Addiction , the Brain, and Evidence Based Treatment

1. Addiction, the Brain, and Evidence Based Treatment NIJ Research for the “Real World” Seminar March 5, 2012 Redonna K. Chandler, Ph.D.Services Research Branch Division of Epidemiology, Services, and Prevention Research National Institute on Drug Abuse

2. Goals for this Presentation • Public Health Problems in the Criminal Justice System • Neurobiology of Addiction • Evidence Based Treatment • Research Initiatives

3. NIDA Priority Research Areas Prevention Genetics Environment Development Neurobiology Interventions Policy Treatment Neural mechanisms Behavioral Treatment Medications Development Implementation Consequences HIV/AIDS Fetal Exposure

4. Overview of CJ Portfolio

5. Drugs of Abuse and Crime are Linked • Alcohol Use at Time of Offense1 • Violent crime: 37% state; 23% federal prison • Property crime: 37% state; 13% federal prison • Drug trafficking: 21% state: 19% federal prison • Costs3 • $107 Billion for Drug Related Crime • Regular Drug Use1 • 69% state, 64% federal prisoners • Drug Dependence/Abuse1, 2 • 53% jail; 53% state prison; 45% federal prison • Drug Use at Time of Offense1 • violent crime: 28% state; 24% federal prison • property crime: 39% state; 14% federal prison • drug trafficking: 42% state; 34% federal prison SOURCES: 1: BJS 2004 Survey of Prisoners (Mumola & Karberg, 2006/7); 2: BJS 2002 Survey of Jail Inmates (Karberg & James, 2005); 3:ONDCP, 2004

6. Smoking in Criminal Justice • Rates of smoking 4 times higher in CJ than general population1, 2 • Among Prisoners: 70% males; 80% females smoke3 • 50% adolescentsin juvenile justice daily smokers2 • Smoking bans in prisons most prevalent intervention • 97% smokers relapse within 6 months of release to community4 SOURCES: 1: Cropsey & Kristeller, 2003; 2: Cropsey, Linker & Waite, 2008; 3: Conklin, Lincoln & Tuthill, 2000; 4: Lincoln et al, 2009

7. Mental Health Disorders Among Incarcerated Populations SOURCE: BJS Special Report, Mental Health Problems of Prison & Jail Inmates , 2006

8. Prevalence of Psychiatric Disorders: Northwestern Juvenile Project (N=1,829) and General Population GP: General Population | JJ: Juvenile Justice Population

9. Death Among Recent Inmates of the Washington State Corrections Compared to Other State Residents SOURCE: Binswanger et al, NEJM 2007;356:157-165

10. Treatment planning for drug abusing offenders should include strategies for chronic medical conditions(e.g. HIV/AIDS, Hep B/C, & TB) In a Given Year . . . About 21% of all people in the US with HIV, & 33% of those with HCV, & 40% of those with TB -- will pass through a correctional facility. SOURCES: Spaulding, et al, 2009, PLoS ONE, 1-6; Hammett, Harmon & Rhodes (2002), AJPH, 92 (11), 1789-1794

11. Estimated Size of the Correctional Population: 8+ M Adults, 650K Juveniles 424,046 adultsreceive tx (7.6%) 5,613,739 adults need TX(4.5M males, 1.1M females) 253,034juveniles need TX(198,000 males, 54,000 females) 54,496 juveniles GET tx (21.5%) Sources: Bureau of Justice Statistics, 2005 adjusted with estimates from Taxman, et al, 2007

12. Many prison inmates have a drug use disorder… but few receive treatment Sources: BJS: Mumola & Karberg, 2006, revised 1/2007; Drug use and dependence, State and Federal prisoners, 2004.

13. Addressing Drugs and Crime Public Health Approach -disease -treatment Public Safety Approach -illegal behavior -punish HIGH ATTRITION HIGH RECIDIVSM

14. Integrated Public Health-Public Safety Strategy Close supervision Community-based treatment Blends functions of criminal justice and treatment systems to optimize outcomes Opportunity to avoid incarceration or criminal record Consequences for noncompliance are certain and immediate

15. Criminal Justice System:Key Participants and Intervention Opportunities ENTRY(Arrest) PROSECUTION(Court, Pre-Trial Release, Jail) ADJUDICATION(Trial) COMMUNITY REENTRY(Probation, Parole, Release) SENTENCING(Fines, Community Supervision, Incarceration) CORRECTIONS(Probation, Jail, Prison) Key Participants Crime victim Police FBI Probation Officers Correctional Personnel Crime victim Police FBI Judge Prosecutor Defense Attorney Defendant Jury Judge Judge Jury Probation/ Parole Officers Family Community-based providers Intervention Opportunities N/A Drug Court Terms of Incarceration Release Conditions Drug Treatment Drug Treatment Aftercare Housing Employment Mental Health Half-way House TASC Diversion Programs Drug Courts Community Treatment TASC Screening/Referral

16. What is Addiction? • A common brain disease expressed as a compulsive behavior. • The continued use of a drug despite negative consequences • Often chronic with a high potential for relapse

17. ADDICTION IS A DISEASE OF THE BRAIN …as other diseases it affects the tissue function Decreased Brain Metabolism in Drug Abuse Patient No Cocaine Abuse Cocaine Abuser High Decreased Heart Metabolism inHeart Disease Patient Healthy Heart No Heart Disease Diseased Heart Low SOURCES: From the laboratories of Drs. N. Volkow and H. Schelbert

18. Key Question: Why Can’t Addicts Just Quit?

19. Addiction is a Brain Disease Addiction comes about (by)… laying down and strengthening of new memory connections in various circuits in the brain. Long-lasting brain changes are responsible for the distortions of cognitive (thinking) and emotional functioning that characterize addicts, particularly including the compulsion to use drugs that is the essence of addiction.

20. REWARD NAcc VP • Reward Circuit Drugs of Abuse Engage Systems in the Motivation Pathways of the Brain

21. Reward Circuits Involved In Drug Abuse and Addiction

23. Dopamine Movement Motivation Reward& well-being Addiction

24. It’s About Dopamine (mostly) • Dopamine is brain’s primary “pleasure chemical” • Plays role in attention, problem solving, and anticipation of reward • Implicated in drug high and caving that accompanies withdrawal

25. Natural Rewards Elevate Dopamine Levels 1 2 3 4 5 6 7 8 Sex Food 200 200 NAc shell 150 150 DA Concentration (% Baseline) % of Basal DA Output 100 100 Empty 50 Box Feeding Female Present 0 Sample Number 0 60 120 180 Time (min) Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, 1997.

26. Drugs Elevate on Dopamine Release Accumbens Accumbens 400 1100 1000 900 DA 300 DOPAC 800 DA HVA 700 DOPAC HVA 600 % of Basal Release 200 % of Basal Release 500 400 300 100 200 100 0 0 0 1 2 3 4 5 hr 0 1 2 3 4 5 hr 250 Accumbens 250 Dose 200 Accumbens mg/kg 0.5 Caudate 200 mg/kg 1.0 150 mg/kg 2.5 mg/kg 10 150 100 % of Basal Release % of Basal Release 0 1 2 3 hr 100 0 0 0 1 2 3 4 5 hr Time After Drug Amphetamine Cocaine Morphine Nicotine Time After Drug Di Chiara and Imperato, PNAS, 1988

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

28. Hipp MEMORY/ LEARNING Amyg 2. Memory Circuit “People, Place and Things…” Image: iStockphoto/Samuel Chesterman

29. Memory Circuits Involved In Drug Abuse and Addiction

30. [11C]Raclopride Binding In Cocaine Abusers (n=18) Viewing a Neutral and a Cocaine-Cue Video Neutral video Viewing a video of cocaine scenes decreased specific binding of [11C]raclopride presumably from DA increases SOURCE: Volkow et al , J Neuroscience, 2006

31. Cocaine Craving: Population (Cocaine Users, Controls) x Film (Cocaine) Cingulate Ant Cing Signal Intensity (AU) Cocaine Film IFG Controls Cocaine Users SOURCE: Garavan et al A .J. Psych 2000

32. Cocaine Craving: Population (Cocaine Users, Controls) x Film (Cocaine, Erotic) Cingulate Ant Cing Signal Intensity (AU) IFG Controls Cocaine Users SOURCE: Garavan et al A .J. Psych 2000

33. Even Unconscious Cues Can Elicit Brain Responses Brain Regions Activated by 33 millisecond Cocaine Cues (too fast for conscious recognition) SOURCE: Childress, et al, PLoS ONE 2008

34. Circuits Involved In Drug Abuse and Addiction All of these brain regions must be considered in developing strategies to effectively treat addiction

35. Effective Strategies Attend to Multiple Aspects of Addiction: • Biology • Behavior • Social Context

36. Non-Addicted Brain Control STOP Saliency Drive Memory Treatments for Relapse Prevention: Medications Vaccines Enzymatic degradation Naltrexone DA D3 antagonists CB1 antagonists AddictedBrain Interfere with drug’s reinforcing effects Control Biofeedback Modafinil Bupropion Stimulants Executive function/ Inhibitory control Adenosine A2 antagonists DA D3 antagonists GO Strengthen prefrontal- striatal communication Drive Saliency Antiepileptic GVG N-acetylcysteine Interfere with conditioned memories Memory Cycloserine Teach new memories CRF antagonists Orexin antagonists Counteract stress responses that lead to relapse

37. Non-Addicted Brain Control STOP Saliency Drive Memory Treatments for Relapse Prevention: Behavioral AddictedBrain Interfere with drug’s reinforcing effects Contingency Management Control Executive function/ Inhibitory control Cognitive Therapy GO Strengthen prefrontal- striatal communication Drive Saliency Motivation Therapies Interfere with conditioned memories Biofeedback Desensitization Memory Behavioral Therapies Teach new memories Counteract stress responses that lead to relapse Relaxation Behavioral therapies

39. Principles of Drug Abuse Treatment For Criminal Justice Populations Drug addiction is a chronic brain disease that affects behavior: relapse rates are similar to other chronic medical conditions Recovery from drug addiction requireseffective treatment, followed by management of the problem over time Treatment must last long enough to produce stable behavioral changes Assessment is the first step in treatment

40. 50 to 70% 50 to 70% 40 to 60% 30 to 50% Drug Addiction is a Chronic Disease: Relapse Rates are Similar to Other Chronic Medical Conditions 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

41. What does recovery look like on average? • Months 1-12 of Abstinence: • More clean and sober friends • Less use, homelessness, violence and victimization • Less illegal activity and incarceration • Years 1-3 of Abstinence: • Virtual elimination of illegal activity and illegal income • Better housing and living situations • Increasing employment and income • Years 4-7 of abstinence: • More social and spiritual support • Better Mental Health • Housing and living situations continue to improve • Dramatic rise in employment and income • Dramatic drop in people living below the poverty line SOURCE: Dennis, Foss & Scott, 2007

42. Principles of Drug Abuse Treatment For Criminal Justice Populations Drug addiction is a chronic brain disease that affects behavior: relapse rates are similar to other chronic medical conditions Recovery from drug addiction requireseffective treatment, followed by management of the problem over time Treatment must last long enough to produce stable behavioral changes Assessment is the first step in treatment

43. Assessments over time used to measure ‘Risks/Needs/Progress’ • Early Recovery • Changes in • Thinking • Acting • Early • Engagement • Participation • Therapeutic Relationship • Treatment • Readiness: • Motivation • Anger/Hostility • Co-occurring Discharge Engagement (CEST/CAI) Engagement (CEST/CAI) Psychosocial(CEST/CAI) Psychosocial(CEST/CAI) Criminal Thinking(CTS) Criminal Thinking(CTS) Pre-release Risk (IPASS) Assessing Risks/Needs/Progress Engagement (CEST/CAI) Psychosocial(CEST/CAI) Psychosocial(CEST/CAI) Criminal Thinking(CTS) Criminal Thinking(CTS) Co-occurring (CODSI)

44. Criminal Justice CEST

45. Red Flag Red Flag Client: A 25th %tile 75th %tile Client Level Functioning Social Good? Criminal Thinking Engagement Psychological Motivation Good

46. Specialized Interventions? Higher Criminal Thinking Lower Treatment Readiness Lower Psychological Functioning Lower Treatment Engagement Relationship between Hostility and Other Scales Higher Hostility: Red Flag

47. Principles of Drug Abuse Treatment For Criminal Justice Populations Tailoring services to fit the needs of the individual is important: Match judicial supervision to individual risk and needs Drug use during treatment should be carefully monitored Treatment should target factors that are associated with criminal behavior – i.e., “criminogenic needs” including, but not limited to, substance abuse Criminal justice supervision should incorporate treatment planning for drug abusing offenders & treatment providers should be aware of correctional supervision requirements

50. Tailoring supervision to fit the needs of the individual is important.