Addiction and the criminal justice system

1. Addictionandthecriminaljustice system Dr. Eric Blaauw Professor in Addiction studies Hanze University of Applied Sciences

2. Content • What is addiction? • The Dutch criminal justice system • Addiction and crime • Forensic addiction care

3. ADDICTION

4. What is addiction? Craving or using more than intended • Taking the substance in larger amounts or for longer than you meant to • Wanting to cut down or stop using the substance but not managing to • Spending a lot of time getting, using, or recovering from use of the substance • Cravings and urges to use the substance Negative consequences, also for others • Not managing to do what you should at work, home or school, because of substance use • Continuing to use, even when it causes problems in relationships • Giving up important social, occupational or recreational activities because of substance use • Using substances again and again, even when it puts the you in danger Tolerance and dependence • Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance • Needing more of the substance to get the effect you want (tolerance) • Development of withdrawal symptoms, which can be relieved by taking more of the substance.

5. Prevalence of use Recent use in the Netherlands (2009) • Alcohol: 78% • Tobacco: 27% • Cannabis: 3,3% • Cocaine: 0.3% • Opioids: 0.1%

6. Alcohol addiction (%)

7. Drug addiction (%)

8. National Health Council: no alcoholic beverages at all. Certainly not more than one a day. Not more than five days Accepted amounts of alcohol

9. Enjoy, but….

10. Prevalence in community (NL) • Lifetime prevalence • Substance use disorder 20% • Affective disorder 20% • Anxiety disorder 19% • Year prevalence • 5.6% substance use disorder • 18% other disorder

11. What is addiction? • It is a character weakness (moral model) • It is due to the substance (pharmacological model) • It is a disease for those who are vulnerable for it (disease model) • Leshner (1997): Addiction is a chronic relapsing disease of the brain (brain disease model)

13. What is addiction? • Addiction is a complexe interplay of biological, psychologicalandsocial factors (biopsychosocial model) • But alsopay attention tothingsthatgivemeaningtoaddictionand life (a.o. Frankl, 1946, 2011).

14. VIDEO

15. What is addiction?

16. What is addiction? • Strong craving (aberrations in anterior gyrus cinguli) • Decreased behavioral control (frontostriatal dysfunctions) • Decreased cognitive control: • Reduced error processing (less recognition of mistakes and learning from mistakes) • Attentional bias • Reduced sensitivity for rewards and punishment • More sensitivity to stress

17. Treatment goals • Reduce craving: attention to attentional bias, acceptance of craving, virtual reality • Improve behavioral control: reduce impulsivity and compulsivity, pay attention tot error processing, (re)activate alternative rewarding behaviors • Reduce sensitivity to stress: pay attention to underlying factors, (social) skills training

18. Specific points of attention from biopsychosocial model • Pay attention to somatic problems • Pay attention to transfer of addiction (and crime) • Pay attention to underlying vulnerability • Involve the environment in treatment • Pay attention to life areas • Consider that relapse may (will) occur • Think about the aim: abstinence or control, improvement in life areas, quality of life

19. The Dutch criminaljustice system

20. Courts • 11 arrondissemental courts • 4 “ressorts” • North east Netherlands (Leeuwarden) • North Holland (Amsterdam) • South Holland (The Hague) • South Netherlands (Den Bosch) • 1 High court (The Hague)

22. Arrondissement • Court • Crown Council (OpenbaarMinisterie) • Parole office • Addiction parole (SVG) • Salvation Army parole • Parole office Netherlands (Reclassering Nederland) • Netherlands Institute for Forensic Psychiatry and Psychology (NIFP)

23. Crimes in the Netherlands

24. Violent crimes

25. Prisoners in the Netherlands

26. 30 penal institutions in 2018

27. Prisoners • 9.145 prisoners in 2015 • 94% male • 59% from the Netherlands (vs 71%), • 8% Suriname (2%) • 6% Antilles (1%) • 6,5% Morocco (2%), • 4% Turkey (2%) • 17% other (12%) • More than half 20-35 years old (vs 29%)

28. TBS institutions • State institutions • Veldzicht, Balkbrug (illegal aliens) • Oostvaarders clinic, Almere • Private institutions • FPC dr. S. van Mesdag clinic, Groningen • De Kijvelanden, Poortugaal • De Rooyse Wissel, Venray • Pompestichting, Nijmegen • Van der Hoeven clinic, Utrecht • Woenselsepoort, Eindhoven

31. Summary • Justice system is organized in regions • Crime rates are decreasing • No of prisoners and TBS patients decreasing • Most prisoners are young males • Relationship with development of brain?

32. Addictionandthecriminaljustice system

33. In prison system • In remand centers 60% substance use disorder: 30% alcohol, 38% drugs • In juvenile institutions more than 55% substance use disorders • ISD institutions: 100% substance use disorder • On average 54-63% have psychiatric disorder (year)

34. In tbs settings • In TBS 100% psychiatric disorder, • In TBS 65% (year) substance use disorder • At time of index offence • 46% under influence of substance(s) • 38% substance played some role in offence • Intoxication caused escalation in 21%

35. Problem of comorbidity • In presence of comorbid disorder, substance use disorder is more severe and persistent • In presence of substance use disorder, disorders are more severe and persistent • More admissions in clinics • More suicides • More loss of fixed abodes • More illnesses • More violence • More incarcerations

36. SUDs and crimes • Psychiatric disorders increase risk of offending • Substance use disorders also increase risk of offending • Crack: 6 x • Heroin: 3 x • Cocaine: 2.5 x • Amphetamines: 2.5 x • Cannabis: 1.5 x

37. SUDS andintimate partner violence • Huge meta-analysis (285 studies, N=627.726) done by Cafferky et al (2016) • Substance abuse related to IPV • Relation stronger for drugs than for alcohol • Problematic alcohol use measures equally strong related as consumption measures • Problematic drug use measures stronger related than consumption measures • Amphetamines, cocaine, marijuana and other (except heroin/opiate) all equally related • Meta-analysis (96 studies, N=79.698) done by Moore et al (2008) • Increase in drug use and drug-related problems associated with psychological, physical and sexual aggression between intimate partners • Regardless of sex of drug user and perpetrator • Cocaine had strongest relation, followed by marijuana and mixed • No association with opiates

38. Alcohol andviolence • 62% of seriously violent offenders (murder, rape, domestic violence, child abuse) drank before the offence (Review in 11 countries: Murdock e.a., 1990) • Risk of aggression among alcoholics estimated to be 12 times as high (Murdock e.a., 1990). • All indicators of alcohol use clearly related to intimate partner violence (reviews Cafferky et al., 2016; Foran & O’Leary, 2007) • In communities with high alcohol consumption more life crimes (Bye, 2007) • More domestic violence near places that sell alcohol (Livingston, 2011) • 50-60% of alcoholics in treatment commit domestic violence (Murphy & O’Farell, 1996) • More sexual violence among alcoholics (o.a. Kraanen & Emmelkamp, 2011)

39. Relationship SUD and crimes • SUDS lead to crimes. Tripartite model (Goldstein, 1995) • Psychopharmacological effect • Economic necessity (need money for drugs), aka economic motivation model (Bean, 2001) • The drug market is associated with violence and theft (systemic relationship) • Crimes lead to suds • Psychopharmacological effect (need for soothing, guilt) • Economical side effect (money is available for drugs) • In criminal groups substance use is more common • Reciprocal relationship Crimes -> Drugs -> Crimes ->

40. Relationship SUD and violence • Drugs have a direct effect on people through a psychopharmacological effect (proximal effect model) on increased stress, reduced cognitive functioning, reduced anxiety regarding receiving punishment, reduced behavioral control, etc. • Pharmacological effects (intoxication) • Withdrawal symptoms • Neurotoxic effects (prolonged use) • Drugs mag indirectly increase risk of violence (indirect effects model) • Marital conflict over use of drugs or alcohol • Dissatisfaction, e.g. about worse living circumstances

42. Fourthexplanation: common factors • Spurious model: there is a common underlying factor to both phenomena • General deviance theory: individuals prone to drug use are also prone to violence (Harrison et al., 2001; Harrison & Gfroerer, 1992; Osgood et al., 1988). But, because behaviors are unique, one should pay attention to environmental factors in onset of both behaviors • Biopsychological model: distal (personality, antisocial attitudes, marital stress, etc) and proximal factors (intoxication, situation, reduced error processing, impulsivity, etc) increase risk of violence in the context of conflict (e.g. Moore & Stewart,2005) • Multiple treshold model (Fals-Stewart et al., 2003, 2005): personality and relationship risk factors increase likelihood of violence ween the individual starts using alcohol or drugs

43. Spurious model Substancesincreasetendenciesthat are already present. Underlyingsymptomandcharacter clusters are relatedtoheightened risk of aggression Problematic symptomand Character clusters Impulse control

44. Clusters relatedtoaggression • Stress, depression, anxiety, arousal • Impulsivity • Sensation seeking • Hostility and antisocial attitudes • Hyperactivity • Attentional deficits • Compulsivity

45. Summary SUD and crimes • All models have some validity • Alcohol and drugs seem to reinforce tendencies that are already present: character and situation are the underlying factors for crimes • Severe drug use creates economic necessity and leads to deviant lifestyle • Substance use increases the intensity and frequency of crimes • Certain symptom clusters (lack of control, increased arousal) and character clusters (impulsivity, compulsivity, antisocial attitudes) are related to increased risk of crimes • Thus: pay attention to the relevant symptom clusters and character clusters and pay attention to the situation

46. Forensic (addiction) care

47. Effects of efforts • In the past ten years • 200.000 less registered crimes • 78.000 less suspects • 5.500 less prisoners • Recidivism after two years: • After prison 48% • After parole 39% • After forensic treatment 30%

48. Forensic addiction treatment • Collaboration between parole and health care • Advice for the courts • Mandatory treatment with evaluations • Use of three partite agreement • Aimed at reduction of risk of recidivism • Working with principles of Risk-Need-Responsivity (Andrews &Bonta, 1990, 2007, 2010)

49. Forensicaddiction treatment • Risk assessment • Risk management with relapse prevention and signaling plan • Treatment of addiction • Treatment of comorbid disorders • Improvement of life areas (finance, work, housing, free time, relationships) • Restoration of roles

50. Further information • E.blaauw@vnn.nl