Addiction and the criminal justice system Dr. Eric Blaauw Professor in Addiction studies Hanze University of Applied Sciences Dit is het voorblad. De enige tekst die hier toegevoegd mag worden is de naam van de persoon die de presentatie geeft.

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

ADDICTION

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.

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

Alcohol addiction (%)

Drug addiction (%)

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

Enjoy, but….

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

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)

What is addiction? Addiction is a complexe interplay of biological, psychological and social factors (biopsychosocial model) But also pay attention to things that give meaning to addiction and life (a.o. Frankl, 1946, 2011).

VIDEO

What is addiction?

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

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

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

The Dutch criminal justice system

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)

Arrondissement Court Crown Council (Openbaar Ministerie) Parole office Addiction parole (SVG) Salvation Army parole Parole office Netherlands (Reclassering Nederland) Netherlands Institute for Forensic Psychiatry and Psychology (NIFP)

Crimes in the Netherlands

Violent crimes

Prisoners in the Netherlands

30 penal institutions in 2018

Prisoners More than half 20-35 years old (vs 29%) 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%)

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

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?

Addiction and the criminal justice system

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)

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%

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

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

SUDS and intimate 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

Alcohol and violence 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)

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 ->

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

Use Withdrawal Remark Cannabis Usually decreased Anxiety induced Agitation More dangerous with speed/cocaine Amphetamines Increased More dangerous with alcohol MDMA/XTC GHB/GBL Decreased? Risk with sudden withdrawal Heroin Cocaine

Fourth explanation: 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

Spurious model Substances increase tendencies that are already present. Underlying symptom and character clusters are related to heightened risk of aggression Problematic symptom and Character clusters Impulse control

Clusters related to aggression Stress, depression, anxiety, arousal Impulsivity Sensation seeking Hostility and antisocial attitudes Hyperactivity Attentional deficits Compulsivity

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

Forensic (addiction) care

Effects of efforts Recidivism after two years: 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%

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)

Forensic addiction 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

Further information E.blaauw@vnn.nl