Download Improving Drug Abuse Services in Criminal Justice Settings

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