Addressing Public Health & Drug Abuse Treatment within the Criminal Justice System

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 6th 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

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 prisoners1 • 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. Overview of the Criminal Justice System ENTRY/PRETRIAL (Arrest) PROSECUTION (Court, Pre-Trial Release, Jail) ADJUDICATION (Trial) SENTENCING (Fines, Community Supervision, Incarceration) CORRECTIONS (Probation, Jail, Prison) COMMUNITY REENTRY (Probation, Parole, Release) Key Players Crime victim Police FBI Crime victim Police FBI Judge Prosecutor Defense Attorney Defendant Jury Judge Judge Jury Probation Officers Correctional Personnel Judge Probation/ Parole Officers Family Community-based providers Intervention Opportunities Educate Drug treatment Aftercare Housing Employment Mental Health Half-way House TASC Screening/ Referral Diversion Programs Drug Courts Community Treatment TASC Drug Court Terms of Incarceration Release Conditions Drug Treatment

9. 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 Close supervision Community-based treatment Blends functions of criminal justice and treatment systems to optimize outcomes Consequences for noncompliance are certain and immediate Opportunity to avoid incarceration or criminal record

12. Current Rates of Drug Use Disorders and Treatmentin Criminal Justice

13. Estimated Size of the Correctional Population: 8+ M Adults, 650K Juveniles 424,046 adultsreceive tx (7.6%) 5,613,739 adults need TX(4.5M males, 1.1M females) 253,034juveniles need TX(198,000 males, 54,000 females) 54,496juveniles GET tx (21.5%) *Bureau of Justice Statistics, 2005 adjusted with estimates from Taxman, et al, 2007.

14. Many prison inmates have a drug use disorder… but few receive treatment Souces: BJS: Mumola & Karberg (2006, revised 1/2007). Drug use and dependence, state and federal prisoners, 2004.

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

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

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

18. Methadone Treatment Pre- and Post-Prison Release: Results 12-mo Post Release (N=204) Treatment Drugs Crime Experimental Conditions:A: Methadone referral at releaseB: Methadone treatment on releaseC: Methadone treatment pre- and post-release -- sig. diff from referral only; -- sig. diff from tx on release 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.

19. 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 • 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 Nun et al. (2009). DAD, 83-88.

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

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

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

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

26. HCV Infection in Criminal Justice 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.

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

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

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

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

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. HIV Infection in the Criminal Justice System 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.

33. AIDS-Related Mortality Achieves Parity in Prisons and the General Population State inmates General population 34.2% HAART (1996) AIDS-Related Deaths Relative to All Deaths (%) 10.2% 3.4% 3.5% 2008 1995 Maruschak LM. Bur Justice Stat Bull. December 2009. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/hivp08.pdf.

34. HIV-Infected Recidivistsand HIV-Related Outcomes HIV RNA Change CD4 Change +1.14 +67 P<0.0001 P<0.0001 Change (log10 copies/mL) CD4 Change (cells/mm3) -1.04 -80 Incarcerated Prisoners (n=292) Re-Incarcerated Prisoners (n=292) Incarcerated Prisoners (n=292) Re-Incarcerated Prisoners (n=292) 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. Percentage of Inmates Who Filled an ART Prescription Within 60 Days of Release 100 Only a small percentage of Texas prison inmates Receiving ART while incarcerated filled an initial ART prescription within 60 days of their release 80 60 Percent 30% 40 17.7% 20 5.4% 0 Had prescription filled within: 10days 30 days 60 days Baillargeon J et al., JAMA 301(8):848-857, 2009.

37. TB Infection in the Criminal Justice 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.

39. Principles of Drug Abuse Treatment For Criminal Justice Populations Drug addiction is a brain disease that affects behavior Recovery from drug addiction requireseffective treatment, followed by management of the problem over time Treatment must last long enough to produce stable behavioral changes Assessment is the first step in treatment

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

41. Principles of Drug Abuse Treatment For Criminal Justice Populations Continuity of care is essential for drug abusers re-entering the community A balance of rewards and sanctions encourages prosocial behavior & treatment participation 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)

42. What Can Physicians Do? • 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

43. Assistance for Physicians Related to Drug Use

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

45. 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. In Specialty Treatment – 2,100,000 ? Abuse/Dependent – 23,000,000 “Harmful Users” – ??,000,000

46. Resource Guide: • 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

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

48. 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 Download PDF Version

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. STEP 3 Choose intervention based on patient’s risk level High Risk Use Brief Intervention AND Refer to Specialty Care. Score of 27 or higher Score of 4-26 Moderate Risk Brief Intervention. Lower Risk Score of 0-3 Encourage abstinence. Use clinical judgment regarding level of risk. Consider follow up plans (Step 4)