1. Addressing Public Health & Drug Abuse Treatment within the Criminal Justice System Redonna K. Chandler, Ph.D. Chief Services Research Branch Division of Epidemiology, Services, and Prevention Research National Institute on Drug Abuse NYSAM 6 th Annual Conference February 6, 2010

2. 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.

3. U.S. Adult Offender Population Drug 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 drug treatment (GAO, 1991) 68% of jail inmates report regular drug use (BJS, 2005) 2007, an estimated 7.3 million adults were involved in the criminal justice system 2007, an estimated 7.3 million adults were involved in the criminal justice system

4. U.S. imprisons more people per capita than any other country in the world, with 239% growth in 1990s Source: International Centre for Prison Studies, www.prisonstudies.org

5. 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

6. 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

7. Drugs of Abuse and Crime are Linked Regular Drug Use: 69% state, 64% federal prisoners 1 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

8. 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 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 Judge 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 Educate Overview of the Criminal Justice System

9. StageOffender EventParticipantsIntervention Opportunities EntryArrestCrime victim Police, FBI Screening or Referral ProsecutionPretrial Release, Court, or Jail Crime victim, Police, FBI, and Judge Diversion, Drug court, Community treatment AdjudicationTrialProsecutor, Defense Attorney, Defendant, Jury, and Judge Educate Participants SentencingFines, Community supervision, Incarceration Jury, JudgeDrug court, terms of incarceration, release conditions, tx needs CorrectionProbation, 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.

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

11. 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

12. Current Rates of Drug Use Disorders and Treatment in Criminal Justice

13. 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 adults receive tx (7.6%)

14. 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

15. Other Behavioral and Health Conditions and Treatment in Criminal Justice

16. Binswanger IA et al. N Engl J Med 2007;356:157-165 Relative Risk of Death Among Former Inmates of the Washington State Department of Corrections Compared to Other State Residents

17. Binswanger IA et al. N Engl J Med 2007;356:157-165 Causes of Death among Former Inmates Adjusted for Age, Sex, and Race

18. 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. -- sig. diff from referral only; -- sig. diff from tx on release TreatmentDrugsCrime Experimental Conditions: A: Methadone referral at release B: Methadone treatment on release C: Methadone treatment pre- and post-release

19. NE N (%)South N (%)MW N (%)West N (%)FederalTotal N (%) Methadone Offered in Prison Yes6(67)6(35)7(64)8(62)128(55) No3(33)11(65)4(36)5(38)023(45) Buprenorphine Offered in Prison Yes3(33)2(12)1(9)1(8)07(14) No6(67)15(88)10(91)12(92)144(86) Referral to Community-Based Methadone Yes7(78)7(41)5(45)4(31)023(45) No2(22)10(59)6(55)9(69)128(55) Referral to Community-Based Buprenorphine Yes6(67)4(24)2(18)3(23)015(29) No3(33)13(76)9(82)10(77)136(71) Availability of Opiate Replacement Therapy in US Prisons Nun et al. (2009). DAD, 83-88. Geographic region defined by CDC

20. State Prisons Offering ORT Nun et al. (2009). DAD, 83-88.

21. 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

22. Binswanger IA et al. N Engl J Med 2007;356:157-165 Causes of Death among Former Inmates Adjusted for Age, Sex, and Race

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

24. 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 Youth 0 200 400 600 800 Annual Deaths per 100 000 person-years Total AAWHTotal AAWH Male Female 83.5 Crude U.S. Mortality Ages 15-24 * 806 184 847 887 435 228 60 807 283 36 233 42 315 22 501 18 195 83 Source: Teplin L, McClelland G, Abram K, & Mileusnic D. (2005) Pediatrics

25. Binswanger IA et al. N Engl J Med 2007;356:157-165 Causes of Death among Former Inmates Adjusted for Age, Sex, and Race

26. In a Given Year... 33% of those with HCV, will pass through a correctional facility. 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

27. Binswanger IA et al. N Engl J Med 2007;356:157-165 Causes of Death among Former Inmates

28. Severe Mental Disorders Among the General Population & Jail Admissions Source: National GAINS Center

29. Prevalence of Psychiatric Disorders: Northwestern Juvenile Project (N=1,829) % FemalesMales

30. Binswanger IA et al. N Engl J Med 2007;356:157-165 Causes of Death among Former Inmates

31. 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)

32. In a Given Year... 21% of all people in the US with HIV, -- will pass through a correctional facility. 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

33. AIDS-Related Mortality Achieves Parity in Prisons and the General Population AIDS-Related Deaths Relative to All Deaths (%) 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)

34. HIV-Infected Recidivists and HIV-Related Outcomes Change (log 10 copies/mL) -1.04 HIV RNA Change +1.14 Incarcerated Prisoners (n=292) Re-Incarcerated Prisoners (n=292) CD4 Change (cells/mm 3 ) +67 CD4 Change Incarcerated Prisoners (n=292) Re-Incarcerated Prisoners (n=292) -80 P<0.0001 Springer SA, et al. Clin Infect Dis. 2004;38:1754-1760.

35. Prevalence of Health Screening & Services in Adult CJ % Facilities Providing Service Source: CJ-DATS National Criminal Justice Treatment Practices Survey, NIDA

36. Baillargeon J et al., JAMA 301(8):848-857, 2009. Percentage of Inmates Who Filled an ART Prescription Within 60 Days of Release Percent 5.4% 17.7% 30% 0 20 40 60 80 100 10 days30 days60 days Only a small percentage of Texas prison inmates Receiving ART while incarcerated filled an initial ART prescription within 60 days of their release Had prescription filled within:

37. In a Given Year... 40% of those with TB -- will pass through a correctional facility. 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

39. 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

40. 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

41. 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

42. 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?

43. Assistance for Physicians Related to Drug Use

44. NIDA Screening and Treatment Resources for Medical and Health Professionals

45. 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. ?

46. 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:

47. 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: o Leads to next appropriate question o Determines substance involvement score (i.e., risk level not a diagnosis) Links to additional resources 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: o Leads to next appropriate question o Determines substance involvement score (i.e., risk level not a diagnosis) Links to additional resources

48. Download PDF Version Introduction Before You Begin Screening and brief intervention for drug use Step 1: Ask about drug use Step 2: Screen for substance use disorders Step 3: Discuss results & conduct brief intervention Step 4: Offer continuing care at follow-up visits Appendices Support Materials Frequently Asked Questions Glossary of Terms

49. 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)

50. High Risk Use Moderate Risk Lower Risk Choose intervention based on patient’s risk level Score of 27 or higher Score of 4-26 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 of 0-3 STEP 3

51. 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

52. Quick Reference Guide

53. 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

54. 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

55. NIDA NATIONAL INSTITUTE ON DRUG ABUSE www.drugabuse.gov www.drugabuse.gov/blendi ng www.nnp.drugabuse.gov