Understanding Addiction as a Brain Disease: Implications for the Criminal Justice System

1. Understanding Addiction as a Brain Disease: Implications for the Criminal Justice System Redonna K. Chandler, Ph.D. Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse August 14, 2013

2. Addiction Medical DRUGS Economic Social Neurotoxicity AIDS, Cancer Mental illness Health care Productivity Accidents Homelessness Crime Violence

3. What is Addiction? • A common, developmental brain disease expressed as a compulsive behavior. • The continued use of a drug despite negative consequences.

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

5. Brain Differences: Lower Dopamine D2 Receptors 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

6. Addiction Is Developmental Age of Onset of Drug Abuse and Dependence Source: Compton, et al. Archives of General Psychiatry2007. NESARC Study.

7. Dopamine Movement Motivation Reward& well-being Addiction

8. But Dopamine is only Part of the Story Other neurotransmitter systems are also implicated Serotonin Regulates mood, sleep, etc. Glutamate Regulates learning and memory, etc. And Others These and other brain neurochemicals and electrical signals are responsible for your ability to think, move, feel, and behave.

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

10. EXECUTIVEFUNCTION/ INHIBITORY CONTROL PFC ACG Hipp OFC SCC NAcc REWARD MOTIVATION/ DRIVE VP MEMORY/ LEARNING Amyg Circuits Involved In Drug Abuse and Addiction

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

12. 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.

13. Drugs of Abuse Cause a Release of Dopamine COCAINE AMPHETAMINE Accumbens 1100 Accumbens 400 1000 900 DA 800 DA 300 DOPAC 700 DOPAC % of Basal Release HVA HVA 600 % of Basal Release 500 200 400 300 100 200 100 0 0 0 1 2 3 4 5 hr Time After Amphetamine Time After Cocaine MORPHINE NICOTINE 250 Accumbens 250 Dose (mg/kg) 200 Accumbens 0.5 200 Caudate 1.0 2.5 % of Basal Release 150 % of Basal Release 10 150 100 0 1 2 3 hr 100 0 1 2 3 4 5 hr 0 0 0 1 2 3 4 5hr Time After Nicotine Time After Morphine Source: Di Chiara and Imperato

14. Hipp MEMORY/ LEARNING Amyg 2. Memory circuit “People, Place and Things…”

15. CRAVING INDUCTION IN PET SETTING N = 13 5 4 3 2 1 0 -1 CRAVING Neutral Cocaine STIMULI

16. Dopamine Release Increases when Viewing Cocaine Cues: [11C]RacloprideBinding 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 Volkow et al J Neuroscience 2006

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

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

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

20. EXECUTIVE FUNCTION PFC ACG INHIBITORY CONTROL OFC SCC MOTIVATION/ DRIVE • Motivation & Executive • Control Circuits Dopamine is also associated with motivation and executive function via regulation of frontal activity.

21. The fine balance in connections that normally exists between brain areas active in reward, motivation, learning and memory, and inhibitory control Hipp NAcc VP Amyg EXECUTIVE FUNCTION PFC ACG INHIBITORY CONTROL OFC REWARD SCC MOTIVATION/ DRIVE MEMORY/ LEARNING Becomes severely disrupted in ADDICTION

22. Control Control CG STOP Saliency Saliency Drive Drive Drive OFC GO Saliency NAc Memory Memory Memory Amygdala Non-Addicted Brain Addicted Brain Stress Reactivity Stress Reactivity

23. Partial Recovery of Brain Dopamine Transporters in Methamphetamine (METH) Abuser After Protracted Abstinence METH Abuser (1 month detox) Normal Control METH Abuser (14 months detox) Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.

24. Addiction is Chronic but NOT Permanent: Yr 8 Abstinence by Yr 7 Abstinence Length Dennis ML, Foss MA, Scott CK. Eval Rev 2007;31:585-612

25. Summary: Drug Addiction is a Brain Disease Involving Reward, Memory and Control Ciruits • Addiction comes about by laying down and strengthening 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.

26. Is there a need for drug treatment in the criminal justice system? • 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

27. Are offenders getting treatment? 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%) *Bureau of Justice Statistics, 2005 adjusted with estimates from Taxman, et al, 2007.

28. Benefits of integrated system: The potential to save lives Death Among Recent Inmates of the Washington State CorrectionsCompared to Other State Residents • Binswanger et al. NEJM • 2007;356:157-165

29. Benefits of integrated system: The potential to reduce recidivism Texas Prison Program: 3-Year Return-to-Custody Rates (%) Knight, Simpson, & Hiller, 1999, The Prison Journal

30. Benefits of integrated system: The potential to save money • Cost to society of drug use = $180 billion/yr • Treatment is less expensive than incarceration: Methadone maintenance = $4,700/yr Imprisonment = $18,400/yr • Every $1 invested in treatment yields up to $7 in reduced crime-related costs.

31. Benefits of integrated system: The potential to improve individual and public health In a Given Year . . . About 14%of all people in the US with HIV, & 33% of those with HCV, & 40% of those with TB -- will pass through a correctional facility. Source: Spaulding et al. (2009); Hammett, Harmon, & Rhodes (2002).  AJPH, 92 (11), 1789-1794.

32. 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

33. Non-Addicted Brain Control STOP Saliency Drive Memory Treatments for Relapse Prevention: Psychotherapies 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

34. What drug treatments are effective with offenders? Effective Residential TC’s CBT Contingency Management Medications Drug Courts Motivational Enhancement Promising Moral Reasoning Biofeedback/ Desensitization Relaxation/Counter Stress Recovery Check-ups Computer delivered treatment Not Effective Boot Camp Intensive Supervision Generic Case Management Lengthy Incarceration Harsh Punishment Research Needed Re-entry Courts Triage Models of Service Delivery New Medications Role of Judge

35. Summary: Drug Addiction Treatment in Criminal Justice Settings • There is a need for evidence based drug treatment in criminal justice settings. • Evidence-based drug treatment has public health and public safety benefits. • There are a variety of evidence based behavioral and medications for offenders with substance abuse problems. • Addiction is chronic requiring sustained treatment. • Relapse is commonly part of recovery requiring a consistent, coordinated response.

37. www.drugabuse.gov