Transcript Effectively Breaking the Cycle of RESEARCH and TREATMENT Provide the Answers Nora D.

Effectively Breaking the Cycle of
RESEARCH and TREATMENT
Provide the Answers
Nora D. Volkow, M.D.
Director
National Institute on Drug Abuse
ADDICTION IS A DISEASE OF THE BRAIN
As other diseases, it affects tissue function
Decreased Brain Metabolism in Drug Abuse Patient
High
Control
Cocaine Abuser
Decreased Heart Metabolism in Heart Disease Patient
Low
Healthy Heart
Diseased Heart
Sources: From the laboratories of Drs. N. Volkow and H. Schelbert
100
Addiction Treatment Does Work
90
80
40
30
20
50 to 70%
50
30 to 50%
60
50 to 70%
70
40 to 60%
Percent of Patients Who Relapse
Relapse Rates Are Similar for Drug Dependence
And Other Chronic Illnesses
10
0
Drug
Dependence
Type I Hypertension Asthma
Diabetes
Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.
Evaluation of A Hypothetical Treatment
Symptom Severity
10
HYPERTENSION
9
8
7
6
5
4
3
2
1
0
Pre
During
Symptom Severity
10
During
During
Post
ADDICTION
9
8
7
Just Like Hypertension,
Addiction Is A
Chronic Disease That
Requires Continued Care
6
5
4
3
2
1
0
Pre
During
During
During
Stage of Treatment
Post
Source: McLellan, AT, Addiction 97, 249-252, 2002.
% Retained 90 Days
Time in Treatment (Retention) Is the Most
Reliable Predictor of Post-Discharge Outcomes…
Legal Pressure Was the Strongest
Predictor Of Remaining in Treatment
80
Low Pressure
Treatment
Works
Even
70
Moderate-to-High Pressure
If
It’s
Not
Voluntary
60
55
52
50
40
39
40
30
28
25
20
10
0
Program A (42%) Program B (69%) Program C (88%)
Three Programs (with % of Caseload CJ Supervised)
Source: Hiller, et al., Legal Pressure and Treatment Retention in DATOS (ASC Meeting, San Diego, Nov 1997)
In 2003, An Estimated
21.6 Million Americans
Were Dependent On or Abused
Any Illicit Drugs or Alcohol
But…Only 3.3 Million (15%)
of These Individuals
Had Received Some Type of
Treatment In the Past Year
Drug Use Connected to Criminal Activity
In 2003, the combined federal,
state, and local adult correctional
population reached a new record of
almost 6.9 million (Bureau of Justice
Statistics, 2004).
•
•
64% jail, state/federal inmates report regular drug use (BJS, 1997)
Drug use involved > 50% of violent crimes and 60-80% of child
abuse/neglect (NIJ, 1999)
Minorities are Disproportionately Impacted by
Incarceration and HIV/AIDS
100%
80%
6
4
3
1
12
11
15
18
23
16
60%
40%
20%
0%
43
70
50
65
35
26
Other
Hispanic
Black
White
Integrated
PUBLIC
HEALTH
Addressing Drugs and Crime
PUBLIC SAFETY Strategy
Communitybased
treatment
Close
`
supervision
INTEGRATED
Public Safety
Public Health
Approach STRATEGY Approach
- disease Blends functions- ofillegal behavior
criminal justice & treatment
- punishment
- treatment
systems to optimize outcomes
High Attrition
Opportunity to
avoid incarceration
or criminal record
High Recidivism
Consequences for
noncompliance are
certain & immediate
NIDA Response
• Research Portfolio
Integrating Treatment into CJ Settings
Drug Courts
Prisons/Jails
Probation/Parole
HIV/AIDS
Re-entry
• Translating Research
Principles of Effective Treatment with
Drug Abusing Offenders
Judicial Training
Criminal Justice Drug Abuse Treatment Studies
(CJ-DATS)
To improve outcomes for offenders with substance use
disorders by improving the integration of drug abuse
treatment with other public health & public safety systems
Research Centers
Coordinating Center
Delaware Work Release TC (Crest) + Aftercare
Drug-Free an Arrest-Free 3 Years After Release (N=448)
AFTERCARE
is Indispensable
100
80
Arrest-Free
Drug-Free
69*
55*
60
35 *
27 *
40
29
28
17 *
20
5
0
* p < .05 from Comparison
Martin, Butzin, Saum, & Inciardi (1999), The Prison Journal
Amity Prison TC 3-Year Outcomes
Reincarceration Rates (N=478)
Percent Reincarcerated
100%
82%
75%
79%
75%
AFTERCARE
is Indispensable
50%
27%
25%
0%
Control
Prison Treatment Completed Prison
Dropout
TC (No Aftercare)
Completed
Aftercare
Wexler et al., Three-year reincarceration outcomes for Amity…, Prison Journal 79:321-336, 1999.
Components of Comprehensive
Drug Abuse Treatment
A Variety of Ancillary Services are Key to
Successful Transition into the Community
Child Care
Services
Family
Services
Housing /
Transportation
Services
Behavioral
Therapy and
Counseling
Intake Processing /
Assessment
Detoxification
Vocational
Services
Substance Use
Monitoring
Mental Health
Services
Treatment Plan
Financial
Services
Self-Help / Peer
Support Groups
Clinical and Case
Management
Pharmacotherapy
Legal
Services
Continuing Care
Medical
Services
Educational
Services
AIDS / HIV
Services
NIDA Principles of Drug Addiction Treatment: A Research-Based Guide (2000)
What Are the
ROADBLOCKS ?
•
Lack of Methadone Treatment Access
Availability of BUPRENORPHINE may facilitate
more widespread use of pharmacological treatments
•
Changing the Culture
Education of judges
Secondary CJ-DATS goal – to help change
the culture by embedding research into existing settings
•
Infrastructure to Support Transition to the Community
Ancillary services are critical to successful transition
Where Do We Need
to Go From Here?
We Need to…
SCIENCE
and to…
Erase the STIGMA
Advance the
frontal
cortex
% of Basal Release
Dopamine
Neurotransmission
1100
1000
900
800
700
600
500
400
300
200
100
0
AMPHETAMINE
0
1
2
3
4
5 hr
nucleus
accumbens
VTA/SN
% of Basal Release
Time After Amphetamine
FOOD
200
150
100
50
0
Empty
Box Feeding
0
60
120
180
Time (min)
Di Chiara et al.
Brain Dopamine System
DA Transporters
Anatomy
DA DA
DA Receptors
DA
DA DA
DA
DA
signal
Dopamine Cell
Metabolism
Dopamine D2 Receptors are Lower in Addiction
Cocaine
DADA
DA
DA DA
DADA
Meth
DA
DA
DA DA
DA
Reward Circuits
Non-Drug Abuser
Alcohol
DADA
DA
DA
DA
DA
Heroin
Reward Circuits
control
addicted
Drug Abuser
Effects of a Social Stressor on Brain DA D2 Receptors
and Propensity to Administer Drugs
Individually
Housed
Group
Housed
Dominant
50
Becomes Dominant
No longer stressed
40
30
Isolation Can Change Neurobiology
Subordinate
20
* *
10
Becomes Subordinate
Stress remains
0
S.003 .01 .03 .1
Cocaine (mg/kg/injection)
Morgan, D. et al. Nature Neuroscience, 5: 169-174, 2002.
Criminal Justice Involvement of Patients
in Community-Based Drug Treatment
TREATMENT WORKS EVEN WHEN
ITS NOT VOLUNTARY
100
80
66
59
60
56
43
40
33
29
31
20
2
0
Residential
Out-Pt
CJ Status
Methadone
CJ Referral
Simpson et al. (1997), Psych Addictive Behaviors
Total