1. Nora D. Volkow, M.D. Director National Institute on Drug Abuse Nora D. Volkow, M.D. Director National Institute on Drug Abuse RESEARCH and TREATMENT Provide the Answers RESEARCH and TREATMENT Provide the Answers Effectively Breaking the Cycle of Effectively Breaking the Cycle of

2. Healthy Heart Diseased Heart Decreased Heart Metabolism in Heart Disease Patient ADDICTION IS A DISEASE OF THE BRAIN As other diseases, it affects tissue function Control Cocaine Abuser Decreased Brain Metabolism in Drug Abuse Patient Sources: From the laboratories of Drs. N. Volkow and H. Schelbert High Low

3. Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses 0 0 10 20 30 40 50 60 70 80 90 100 Drug Dependence Drug Dependence Type I Diabetes Type I Diabetes Hypertension Asthma 40 to 60% 30 to 50% 50 to 70% Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000. Percent of Patients Who Relapse Addiction Treatment Does Work

4. Stage of Treatment Symptom Severity Evaluation of A Hypothetical Treatment HYPERTENSION ADDICTION Just Like Hypertension, Addiction Is A Chronic Disease That Requires Continued Care Just Like Hypertension, Addiction Is A Chronic Disease That Requires Continued Care Source: McLellan, AT, Addiction 97, 249-252, 2002.

5. 0 0 10 20 30 40 50 60 70 80 Low Pressure Moderate-to-High Pressure % Retained 90 Days Program A (42%) Program B (69%) Program C (88%) 28 40 39 55 25 52 Three Programs (with % of Caseload CJ Supervised) Source: Hiller, et al., Legal Pressure and Treatment Retention in DATOS (ASC Meeting, San Diego, Nov 1997) Treatment Works Even If It’s Not Voluntary Treatment Works Even If It’s Not Voluntary Time in Treatment (Retention) Is the Most Reliable Predictor of Post-Discharge Outcomes… Time in Treatment (Retention) Is the Most Reliable Predictor of Post-Discharge Outcomes… Legal Pressure Was the Strongest Predictor Of Remaining in Treatment Legal Pressure Was the Strongest Predictor Of Remaining in Treatment

6. 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 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

7. 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) 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)

8. Minorities are Disproportionately Impacted by Incarceration and HIV/AIDS 70 65 35 26 11 16 43 50 12 15 18 23 6 6 4 4 3 3 1 1 0% 20% 40% 60% 80% 100% Population Abuse/Dependent Prisoners IDUs w/ HIV-AIDS Other Hispanic Black White

9. Public Health Approach Public Health Approach Public Safety Approach Public Safety Approach High Attrition High Recidivism - disease - treatment - disease - treatment - illegal behavior - punishment - illegal behavior - punishment Addressing Drugs and Crime ` Blends functions of criminal justice & treatment systems to optimize outcomes Blends functions of criminal justice & treatment systems to optimize outcomes Community- based treatment Opportunity to avoid incarceration or criminal record Close supervision Consequences for noncompliance are certain & immediate Consequences for noncompliance are certain & immediate INTEGRATED STRATEGY INTEGRATED STRATEGY Integrated PUBLIC HEALTH PUBLIC SAFETY Strategy Integrated PUBLIC HEALTH PUBLIC SAFETY Strategy

10. 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 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

11. Research Centers Coordinating Center 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

12. * p <.05 from Comparison Delaware Work Release TC (Crest) + Aftercare Drug-Free an Arrest-Free 3 Years After Release (N=448) Delaware Work Release TC (Crest) + Aftercare Drug-Free an Arrest-Free 3 Years After Release (N=448) No Treatment CREST Dropouts CREST Completers CREST Completers + Aftercare * * * * * Drug-FreeDrug-Free Arrest-FreeArrest-Free No Treatment CREST Dropouts CREST Completers CREST Completers + Aftercare Martin, Butzin, Saum, & Inciardi (1999), The Prison Journal AFTERCARE is Indispensable AFTERCARE is Indispensable

13. Amity Prison TC 3-Year Outcomes Reincarceration Rates (N=478 Amity Prison TC 3-Year Outcomes Reincarceration Rates (N=478) Percent Reincarcerated Wexler et al., Three-year reincarceration outcomes for Amity…, Prison Journal 79:321-336, 1999. AFTERCARE is Indispensable AFTERCARE is Indispensable

14. Intake Processing / Assessment Treatment Plan Pharmacotherapy Continuing Care Clinical and Case Management Self-Help / Peer Support Groups Behavioral Therapy and Counseling Substance Use Monitoring Detoxification Child Care Services Child Care Services Vocational Services Medical Services Medical Services Educational Services AIDS / HIV Services Family Services Family Services Financial Services Legal Services Mental Health Services Housing / Transportation Services NIDA Principles of Drug Addiction Treatment: A Research-Based Guide (2000) Components of Comprehensive Drug Abuse Treatment A Variety of Ancillary Services are Key to Successful Transition into the Community A Variety of Ancillary Services are Key to Successful Transition into the Community

15. Lack of Methadone Treatment Access Availability of BUPRENORPHINE may facilitate more widespread use of pharmacological treatments Availability of BUPRENORPHINE may facilitate more widespread use of pharmacological treatments What Are the ROADBLOCKS ? What Are the ROADBLOCKS ? Changing the Culture Education of judges Secondary CJ-DATS goal – to help change the culture by embedding research into existing settings 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

16. Where Do We Need to Go From Here? Where Do We Need to Go From Here? We Need to… Advance the SCIENCE Erase the STIGMA and to… Erase the STIGMA and to…

17. Dopamine Neurotransmission VTA/SN nucleus accumbens nucleus accumbens frontal cortex frontal cortex 0 0 100 200 300 400 500 600 700 800 900 1000 1100 0 0 1 1 2 2 3 3 4 4 5 hr Time After Amphetamine % of Basal Release AMPHETAMINE 0 0 50 100 150 200 0 0 60 120 180 Time (min) % of Basal Release Empty Box Feeding Di Chiara et al. FOOD

18. Anatomy DA signal Dopamine Cell DA Transporters DA Receptors Metabolism Brain Dopamine System

19. DA D2 Receptor Availability control addicted Cocaine Alcohol DA Reward Circuits DA Reward Circuits DA Drug Abuser Non-Drug Abuser Heroin Meth Dopamine D2 Receptors are Lower in Addiction

20. Becomes Subordinate Stress remains Individually Housed Group Housed Morgan, D. et al. Nature Neuroscience, 5: 169-174, 2002. * * S.003.01.03.1 0 10 20 30 40 50 Reinforcers (per session) Cocaine (mg/kg/injection) Dominant Subordinate Becomes Dominant No longer stressed Isolation Can Change Neurobiology Effects of a Social Stressor on Brain DA D2 Receptors and Propensity to Administer Drugs

21. Simpson et al. (1997), Psych Addictive Behaviors Criminal Justice Involvement of Patients in Community-Based Drug Treatment TREATMENT WORKS EVEN WHEN ITS NOT VOLUNTARY