Judges’ Roles in Implementing the Science of Addiction Treatment

1. Judges’ Roles in Implementing the Science of Addiction Treatment Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation slides for the Maryland Judicial Institutes “Sentencing Workshop” , Annapolis, MD, April 19, 2012. This presentation was supported by funds from Maryland Judicial Institute and Bureau of Justice Assistance Edward Byrne Grant. It also uses data from NIDA grants no. R01 DA15523, R37-DA11323, and CSAT contract no. 270-07-0191. It is available electronically at http://www.gaincc.org/presentations. The opinions are those of the authors do not reflect official positions of the government. Please address comments or questions to the author at mdennis@chestnut.org or 309-451-7801.

2. Part 1. Chronic Nature of Addiction and the Correlates of Recovery

3. Science Learning Objectives • Understand that Addiction is a Chronic Disease / Condition • Identify the major predictors of positive treatment outcomes • Understand that Recovery is broader than just abstinence and takes time

4. Brain Activity on PET Scan After Using Cocaine Rapid rise in brain activity after taking cocaine Actually ends up lower than they started Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377.

5. Prolonged Substance Use Injures The Brain: Healing Takes Time Normal levels of brain activity in PET scans show up in yellow to red Normal Reduced brain activity after regular use can be seen even after 10 days of abstinence 10 days of abstinence After 100 days of abstinence, we can see brain activity “starting” to recover 100 days of abstinence Source: Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.

6. pain Adolescent Brain Development Occurs from the Inside to Out and from Back to Front Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana. 6

7. Over 90% of use and problems start between the ages of 12-20 It takes decades before most recover or die Alcohol and Other Drug Abuse, Dependence and Problem Use Peaks at Age 20 100 People with drug dependence die an average of 22.5 years sooner than those without a diagnosis 90 Percentage 80 70 60 Severity Category 50 Other drug or heavy alcohol use in the past year 40 30 Alcohol or Drug Use (AOD) Abuse or Dependence in the past year 20 10 0 65+ 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Age Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000

8. Overlap with Crime and Civil Issues • Committing property crime, drug related crimes, gang related crimes, prostitution, and gambling to trade or get the money for alcohol or other drugs • Committing more impulsive and/or violent acts while under the influence of alcohol and other drugs • Crime levels peak between ages of 15-20 (periods or increased stimulation and low impulse control in the brain) • Adolescent crime is still the main predictor of adult crime • Parent substance use is intertwined with child maltreatment and neglect – which in turn is associated with more use, mental health problems and perpetration of violence on others

9. Yet Recovery is likely and better than average compared with other Mental Health Diagnoses SUD Remission Rates are BETTER than many other DSM Diagnoses 89% 89% 83% 77% 66% 58% 56% 48% 50% 40% 46% 39% 45% 31% 25% 20% 10% 10% 8% 8% 7% 18% 15% 12% 11% 10% 10% 8% 9% 7% 4% 4% 3% Past Year Recovery (no past year symptoms) Recovery Rate (% Recovery / % Dependent) 100% 90% 80% 70% 60% Median of 8 to 9 years in recovery 50% 40% 30% 15% 20% 13% 8% 10% 0% Drug Mood : Alcohol Anxiety : Conduct Any AOD Intermittent Explosive Defiant Oppositional Posttraumatic Stress Externalizing Any Attention Deficit Any Internalizing Lifetime Diagnosis 9 Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication

10. People Entering Publicly Funded Treatment Generally Use For Decades It takes 27 years before half reach 1 or more years of abstinence or die 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent still using Years from first use to 1+ years of abstinence 0 5 10 15 20 25 30 Source: Dennis et al., 2005

11. The Younger They Start, The Longer They Use 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent still using Age of First Use Years from first use to 1+ years of abstinence under 15* 60% longer 15-20 21+ 0 5 10 15 20 25 30 * p<.05 Source: Dennis et al., 2005

12. The Sooner They Get To Treatment, The Quicker They Get To Abstinence Years to first Treatment Admission* 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent still using 20 or more years Years from first use to 1+ years of abstinence 57% quicker 10 to 19 years 0 to 9 years 0 5 10 15 20 25 30 * p<.05 Source: Dennis et al., 2005

13. After Initial Treatment… • Relapse is common, particularly for those who: • Are Younger • Have already been to treatment multiple times • Have more mental health issues or pain • It takes an average of 3 to 4 treatment admissions over 9 years before half reach a year of abstinence • Yet over 2/3rds do eventually abstain • Treatment predicts who starts abstinence • Self help engagement predicts who stays abstinent Source: Dennis et al., 2005, Scott et al 2005

14. 86% 66% 36% The Likelihood of Sustaining Abstinence Another Year Grows Over Time After 4 years of abstinence, about 86% will make it another year After 1 to 3 years of abstinence, 2/3rds will make it another year 100% . Only a third of people with 1 to 12 months of abstinence will sustain it another year 90% 80% 70% 60% % Sustaining Abstinence Another Year 50% 40% 30% 20% 10% 0% 1 to 12 months 1 to 3 years 4 to 7 years But even after 7 years of abstinence, about 14% relapse each year Duration of Abstinence* * p<.05 Source: Dennis, Foss & Scott (2007) 14

15. What does recovery look like on average? Duration of Abstinence 1-12 Months 1-3 Years 4-7 Years • More clean and sober friends • Less illegal activity and • incarceration • Less homelessness, violence and • victimization • Less use by others at home, work, • and by social peers • Virtual elimination of illegal activity and illegal • income • Better housing and living situations • Increasing employment and income • More social and spiritual support • Better mental health • Housing and living situations continue to improve • Dramatic rise in employment and income • Dramatic drop in people living below the poverty line Source: Dennis, Foss & Scott (2007) 15

16. The Risk of Death goes down with years of sustained abstinence Sustained Abstinence Also ReducesThe Risk of Death* Users/Early Abstainers more likely to die in the next 12 months It takes 4 or more years of abstinence for risk to get down to community levels Deaths in the next 12 months - (Matched on Gender, Race & Age) * p<.05 Source: Scott, Dennis, Laudet, Funk & Simeone (in press)

17. Other factors related to death rates • Death is more likely for those who • Are older • Are engaged in illegal activity • Have chronic health conditions • Spend a lot of time in and out of hospitals • Spend a lot of time in and out of substance abuse treatment • Death is less common for those who • Have a greater percent of time abstinent • Have longer periods of continuous abstinence • Get back to treatment sooner after relapse Source: Scott, Dennis, Laudet, Funk & Simeone (2011)

18. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery (Pathway Adults) P not the same in both directions 6% 7% 25% 30% 8% 28% 29% 4% 7% 44% 31% 13% Treatment is the most likely path to recovery Over half change status annually Incarcerated (37% stable) In the In Recovery Community (58% stable) Using (53% stable) In Treatment (21% stable) Source: Scott, Dennis, & Foss (2005)

19. Predictors of Change Also Vary by Direction • Probability of Transitioning from Using to Abstinence • mental distress (0.88) + older at first use (1.12) • ASI legal composite (0.84) + homelessness (1.27) • + # of sober friend (1.23) • + per 8 weeks in treatment (1.14) In the 28% In Recovery Community (58% stable) Using 29% (53% stable) Probability of Sustaining Abstinence - times in treatment (0.83) + Female (1.72) - homelessness (0.61) + ASI legal composite (1.19) - number of arrests (0.89) + # of sober friend (1.22) + per 77 self help sessions (1.82) Source: Scott, Dennis, & Foss (2005)

20. Summary of Key Points • Addiction is a brain disorder with the highest risk being during the period of adolescent to young adult brain development • Addiction is chronic in the sense that it often lasts for years, the risk of relapse is high, and multiple interventions are likely to be needed • Yet over two thirds of the people with addiction do achieve recovery • Treatment increases the likelihood of transitioning from use to recovery • Self help, peers and recovery environment help predict who stays there • Recovery is broader than just abstinence

21. Part 2. The Need and Value of Standardized Screening

22. Science Learning Objectives • To show the large gap between need for and receipt of substance abuse treatment • To demonstrate the feasibility, validity and usefulness of low cost screening to identify substance use and co-occurring mental health, monitor placement, and predict the risk of recidivism

23. While Substance Use Disorders are Common, Treatment Participation Rates Are Low Few Get Treatment: 1 in 20 adolescents, 1 in 18 young adults, 1 in 11 adults Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Much of the private funding is limited to 30 days or less and authorized day by day or week by week Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]

24. Potential AOD Screening & Intervention Sites:Adolescents (age 12-17) Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]

25. Potential AOD Screening & Intervention Sites:Adults (age 18+) Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]

26. Adolescent Rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in WA State Problems could be easily identified Virtually all Sub. Use co-occurring in school Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

27. Adult rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in WA State Lower than expected rates of SA in mental health & children’s admin Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

28. Adolescent Client Validation of High Co-Occurring from GAIN Short Screener vs. Clinical Records by Setting in WA State Two-page measure closely approximated all found in the clinical record after the next 2 years Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

29. Higher rate in clinical record in mental health and children’s administration (But that was past on “any use” vs. “abuse/dependence” and 2 years vs. past year) Adult Client Validation of High Co-Occurring from GAIN Short Screener vs. Clinical Records by Setting in WA State Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

30. Where in the System are the Adolescents with Mental Health, Substance Abuse and Co-occurring? School Assistance Programs (SAP) largest part of BH/MH system; 2nd largest of SA & Co-occurring systems Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

31. Where in the System are the Adults with Mental Health, Substance Abuse and Co-occurring? More Mental Health than Substance Abuse Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

32. Total Disorder Screener Severity by Level of Care: Adolescents About 30% of OP are in the high severity range more typical of residential About 41% of Resid are below 10 (more likely typical OP Outpatient Median=6.0 Residential Median= 10.5 Few missed (1/2-3%) Source: SAPISP 2009 Data and Dennis et al 2006 32

33. Total Disorder Screener Severity by Level of Care: Adults Outpatient Median=4.5 (29% at 10+) Youth have to be more severe on average to access services Residential Median= 8.5 (41% below) 10% of adult OP missed) Source: SAPISP 2009 Data and Dennis et al 2006 33

34. Any Illegal Activity in the Next Twelve Months by Intake Severity on Crime/Violence and Substance Disorder Screeners Source: CSAT 2010 Summary Analytic Dataset (n=20,982)

35. Predictive Power of Simple Screener * p<.05 \a Odds of row (%/(1-%) over low/low odds across all groups Source: CSAT 2010 Summary Analytic Dataset (n=20,932)

36. Summary of Key Points • There is a large gap between those getting treatment and those in need, ranging from 1-20 adolescents to 1 in 11 adults • The people in need are coming into contact with a range of systems that could serve as screening sites where problems could be identified and addressed before people end up in the courts • Simple Screening tools are feasible, valid and useful to identify substance use disorders, co-occurring behavioral health, monitor placement and predict the risk of recidivism

37. Part 3. What works in Treatment?

38. Science Learning Objectives • Define what we mean by treatment • Hand out NIDA handbook on the Principals of Addiction Treatment in the Justice System • Identify the key predictors of effectiveness • Highlight some of the serious limitations and problems of the current public treatment

39. What is Treatment? • Motivational Interviewing and other protocols to help them understand how their problems are related to their substance use and that they are solvable • Residential, IOP and other types of structured environments to reduce short term risk of relapse • Detoxification and medication to reduce pain/risk of withdrawal and relapse, including tobacco cessation • Evaluation of antecedents and consequences of use • Community Reinforcement Approaches (CRA) • Relapse Prevention Planning • Cognitive Behavioral Therapy (CBT) • Proactive urine monitoring • Motivational Incentives / Contingency Management • Access to communities of recovery for long term support, including 12-step, recovery coaches, recovery schools, recovery housing, workplace programs • Continuing care, phases for multiple admission

40. Other Specific Services that are Screened for and Needed by People in Treatment: • Trauma, suicide ideation, and para-suicidal behavior • Child maltreatment and domestic violence interventions (not just reporting protocols) • Psychiatric services related to depression, anxiety, ADHD/Impulse control, conduct disorder/ ASPD/ BPD, Gambling • Anger Management • HIV Intervention to reduce high risk pattern of behavior (sexual, violence, & needle use) • Tobacco cessation • Family, school and work problems • Case management and work across multiple systems of care and time

41. Number of Problems by Level of Care (Triage) Clients entering Short Term Residential (usually dual diagnosis) have 5.5 times higher odds of having 5+ major problems* * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824)

42. No. of Problems* by Severity of Victimization Those with high lifetime levels of victimization have 13 times higher odds of having 5+ major problems* Severity of Victimization * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824)

43. Components of Comprehensive Drug Addiction Treatment Recommended by NIDA www.drugabuse.gov

44. Two Key Resources Available from NIDA (http://www.drugabuse.gov)

45. Major Predictors of Bigger Effects • A strong intervention protocol based on prior evidence • Quality assurance to ensure protocol adherence and project implementation • Proactive case supervision of individual • Triage to focus on the highest severity subgroup

46. Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice Studies in Lipsey Meta Analysis The more features, the lower the recidivism Average Practice Source: Adapted from Lipsey, 1997, 2005

47. Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing Juvenile Recidivism (29% vs. 40%) • Aggression Replacement Training • Reasoning & Rehabilitation • Moral Reconation Therapy • Thinking for a Change • Interpersonal Social Problem Solving • MET/CBT combinations and Other manualized CBT • Multisystemic Therapy (MST) • Functional Family Therapy (FFT) • Multidimensional Family Therapy (MDFT) • Adolescent Community Reinforcement Approach (ACRA) • Assertive Continuing Care NOTE: There is generally little or no differences in mean effect size between these brand names Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004

48. On-site Urine Feedback Protocol associated with Lower False Negatives (19 v 3%) Impact of Simple On-site Urine Protocol with Feedback On False Negative Urines Source: Scott & Dennis (in press)

49. Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate) The best is to have a strong program implemented well The effect of a well implemented weak program is as big as a strong program implemented poorly Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005

50. Less than half stay the 90 or more days Recommended by Research Source: Office of Applied Studies 2007Discharge – Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm