1. Addressing Adolescent Drug Abuse: Effective Treatment and Principles New Frontiers of Action and New Challenges of Management in Citizen Security San Jose, Costa Rica October 8, 2009 Redonna K. Chandler, Ph.D. Chief, Services Research Branch National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Redonna K. Chandler, Ph.D. Chief, Services Research Branch National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services

2. NIDA Research …To Managed Care From Molecules… …Drug Courts …Community Coalitions

3. NEUROTOXICITY OBESITY AIDS CANCER MENTAL ILLNESS NEUROTOXICITY OBESITY AIDS CANCER MENTAL ILLNESS HEALTH CARE COSTS PRODUCTIVITY LOSS ACCIDENTS HEALTH CARE COSTS PRODUCTIVITY LOSS ACCIDENTS HOMELESSNESS CRIME VIOLENCE HOMELESSNESS CRIME VIOLENCE

4. Priority Areas for NIDA Treatment Interventions new pharmacotherapies & behavioral tx pilot clinical trials for substance related disorders prescription opioid abuse and pain Treatment Interventions new pharmacotherapies & behavioral tx pilot clinical trials for substance related disorders prescription opioid abuse and pain Prevention Research adolescent brain development genetic and epigenetic factors social neuroscience prescription drug abuse Prevention Research adolescent brain development genetic and epigenetic factors social neuroscience prescription drug abuse HIV/AIDS Research non-injection drug abuse health Disparities non-injection drug abuse health Disparities Translating Research into Practice Transdisciplinary Collaborations

5. In 2007, an estimated 19.9 million Americans, or 8.0 percent of the population aged 12 or older, were current illicit drug users. Source: 2007 National Survey on Drug Use and Health (NSDUH), SAMHSA

6. Adolescent Drug Use in Central America & Dominican Republic Dormitzer et al., 2004

7. Percent of U.S. Students Reporting Past Month Use of Any Illicit Drug Has Decreased Percent of U.S. Students Reporting Past Month Use of Any Illicit Drug Has Decreased 25% Decline 2001 to 2008 Percent P <.001 * * SOURCE: University of Michigan, 2008 Monitoring the Future Study

8. Percentage of U.S. 12 th Grade Students Reporting Past Month Use of Cigarettes and Marijuana, 1975 to 2008 CESAR FAX January 19, 2009, Vol. 18, Issue 2. Adapted by CESAR from University of Michigan, “Trends in 30-Day Prevalence of Use of Various Drugs in Grades 8, 10, and 12,”Monitoring the Future study, 2008.

9. Why do some people become addicted while others do not? What have we learned about Vulnerability?

10. National Epidemiologic Survey on Alcohol and Related Conditions, 2003 Age Age at tobacco, at alcohol and at cannabis dependence, as per DSM IV 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 5 5 10 15 20 25 30 35 40 45 50 55 60 65 % in each age group to develop first-time dependence THC ALCOHOL TOBACCO Addiction Is a Developmental Disease starts in childhood and adolescence Addiction Is a Developmental Disease starts in childhood and adolescence 70 75

11. Environment DRUG Addiction Biology/Genes Biological Factors Have a Profound Influence on An Individual’s Vulnerability to Addiction

12. ADDICTION IS A DISEASE OF THE BRAIN as other diseases it affects the tissue function No Cocaine Abuse Cocaine Abuser Decreased Brain Metabolism in Drug Abuse Patient Sources: From the laboratories of Drs. N. Volkow and H. Schelbert High Low Healthy Heart Diseased Heart Decreased Heart Metabolism in Heart Disease Patient No Heart Disease

13. PFC ACG OFC SCC Hipp NAcc VP Amyg REWARD CONTROL INHIBITORY CONTROL INHIBITORY CONTROL MOTIVATION/ DRIVE MOTIVATION/ DRIVE MEMORY/ LEARNING MEMORY/ LEARNING Circuits Involved In Drug Abuse and Addiction Circuits Involved In Drug Abuse and Addiction

14. Construction Ahead Motivation Emotion Judgment Cerebellum Amygdala Nucleus Accumbens Maturation starts at the back of the brain... and moves to the front Prefrontal Cortex Physical coordination, sensory processing Notice: Judgment is last to develop !

15. Copyright ©2004 by the National Academy of Sciences Source: Gogtay, Nitin et al. (2004) Proc. Natl. Acad. Sci. USA 101, 8174-8179 Right Lateral and Top Views of the Dynamic Sequence of GM Maturation Over the Cortical Surface Right Lateral and Top Views of the Dynamic Sequence of GM Maturation Over the Cortical Surface

16. We Know There’s A Big Genetic Contribution To Drug Abuse and Addiction… Drug Abuse and Addiction… And the Nature of this Contribution Is Extremely Complex Is Extremely Complex We Know There’s A Big Genetic Contribution To Drug Abuse and Addiction… Drug Abuse and Addiction… And the Nature of this Contribution Is Extremely Complex Is Extremely Complex

17. Genetic component of common traits Trait Heritability Type II (adult-onset) diabetes0.3 1 Type I (insulin-dependent) diabetes0.7 2 Hypertension0.3 - 0.5 3 Peanut allergy0.8 4 Cataract (age-related)0.5 5 Alcoholism0.6 6 Nicotine0.5 – 0.6 7 Cocaine and stimulants0.4 – 0.8 8 Heroin and opiates0.5 9 Marijuana0.3 – 0.8 10

18. –FAAH - associated with drug dependence –OPRM1 - associated with opiates and alcoholism –CYP2A6, CYP2B6 - associated with smoking and smoking cessation –ALDH2 - associated with protection against alcoholism –DBH (Dopamine beta-hydroxylase) – cocaine-induced paranoia –DRD2, DRD4 (Dopamine receptors) - reward, craving –NrCAM, neurexins (Cell adhesions genes) - assoc with drug abuse and addiction –Prodynorphin gene - associated with protection against cocaine dependence –Nicotinic alpha 7 promoter – assoc. with decreased expression of its message in different brains regions and with sensory gating defects in schizophrenics -- Alpha 5 and beta 3 (nicotinic receptors) – assoc. with nicotine dependence -- 5HT1B (serotonin receptor) - associated with conduct disorder and alcoholism Some Gene Variants Implicated in Addiction

19. Biology/Genes DRUG Addiction Environment Environmental Factors Play A Key Role in Vulnerability

20. Community Peer Cluster Family Individual Drug Abuse Risk Factors

21. Examples of Risk and Protective Factors Risk FactorsDomainProtective Factors Sensation-seekerIndividualSuccessful student Child of drug userBonds with family No supervisionFamilyConsistent discipline Parent/sibling drug useAnti-drug family rules Pro-drug use normSchoolAnti-drug use norm Availability of drugsHigh academics Crime/povertyCommunityConsistent anti-drug messages No afterschool programs Strong enforcement of anti- drug laws

22. Mapping the number of risk factors creates a 3-D map: ONDCP, July 2003

23. Prevalence of 30 Day Marijuana Use By Number of Risk and Protective Factors Source: David Hawkins, Seattle Social Development Project

24. Addiction DRUG Environment Biology/Genes Biology/ Environment Interaction Ultimately Biological Factors Interact with Environmental Factors to Produce Addiction

25. What have we learned about other aspects of vulnerability?

26. Mental Disorder Mental Disorder Addictive Disorder Addictive Disorder Comorbid Disorders Comorbid Disorders ADDICTIVE DISORDERS OFTEN CO-EXIST WITH MENTAL DISORDERS ADDICTIVE DISORDERS OFTEN CO-EXIST WITH MENTAL DISORDERS

27. Pathways to Substance Disorders through Psychopathology: Yale Family Study Age152025510ADHD Conduct Conduct Bipolar 6.0 5.04.05.0AnxietyDepression 2.0 Phobia Merikangas, unpublished data

29. Problem Behaviors Occur with Drug Use Academic failure Lack of school bonding/affiliation Unsafe sexual practices Conduct problems Delinquency

30. How can we prevent drug use and abuse? What Can We Do About Vulnerability?

31. Goal of Prevention To prevent the initiation of drug use and the escalation to addiction in those who have already started using. To prevent the initiation of drug use and the escalation to addiction in those who have already started using.

32. What Does Science Tell Us About Effective Prevention Programs? Over the past 25 years, scientific research has identified key principles of effective prevention programs.Over the past 25 years, scientific research has identified key principles of effective prevention programs.

33. Prevention Programs Should Enhance Protective Factors and Reduce Risk Factors Prevention Programs Should Enhance Protective Factors and Reduce Risk Factors 33 Reduce these Elevate these

34. Source: Spoth, et al. Arch Pediatr Adolesc Med. 2006;160:876-882 % Ever Using Meth Prevention Programs Should Focus on All Forms of Drug Abuse Prevention Programs Should Focus on All Forms of Drug Abuse

35. The Challenges How can we motivate communities to implement evidence-based prevention programs and assess their effectiveness? How can communities retain the core elements of proven programs while adapting them for their unique conditions (i.e., risk and protective factors)? How can communities implement and sustain effective programs? 35

36. Communities That Care Creating Communities That Care Get Started Get Organized Develop a Profile Create a Plan Implement and Evaluate 24 Communities; ~45,000 participants Fagan, Hawkins & Catalano, 2007; Quinby et al, 2007

37. Pre-post change in risk factors prioritized and targeted in CTC Communities Average Level of Risk Note. Values are model-fitted levels of standardized average risk for students in the Youth Developmental Study panel sample. Nonsignificant difference in means at Grade 5, t (11) = 0.61, p >.05. Significant difference in means at Grade 7, t (11) = -3.13, p =.01. Grade 7 Grade 5 Hawkins et al., in progress

38. What are evidence-based practices for drug abuse? How can we treat drug abuse and addiction?

39. The Most Effective Treatment Strategies Will Attend to All Aspects of Addiction: Biology Biology Stage of Development Stage of Development Behavior Behavior Social Context Social Context

40. CONTROL REWARD DRIVE CONTROL DRIVE MEMORY CONTROL DRIVE MEMORY CONTROL Strengthen frontal control Strengthen frontal control MEMORY Weaken learned positive associations with drugs and drug cues Weaken learned positive associations with drugs and drug cues REWARD Decrease the rewarding value of drugs Decrease the rewarding value of drugs REWARD Increase the rewarding value of non- drug reinforcers Increase the rewarding value of non- drug reinforcers Treating the ADDICTED Brain DRIVE MEMORY REWARD

41. Effective Family-Based Treatments for Adolescent Drug Abuse Brief Strategic Family Therapy (developed specifically for Hispanic adolescent polydrug abusers) Functional Family Therapy (heavily focused on family communication, developed for youth in juvenile justice) Multi-Dimensional Family Therapy (based on family systems theory, heavy focus on family roles and relationships, tested with juvenile justice involved youth) Multi-Systemic Therapy (treatment for conduct disorder, focus on structuring environment and consistency, tested with juvenile justice involved youth and in drug court settings)

42. Other Effective Treatments for Adolescent Drug Abuse Cognitive Behavioral Therapy Group & Individual (teach cognitive strategies change maladaptive thinking, problem-solving, communication, coping skills for stress and cravings, refusal skills, some evidence CBG-G may not be effective with Hispanics) Cognitive Behavioral Therapy-G with Motivational Enhancement (assist with engaging adolescents in treatment) Adolescent Community Reinforcement Approach (promising approach seeks to replace activities supporting drug use with pro- social activities in community)

43. Effectiveness of Treatment for Hispanic Adolescents

45. Estimated Size of the Correctional Population in U.S.: 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 adults receive tx (7.6%)

46. While adolescents are “in” the juvenile justice system….. There is an outstanding “Reachable Moment”

47. ENTRY (Arrest) ADJUDICATION (Trial) PROSECUTION (Court, Pre-Trial Release, Jail) SENTENCING (Fines, Community Supervision, Incarceration) CORRECTIONS (Probation, Jail, Prison) COMMUNITY REENTRY (Probation, Parole, Release) Crime victim Police FBI Crime victim Police FBI Judge Key Players Screening/ Referral Intervention Opportunities Prosecutor Defense Attorney Defendant Jury Judge Jury Probation Officers Correctional Personnel Probation/ Parole Officers Family Community-based providers Diversion Programs Drug Courts Community Treatment TASC Drug Court Terms of Incarceration Release Conditions Drug Treatment Drug treatment Aftercare Housing Employment Mental Health Half-way House TASC N/A Addressing Drug Abuse in the Criminal Justice System

48. Addressing Drugs and Crime Public Health Approach -disease -treatment Public Safety Approach -illegal behavior -punish High Attrition High Recidivism

49. 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

50. Assessment is the first step in treatment. Nature/extent of drug problem Strengths: –Family support –Educational history –Motivation Threats to recovery: –C riminal behavior –Mental health –Physical health –Family Influences –Peers/Gang Activity –Homelessness –HIV/AIDS

51. Clinical Practices Initial Services Sustain & Manage Therapeutic Interventions Assessment “Prescription” for Services Behavioral Counseling and Medications Recovery/Chronic Care Management Screening and Brief Intervention Recovery from drug addiction requires effective treatment followed by management of the disorder over time. A Chronic Care Approach to Drug Treatment

52. Adolescent Drug Abuse Treatments Tested with Juvenile Offenders Functional Family Therapy (heavily focused on family communication, developed for youth in juvenile justice) Multi-Dimensional Family Therapy (based on family systems theory, heavy focus on family roles and relationships, tested with juvenile justice involved youth) Multi-Systemic Therapy (treatment for conduct disorder, focus on structuring environment and consistency, tested with juvenile justice involved youth)

54. Recovery from drug addiction requires effective treatment, followed by management of the problem over time 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 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 Principles of Drug Abuse Treatment For Criminal Justice Populations Drug addiction is a brain disease that affects behavior Drug addiction is a brain disease that affects behavior

55. Tailoring services to fit the needs of the individual is important Tailoring services to fit the needs of the individual is important Drug use during treatment should be carefully monitored Drug use during treatment should be carefully monitored Treatment should target factors that are associated with criminal behavior Treatment should target factors that are associated with criminal behavior Principles of Drug Abuse Treatment For Criminal Justice Populations Principles of Drug Abuse Treatment For Criminal Justice Populations Criminal justice supervisions should incorporate treatment planning for drug abusing offenders & treatment providers should be aware of correctional supervision requirements Criminal justice supervisions should incorporate treatment planning for drug abusing offenders & treatment providers should be aware of correctional supervision requirements

56. Continuity of care is essential for drug abusers re-entering the community Continuity of care is essential for drug abusers re-entering the community Offenders with co-occurring drug abuse & mental health problems often require an integrated treatment approach 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) Treatment 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 Principles of Drug Abuse Treatment For Criminal Justice Populations A balance of rewards and sanctions encourages prosocial behavior & treatment participation

57. We Need to Keep Our Eye on the Real Target the Real Target We Need to Keep Our Eye on the Real Target the Real Target AbstinenceAbstinence Functionality in Family, School and Community Functionality in Family, School and Community In Treating Addiction… Reduced Delinquent Behavior

58. Reduce Crime Save Money Improve Lives

59. NIDA NATIONAL INSTITUTE ON DRUG ABUSE www.drugabuse.gov www.drugabuse.gov/blending www.nnp.drugabuse.gov