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Addressing Public Health & Drug Abuse Treatment within the Criminal Justice System Redonna K. Chandler, Ph.D. Chief Services Research Branch Division of Epidemiology, Services, and Prevention Research National Institute on Drug Abuse NYSAM 6th Annual Conference February 6, 2010 Presentation Overview • Why focus on the criminal justice system? • Public health problems of those in criminal justice system. • Principles of drug abuse treatment for criminal justice populations. • How physicians can help. U.S. Adult Offender Population Drug use involved in >50% of violent crimes and 60-80% of child abuse/neglect cases (NIJ, 1999) Corrections officials estimate 70-85% of inmates need drug treatment (GAO, 1991) 68% of jail inmates report regular drug use (BJS, 2005) 2007, an estimated 7.3 million adults were involved in the criminal justice system U.S. imprisons more people per capita than any other country in the world, with 239% growth in 1990s United States 702 Russian Federation 628 South Africa 400 England and Wales 139 Spain 125 Canada 116 Australia 112 Italy 100 Germany 91 France 85 Sweden 73 Japan 53 0 100 Source: International Centre for Prison Studies, www.prisonstudies.org 200 300 400 Inmates per 100K Citizens 500 600 700 800 Why Focus on Criminal Justice? • Involvement in criminal justice creates opportunity to identify and address: – Infectious Disease – Drug Abuse and Mental Health – Other Medical Conditions • Poor access to routine medical care in community – Underinsured – Care-seeking episodic, symptom-related, costly Inmates Have Constitutional Right to Medical Care (Estelle vs. Gamble, 1976) • Unique opportunity to deliver health care to hard-to-reach population: “…the period of confinement [incarceration or detention] provides a unique chance to reach an otherwise exclusive group, whose risk factors and prevalence rates far exceed those of other populations.” --Glaser and Greifinger, 1993 Drugs of Abuse and Crime are Linked • Regular Drug Use: 69% state, 64% federal prisoners • Drug Dependence/Abuse 1 1, 2 – 53% jail; 53% state prison; 45% federal prison • Drug Use at Time of Offense 1 – violent crime: 28% state; 24% federal prison – property crime: 39% state; 14% federal prison – drug trafficking: 42% state; 34% federal prison • Costs: $107 Billion for Drug-Related Crime 3 SOURCES: 1: BJS 2004 Survey of Prisoners (Mumola & Karberg, 2006/7); 2: BJS 2002 Survey of Jail Inmates (Karberg & James, 2005); 3: ONDCP, 2004 Overview of the Criminal Justice System ENTRY/ PRETRIAL (Arrest) PROSECUTION ADJUDICATION SENTENCING CORRECTIONS (Court, Pre-Trial Release, Jail) (Trial) (Fines, Community Supervision, Incarceration) (Probation, Jail, Prison) COMMUNITY REENTRY (Probation, Parole, Release) Key Players Crime victim Police FBI Crime victim Police FBI Judge Prosecutor Defense Attorney Defendant Jury Judge Judge Jury Probation Officers Correctional Personnel Intervention Opportunities Screening/ Referral Diversion Programs Educate Drug Courts Community Treatment TASC Drug Court Drug Treatment Terms of Incarceration Release Conditions Judge Probation/ Parole Officers Family Community-based providers Drug treatment Aftercare Housing Employment Mental Health Half-way House TASC Opportunities Entry Arrest Crime victim Police, FBI Screening or Referral Prosecution Pretrial Release, Court, or Jail Crime victim, Police, FBI, and Judge Diversion, Drug court, Community treatment Adjudication Trial Prosecutor, Defense Educate Participants Attorney, Defendant, Jury, and Judge Sentencing Fines, Community supervision, Incarceration Jury, Judge Drug court, terms of incarceration, release conditions, tx needs Correction Probation, Jail, Prison Probation officers, Correctional personnel Screening and treatment for substance use, mental health, and medical conditions Community re-entry Probation, Parole, Release Probation or parole Drug treatment, officer, family, Community Aftercare, Housing, provider Employment, Mental Health, Medical Care, Halfway house Adapted from Chandler, Fletcher, and Volkow, 2009. Addressing Addiction and Crime Public Health Approach Public Safety Approach -disease -treatment -illegal behavior -punish High Attrition High Recidivism Integrated Public Health-Public Safety Strategy Close supervision Communitybased 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 Current Rates of Drug Use Disorders and Treatment in Criminal Justice Estimated Size of the Correctional Population: 8+ M Adults, 650K Juveniles 424,046 adults 10 9 8 7 6 5 4 3 2 1 0 5,613,739 adults need TX (4.5M males, 1.1M females) 253,034 juveniles 19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 In Millions receive tx (7.6%) Year Probation Jail Prison *Bureau of Justice Statistics, 2005 adjusted with estimates from Taxman, et al, 2007. Parole Juveniles need TX (198,000 males, 54,000 females) Other Adult 54,496 juveniles GET tx (21.5%) Many prison inmates have a drug use disorder… but few receive treatment Federal Prison State Prison 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Treatment from a Professional Other Programs: Education, self-help Drug Dependence or Abuse Souces: BJS: Mumola & Karberg (2006, revised 1/2007). Drug use and dependence, state and federal prisoners, 2004. Other Behavioral and Health Conditions and Treatment in Criminal Justice Relative Risk of Death Among Former Inmates of the Washington State Department of Corrections Compared to Other State Residents 10 8 6 4 2 Binswanger IA et al. N Engl J Med 2007;356:157-165 Ca nc er CV D Su ic id e M VA as e Li ve rD is e Ho m O ic id e 0 ve rd os e Relative Risk of Death 12 Causes of Death among Former Inmates Adjusted for Age, Sex, and Race 10 8 6 4 2 Binswanger IA et al. N Engl J Med 2007;356:157-165 Ca nc er CV D Su ic id e M VA as e Li ve rD is e Ho m O ic id e 0 ve rd os e Relative Risk of Death 12 Methadone Treatment Pre- and Post-Prison Release: Results 12-mo Post Release (N=204) Community-based Tx days % cocaine UA 200 % opioid UA crime days past yr 180 160 140 120 Treatment Drugs Crime 100 80 60 40 20 0 A B C A B Experimental Conditions: A: Methadone referral at release B: Methadone treatment on release C: Methadone treatment pre- and post-release C A B C -- sig. diff from referral only; -- sig. diff from tx on release Source: Kinlock, T.W., Gordon, M.S., Schwartz, R.P., Fitzgerald, T. T., O’Grady, K.E. (2009). JSAT, 37, 277-285. A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Findings at 12-Months Post-Release. Availability of Opiate Replacement Therapy in US Prisons NE N (%) South N (%) MW N (%) West N (%) Federal Total N (%) Methadone Offered in Prison Yes 6(67) 6(35) 7(64) 8(62) 1 28(55) No 3(33) 11(65) 4(36) 5(38) 0 23(45) Buprenorphine Offered in Prison Yes 3(33) 2(12) 1(9) 1(8) 0 7(14) No 6(67) 15(88) 10(91) 12(92) 1 44(86) Referral to Community-Based Methadone Yes 7(78) 7(41) 5(45) 4(31) 0 23(45) No 2(22) 10(59) 6(55) 9(69) 1 28(55) Referral to Community-Based Buprenorphine Yes 6(67) 4(24) 2(18) 3(23) 0 15(29) No 3(33) 13(76) 9(82) 10(77) 1 36(71) Geographic region defined by CDC Nun et al. (2009). DAD, 83-88. State Prisons Offering ORT Nun et al. (2009). DAD, 83-88. Patients Receiving ORT in US Prisons • Any given year over 200,000 heroin addicts pass through prison • Estimated 1,614 - 1,817 prisoners receive methadone in state and federal prisons • Estimated 57-150 prisoners receive buprenorphine in state and federal prisons • Most common use: pregnant women, acute opiate withdrawal, chronic pain managment Nun et al. (2009). DAD, 83-88. Causes of Death among Former Inmates Adjusted for Age, Sex, and Race 10 8 6 4 2 Binswanger IA et al. N Engl J Med 2007;356:157-165 Ca nc er CV D Su ic id e M VA as e Li ve rD is e Ho m O ic id e 0 ve rd os e Relative Risk of Death 12 Northwestern Juvenile Project Source: Teplin L, McClelland G, Abram K, & Mileusnic D. (2005) Pediatrics Mortality in Delinquent & Community Youth 887 800 600 400 435 36 315 283 184 195 228 83 60 83.5 233 42 22 18 0 Crude U.S. Mortality Ages 15-24* 807 806 501 200 Annual Deaths per 100 000 person-years 847 Total Total AA Male W H Total AA W H Female Detained Population General Population AA= African American; W= Non-Hispanic White; H= Hispanic. *Crude U.S. mortality for the years 1996-2001 was computed from the National Vital Statistics Reports. Source: Teplin L, McClelland G, Abram K, & Mileusnic D. (2005) Pediatrics Causes of Death among Former Inmates Relative Risk of Death Adjusted for Age, Sex, and Race 12 10 8 6 4 2 Binswanger IA et al. N Engl J Med 2007;356:157-165 Ca nc er CV D Su ic id e M VA as e Li ve rD is e ic id e Ho m O ve rd os e 0 HCV Infection in Criminal Justice In a Given Year . . . 33% of those with HCV, will pass through a correctional facility. Source: Hammett, Harmon, & Rhodes (2002). AJPH, 92 (11), 1789-1794. Relative Risk of Death Causes of Death among Former Inmates 12 10 8 6 4 2 Binswanger IA et al. N Engl J Med 2007;356:157-165 Ca nc er CV D Su ic id e M VA as e Li ve rD is e ic id e Ho m O ve rd os e 0 Severe Mental Disorders Among the General Population & Jail Admissions 12 10.5 10 8 6 3.9 4 2 2.8 0.1 0.9 1.0 2.0 1.4 1.4 0 General Population Males Mania Source: National GAINS Center Jail - Males Schizophrenia Jail - Females Major Depression Prevalence of Psychiatric Disorders: Northwestern Juvenile Project (N=1,829) Affective Anxiety Behavioral Substance Use Any Disorder 19 28 21 31 41 46 51 47 66 74 0 20 Males 40 60 Females 80 100 % Relative Risk of Death Causes of Death among Former Inmates 12 10 8 6 4 2 Binswanger IA et al. N Engl J Med 2007;356:157-165 Ca nc er CV D Su ic id e M VA as e Li ve rD is e ic id e Ho m O ve rd os e 0 Smoking in Criminal Justice • Rates smoking 4 times higher in CJ than general population (Cropsey & Kristeller, 2003; Cropsey et al., 2008) • Among Prisoners: 70% males; 80% females smoke (Conklin, Lincoln, & Tuthill, 2000) • 50% adolescents in juvenile justice daily smokers (Cropsey, Linker, & Waite, 2008) • Smoking bans in prisons most prevalent intervention • 97% smokers relapse within 6 months of release to community (Lincoln et al., 2009) HIV Infection in the Criminal Justice System In a Given Year . . . 21% of all people in the US with HIV, -- will pass through a correctional facility. Source: Spaulding, et al. (2009). PLoS ONE, 1-6. AIDS-Related Deaths Relative to All Deaths (%) AIDS-Related Mortality Achieves Parity in Prisons and the General Population State inmates General population 34.2% HAART (1996) 10.2% 3.4% 3.5% 1995 2008 Maruschak LM. Bur Justice Stat Bull. December 2009. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/hivp08.pdf. HIV-Infected Recidivists and HIV-Related Outcomes HIV RNA Change CD4 Change +1.14 P<0.0001 CD4 Change (cells/mm3) Change (log10 copies/mL) +67 P<0.0001 -1.04 Incarcerated Prisoners (n=292) Re-Incarcerated Prisoners (n=292) Springer SA, et al. Clin Infect Dis. 2004;38:1754-1760. Incarcerated Prisoners (n=292) -80 Re-Incarcerated Prisoners (n=292) Prevalence of Health Screening & Services in Adult CJ % Facilities Providing Service 100 80 60 40 20 0 HIV/AIDS Testing Prisons TB Screening Jails Hep C Screening HIV Tx, Counseling Community Corrections Source: CJ-DATS National Criminal Justice Treatment Practices Survey, NIDA Percentage of Inmates Who Filled an ART Prescription Within 60 Days of Release 100 Percent 80 Only a small percentage of Texas prison inmates Receiving ART while incarcerated filled an initial ART prescription within 60 days of their release 60 40 30% 17.7% 20 5.4% Had prescription 0 filled within: 10 days 30 days 60 days Baillargeon J et al., JAMA 301(8):848-857, 2009. TB Infection in the Criminal Justice In a Given Year . . . 40% of those with TB -- will pass through a correctional facility. Source: Hammett, Harmon, & Rhodes (2002). AJPH, 92 (11), 1789-1794. Principles of Drug Abuse Treatment For Criminal Justice Populations Drug addiction is a brain disease that affects behavior Recovery from drug addiction requires effective 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 Principles of Drug Abuse Treatment For Criminal Justice Populations Tailoring services to fit the needs of the individual is important Drug use during treatment should be carefully monitored Treatment should target factors that are associated with criminal behavior Criminal justice supervisions should incorporate treatment planning for drug abusing offenders & treatment providers should be aware of correctional supervision requirements Principles of Drug Abuse Treatment For Criminal Justice Populations Continuity of care is essential for drug abusers re-entering the community A balance of rewards and sanctions encourages prosocial behavior & treatment participation Offenders with co-occurring drug abuse & mental health problems often require an integrated treatment approach Medications are an important part of treatment for many drug abusing offenders Treatment planning for drug abusing offenders should include strategies to prevent & treat serious, chronic medical conditions (HIV/AIDS, Hep B & C & TB) What Can Physicians Do? • Know the common medical conditions among inmates or ex-inmates • Screen for common conditions • Treat or refer for treatment • Counsel to reduce risk • Provide preventive interventions – e.g. vaccination Assistance for Physicians Related to Drug Use NIDA Screening and Treatment Resources for Medical and Health Professionals Goals of NIDAMED Project In Specialty Treatment – 2,100,000 Abuse/Dependent – 23,000,000 “Harmful Users” – ??,000,000 ? • Engage medical community • Identify patients at high risk for a substance use disorder and refer for specialty assessment and treatment, if necessary. • Identify those at lower or moderate risk to intervene early and prevent the escalation to abuse and addiction. Resource Guide: • Targets adult primary care with a key goal of increasing screening for illicit drug abuse – potential use in criminal justice • Provides a clinician-friendly guide to support screening and brief intervention • Strengthens clinicians’ ability to discuss screening results with patients NIDAMED Online Screening Tool • Based on the WHO ASSIST • Screens for tobacco, alcohol, illicit, and non-medical prescription drug use • Based on patients’ responses, automatically: oLeads to next appropriate question oDetermines substance involvement score (i.e., risk level not a diagnosis) • Links to additional resources Download PDF Version Introduction Before You Begin Screening and brief intervention for drug use Step 1: Ask about drug use Step 2: Screen for substance use disorders Step 3: Discuss results & conduct brief intervention Step 4: Offer continuing care at follow-up visits Appendices Support Materials Frequently Asked Questions Glossary of Terms NIDA Resource Guide Groups patients into different risk categories and provides instructions for each category that are color coded to help triage patients to appropriate interventions • High risk (red) • Moderate risk (yellow) • Lower risk (green) STEP 3 Choose intervention based on patient’s risk level High Risk Use Moderate Risk Lower Risk Score of 27 or higher Brief Intervention AND Refer to Specialty Care. Score of 4-26 Brief Intervention. Score of 0-3 Encourage abstinence. Use clinical judgment regarding level of risk. Consider follow up plans (Step 4) Follow Up Care: Key Questions High Risk Use Moderate Risk High Risk Use For patients with high risk use and risky use: Did the patient abstain (or cut back on use)? For patients with high risk use: Did the patient follow through with the referral? Quick Reference Guide Online Resource Guide • Rationale • Instructions on how to implement screening • The five A’s of intervention – Ask, Advise, Assess, Assist, Arrange • Scripts on how to discuss drug use with patients • Additional Resources Involvement in criminal justice provides opportunity to: • Multiple Medical Needs in Criminal Justice System – Behavioral: Mental Health, Addiction – Physical: Infectious Disease, Other • Involvement in System Provides Opportunity to: – Identify Medical Needs – Provide Treatment • Physicians have Essential Role in: – Improving Public Health – Making our Communities Safer NIDA NATIONAL INSTITUTE ON DRUG ABUSE www.drugabuse.gov www.drugabuse.gov/blendi ng www.nnp.drugabuse.gov