DA D2 Receptors and Propensity to Administer Drugs Individually Housed Group Housed Dominant Subordinate 50 Becomes Dominant No longer stressed 40 30 * * Reinforcers (per session) Isolation Can Change Neurobiology 20 10 Becomes Subordinate Stress remains 0 S .003 .01 .03 .1 Cocaine (mg/kg/injection) Morgan, D. et al. Nature Neuroscience, 5: 169-174, 2002.

  21. Criminal Justice Involvement of Patients in Community-Based Drug TreatmentTREATMENT WORKS EVEN WHEN ITS NOT VOLUNTARY Simpson et al. (1997), Psych Addictive Behaviors

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