Addressing Public Health & Drug Abuse Treatment within the Criminal Justice System

Redonna K. Chandler, Ph.D.Chief

Services Research BranchDivision of Epidemiology, Services, and Prevention Research

National Institute on Drug Abuse

NYSAM 6NYSAM 6thth Annual Conference Annual ConferenceFebruary 6, 2010February 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 PopulationDrug 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 drugtreatment (GAO, 1991)

68% of jail inmates report regular drug use (BJS, 2005)

2007, an estimated 7.3 million adults wereinvolved in the criminal justice system

U.S. imprisons more people per capita than any other country in the world, with 239% growth in 1990s

53

100

112

116

125

139

400

628

702

91

73

85

0 100 200 300 400 500 600 700 800

Japan

Sweden

France

Germany

Italy

Australia

Canada

Spain

England and Wales

South Africa

Russian Federation

United States

Inmates per 100K CitizensSource: International Centre for Prison Studies, www.prisonstudies.org

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 prisoners1

• Drug Dependence/Abuse 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

ENTRY/PRETRIAL(Arrest)

ADJUDICATION(Trial)

PROSECUTION(Court, Pre-Trial Release, Jail)

SENTENCING(Fines, Community Supervision,Incarceration)

CORRECTIONS(Probation, Jail, Prison)

COMMUNITY REENTRY(Probation, Parole, Release)

Crime victimPoliceFBI

Crime victimPoliceFBIJudge

Key Players

Screening/Referral

Intervention Opportunities

ProsecutorDefense AttorneyDefendantJuryJudge

JudgeJury

Probation OfficersCorrectional Personnel

JudgeProbation/ Parole OfficersFamilyCommunity-based providers

Diversion ProgramsDrug CourtsCommunity TreatmentTASC

Drug CourtTerms of IncarcerationRelease Conditions

Drug Treatment

Drug treatmentAftercareHousingEmploymentMental HealthHalf-way HouseTASC

Educate

Overview of the Criminal Justice System

Stage Offender Event Participants Intervention Opportunities

Entry Arrest Crime victimPolice, 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 Attorney, Defendant, Jury, and Judge

Educate Participants

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 officer, family, Community provider

Drug treatment, Aftercare, Housing, Employment, Mental Health, Medical Care, Halfway house

Adapted from Chandler, Fletcher, and Volkow, 2009.

Addressing Addiction and Crime

Public Health Approach -disease

-treatment

Public Safety Approach-illegal behavior

-punish

High Attrition High Recidivism

Integrated Public Health-Public Safety Strategy

Blends functions of criminal justice and treatment systems to optimize outcomes

Community-based

treatment

Opportunity to avoid incarceration or criminal record

Close supervision

Consequences for noncompliance are

certain and immediate

Current Rates of Drug Use Disorders and

Treatmentin Criminal Justice

0123456789

10

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

Year

In M

illio

ns

Probation Jail Prison Parole Juveniles Other Adult

Estimated Size of the Correctional Population: 8+ M Adults, 650K Juveniles

*Bureau of Justice Statistics, 2005 adjusted with estimates from Taxman, et al, 2007.

253,034 juveniles need TX(198,000 males, 54,000 females)

54,496 juveniles GET tx (21.5%)

5,613,739 adults need TX(4.5M males, 1.1M females)

424,046 adultsreceive tx (7.6%)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

State Prison

Federal Prison

Treatment from a ProfessionalOther Programs: Education, self-helpDrug Dependence or Abuse

Many prison inmates have a drug use disorder…

Souces: BJS: Mumola & Karberg (2006, revised 1/2007). Drug use and dependence, state and federal prisoners, 2004.

but few receive treatment

Other Behavioral and Health Conditions and Treatment in

Criminal Justice

Binswanger IA et al. N Engl J Med 2007;356:157-165

0

2

4

6

8

10

12Re

lativ

e Ri

sk o

f Dea

th

Relative Risk of Death Among Former Inmates of the Washington State Department of Corrections

Compared to Other State Residents

Binswanger IA et al. N Engl J Med 2007;356:157-165

Causes of Death among Former InmatesAdjusted for Age, Sex, and Race

0

2

4

6

8

10

12Re

lativ

e Ri

sk o

f Dea

th

Methadone Treatment Pre- and Post-Prison Release: Results 12-mo Post Release (N=204)

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.

020406080

100120140160180200

A B C A B C A B C

Community-based Tx days % opioid UA% cocaine UA crime days past yr

-- sig. diff from referral only; -- sig. diff from tx on release

Treatment Drugs Crime

Experimental Conditions:A: Methadone referral at release

B: Methadone treatment on releaseC: Methadone treatment pre- and post-release

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)

Availability of Opiate Replacement Therapy in US Prisons

Nun et al. (2009). DAD, 83-88. Geographic region defined by CDC

State Prisons Offering ORT

Nun et al. (2009). DAD, 83-88.

Patients Receiving ORT in US Prisons

Nun et al. (2009). DAD, 83-88.

• 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

Binswanger IA et al. N Engl J Med 2007;356:157-165

Causes of Death among Former InmatesAdjusted for Age, Sex, and Race

0

2

4

6

8

10

12

Rela

tive

Risk

of D

eath

Source: Teplin L, McClelland G, Abram K, & Mileusnic D. (2005) Pediatrics

Northwestern Juvenile Project

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.

Detained Population General Population

Mortality in Delinquent & Community Youth0

200

400

600

800

Ann

ual D

eath

s pe

r 100

000

pe

rson

-yea

rs

Total Total AA W H Total AA W HMale Female

83.5Crude U.S.

Mortality Ages 15-24*

806

184

847887

435

228

60

807

28336

233 42

315

22

501

18

195

83

Source: Teplin L, McClelland G, Abram K, & Mileusnic D. (2005) Pediatrics

Binswanger IA et al. N Engl J Med 2007;356:157-165

Causes of Death among Former InmatesAdjusted for Age, Sex, and Race

0

2

4

6

8

10

12

Relat

ive R

isk of

Dea

th

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.

HCV Infection in Criminal Justice

Binswanger IA et al. N Engl J Med 2007;356:157-165

Causes of Death among Former Inmates

0

2

4

6

8

10

12

Relat

ive R

isk of

Dea

th

Severe Mental Disorders Among the General Population & Jail Admissions

0.10.9 1.0 1.4

2.83.9

1.42.0

10.5

0

2

4

6

8

10

12

General Population -Males

Jail - Males Jail - Females

Mania Schizophrenia Major Depression

Source: National GAINS Center

28

66

51

41

21

19

31

46

47

74

0 20 40 60 80 100

Any Disorder

Substance Use

Behavioral

Anxiety

Affective

Prevalence of Psychiatric Disorders: Northwestern Juvenile Project

(N=1,829)

%FemalesMales

Binswanger IA et al. N Engl J Med 2007;356:157-165

Causes of Death among Former Inmates

0

2

4

6

8

10

12

Relat

ive R

isk of

Dea

th

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)

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.

HIV Infection in the Criminal Justice System

AIDS-Related Mortality Achieves Parity in Prisons and the General Population

AID

S-R

elat

ed D

eath

sR

elat

ive

to A

ll D

eath

s (%

)

1995

State inmates General population

34.2%

10.2%

2008

3.5% 3.4%

Maruschak LM. Bur Justice Stat Bull. December 2009.Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/hivp08.pdf.

HAART(1996)

HIV-Infected Recidivistsand HIV-Related Outcomes

Cha

nge

(log 10

cop

ies/

mL

)

-1.04

HIV RNA Change+1.14

IncarceratedPrisoners(n=292)

Re-IncarceratedPrisoners(n=292)

CD

4 C

hang

e (c

ells

/mm

3 )

+67

CD4 Change

IncarceratedPrisoners(n=292)

Re-IncarceratedPrisoners(n=292)

-80

P<0.0001 P<0.0001

Springer SA, et al. Clin Infect Dis. 2004;38:1754-1760.

Prevalence of Health Screening & Services in Adult CJ

0

20

40

60

80

100

HIV/AIDSTesting

TB Screening Hep CScreening

HIV Tx,Counseling

Prisons Jails Community Corrections

% Facilities Providing Service

Source: CJ-DATS National Criminal Justice Treatment Practices Survey, NIDA

Baillargeon J et al., JAMA 301(8):848-857, 2009.

Percentage of Inmates Who Filled an ART Prescription Within 60 Days of Release

Perc

ent

5.4%

17.7%

30%

0

20

40

60

80

100

10 days 30 days 60 days

Only a small percentage of Texas prison inmatesReceiving ART while

incarcerated filled an initial ART prescription within 60 days of their release

Had prescriptionfilled within:

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.

TB Infection in the Criminal Justice

Recovery from drug addiction requireseffective treatment, followed by managementof the problem over time

Treatment must last long enough to producestable behavioral changes

Assessment is the first step in treatment

Principles of Drug Abuse Treatment For Criminal Justice Populations

Drug addiction is a brain disease thataffects behavior

Tailoring services to fit the needs of the individual is important

Drug use during treatment should be carefullymonitored

Treatment should target factors that are associated with criminal behavior

Principles of Drug Abuse Treatment For Criminal Justice Populations

Criminal justice supervisions should incorporatetreatment planning for drug abusing offenders& treatment providers should be aware of correctional supervision requirements

Continuity of care is essential for drugabusers re-entering the community

Offenders with co-occurring drug abuse & mentalhealth problems often require an integrated treatment approach

Medications are an important part of treatment for many drug abusing offendersTreatment planning for drug abusing offenders should include strategies to prevent & treat serious, chronic medical conditions (HIV/AIDS, Hep B & C & TB)

Principles of Drug Abuse Treatment For Criminal Justice Populations

A balance of rewards and sanctions encourages prosocial behavior & treatment participation

• 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

What Can Physicians Do?

Assistance for Physicians Related to Drug Use

NIDA Screening and Treatment Resources

for Medical and Health Professionals

In Specialty Treatment – 2,100,000

Abuse/Dependent – 23,000,000“Harmful Users”

– ??,000,000

Goals of NIDAMED Project

• 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.

?

• 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

Resource Guide:

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

DownloadPDF Version

IntroductionBefore You BeginScreening and brief intervention for drug use

Step 1: Ask about drug useStep 2: Screen for substance use disordersStep 3: Discuss results & conduct brief interventionStep 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)

High Risk Use

Moderate Risk

Lower Risk

Choose intervention based on patient’s risk level

Score of 27 or higher

Score of4-26

Brief Intervention AND Refer to Specialty Care.

Brief Intervention.

Encourage abstinence. Use clinical judgment regarding level of risk.

Consider follow up plans (Step 4)

Score of0-3

STEP 3

For patients with high risk use and risky use: Did the patient abstain (or cut back on use)?

High Risk Use

Moderate Risk

Follow Up Care: Key Questions

For patients with high risk use: Did the patient follow through with the referral?

High Risk Use

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

NIDANATIONAL INSTITUTE NATIONAL INSTITUTE

ON DRUG ABUSEON DRUG ABUSE

www.drugabuse.gov

www.drugabuse.gov/blending

www.nnp.drugabuse.gov