Addiction, the Brain, and Evidence-Based Treatment

John Laub: Good morning. I would like to begin this seminar today. I want to welcome you all to "The Research for the Real World: NIJ's Installment of the Translational Criminology Seminar Series." My name is John Laub and I'm the Director of the National Institute of Justice. I want to thank you all for being here. As you know, today's presentation is entitled "Addiction, The Brain, and Evidence Based Treatment" and will feature Dr. Redonna Chandler from the National Institute on Drug Abuse. I have to make a confession: I've been fascinated with the idea of addiction from a very young age.

I remember seeing classic movies in my youth, probably in my childhood, which is a little scary. Otto Preminger's "The Man with the Golden Arm," Frank Sinatra, the heroin addict trying to deal with his girlfriend and family. His girlfriend was Kim Novak; that's another reason why I remember the film. "The Lost Weekend," Ray Milland, 1945, directed by Billy Wilder, a college professor going on a four-day binge of drunkenness. And I remember a classic line in there: "I don't drink. I drink to get drunk." So this issue I think is really fascinating on so many levels and particularly that there's now a science coming to understand addiction apart from movies, literature, poetry, what have you, is very exciting.

In her presentation, Dr. Chandler will discuss why punishment alone is an ineffective response to the problem of drug abuse in the criminal justice system. She will also highlight the neurobiology of addiction and will discuss research efforts on drug abuse treatment that are currently underway at NIDA. In keeping with the spirit of translational criminology, which in short seeks to bridge the gap between research, policy and practice, Dr. Chandler will also highlight evidence-based principles of addiction treatment based on an integrated public health/public safety strategy.

My hope is that you'll leave this seminar with information that you can use in your own work, the reason we call this research for the real world. Now it is my pleasure to introduce Dr. Redonna Chandler. Dr. Chandler is currently the Chief of Services, Research Branch at the National Institute on Drug Abuse, a component of the National Institutes of Health. She provides scientific leadership on the research intended to improve the quality of drug abuse treatment and recovery services with a special emphasis on the implementation of evidence-based interventions. She's also an instructor for the National Judicial College, providing training to presiding judges on addiction research and treatment. Prior to joining NIDA she worked for the Bureau of Prisons, implementing and evaluating substance abuse treatment programs for federally sentenced offenders. Dr. Chandler was trained as a psychologist, received her doctoral degree from the University of Kentucky, and with great pleasure, I will ask you to join me in welcoming Dr. Chandler to this talk.

[Applause]

Redonna Chandler: Thank you for that wonderful introduction. It's a pleasure to be here with you all this morning. I want to spend a little bit of time talking with you this morning about a small selection of findings from the research that we have funded at the National Institute on Drug Abuse for the last two and a half decades or more. I could have picked a lot of different things to talk about, but I tried to select those findings that I thought might have the greatest applicability to the work that you are involved with, both a little bit about the neurobiology of addiction, but also more specifically about what we've learned through our research in working particularly with offender populations, and more with an eye toward application as opposed to more theoretical, research, priority kinds of discussions that we sometimes give.

The goals of this presentation are first of all to give you a little bit of sense about the public health problems that we see within the criminal justice system and why the National Institute on Drug Abuse, which is a part of the NIH, would be interested in criminal justice to begin with, because I'm often asked that question by my colleagues at NIH; a bit about the neurobiology of addiction, certainly not comprehensive and not nearly as thorough as our Institute Director Dr. Volkow, who is one of the premiere neuroscientists in the world, could give, but I'll try to give you a primer on that. Then I'm going to move into my area of science and my passion, which is evidence-based treatment, and then just briefly talk about a couple of research initiatives that you might want to follow over the next few months and couple of years with findings that may be applicable to your work.

We'll start out by talking a little bit about NIDA. As you've heard, NIDA is part of the National Institutes on Health. We fund basic and applied research to look at the area of addiction, both in preventing and treating addiction as well as the consequences of addiction and addictive disorders, particularly with a focus on HIV/AIDS and fetal exposure.

This shows you a little bit about the breadth of our portfolio of work that we currently fund that has application to the criminal justice system. Everything from basic science, looking at animal models of onset and course of aggression, basic neuroscience for social moral processing and psychopathy, treatment development and service delivery, prevention, epidemiology, and then finally even within our medications development portfolio, an eye toward implementation and trying to find ways to take evidence-based medications and apply them to a thinner population and have them delivered within criminal justice settings. So it's quite a robust and broad portfolio of research that spans literally every branch that we have within the institute.

You all probably already know that drugs of abuse and crime are linked. It's one of the reasons that NIDA is interested in the criminal justice system. Regular drug use is reported by well over half of those who are in state and federal prisons. The actual diagnosis of drug abuse and dependence is also high for incarcerated populations, and drug and alcohol use is prevalent at the time that people are involved in committing crimes; everything from violent crime to property crime and drug trafficking. The cost to this country, just the crime-related costs alone are about $105 billion. If you take into the consideration the health care costs of addiction, you go over $500 billion, so that makes this a really high priority for public health intervention.

Something that you may or may not be aware of is that in addition to illicit drug use and alcohol, smoking is also very prevalent for those who are involved in criminal justice. We fund a lot of smoking research because you can be addicted to nicotine just like you're addicted to other substances of abuse. We're very interested in smoking cessation and being able to deal with reducing smoking rates. Interestingly enough, many individuals who are incarcerated will not smoke during the period of their incarceration because that's a banned activity, but they relapse very quickly upon re-entering the community. We see that not only with smoking, but also with all addictive substances. As we know from our science and what we've learned, forced abstinence through some form of incarceration or detention is not the same thing as treatment. You can force people to abstain for a period of time, but when they re-enter the community, when they are left to make their own decisions, when they're back in cue-rich environments, which I'll talk about later on, they quickly relapse and return to their substance-abusing behaviors.

We also know that there is a heavy mental health burden within the criminal justice system. You can see here on the far left, the rates of three different types of mental health disorders in the general population, including mania, psychotic disorders and major depressive disorders. And yet for those who are incarcerated in state, federal systems, or within jails you can see that there is a many-fold increase in the presence of these different mental health conditions.

That's true for adolescents as well. This is data — the Juvenile Justice Data is taken from Linda Teplin's study; she's been longitudinally following adolescents who have been involved in the juvenile justice system for a number of years. I'm pleased to say that her project is being co-funded by NIJ and by NIH for a number of years. Then the general population data comes from a national comorbidity study that follows adolescents who are in the community to determine rates of different types of disorders. You see particularly for behavioral disorders and substance use disorders, that those who are involved in juvenile justice — males in the red, females in the blue — you see a much higher prevalence of behavioral disorders and substance use disorders as compared to the general population.

We also know that there are other very serious health conditions that are borne by those are involved in criminal justice, including cardiovascular disease and cancer. This particular slide depicts data from a study that was conducted in the state of Washington where they were looking at the risk of death within the first two weeks of release to the community of those who had been incarcerated compared to general residents within the state of Washington. What they found was that you were much more likely to die in the first two weeks you were released from prison than someone who had been within the general population. The number one leading cause was overdose from drugs, followed by homicide and liver disease, liver disease largely driven by hepatitis C that was probably contracted due to drug use. Homicide, much of it was involved in drug-related activities, so within these three particular areas, all of them are either directly related or somehow connected to and related to the problem of addiction and drug use.

We know that this is a population with very high rates of infectious diseases as well. That in any given year about 21 percent of all those in the United States with HIV, 33 percent of everyone with hepatitis C, and about 40 percent of all of those with tuberculosis will pass through some type of a correctional facility. Meaning that this is a target population for us to be able to intervene with multiple and varied public health problems.

This slide gets back a little bit to NIDA and to addressing the problem of addiction. There's a lot of people involved in the system when you look across and take into consideration everything from those who were on probation in the community to those who may be in some type of detention or incarceration setting. We know that of those who are involved in criminal justice, about 5.6 million adults would meet a diagnostic criteria that would indicate that they're actually in need of some form of drug abuse treatment. Yet only about 7.6 percent are estimated to receive any type of intervention.

For adolescents we know that over 250,000 juveniles would meet a diagnostic criteria indicating that they're in need of some form of treatment and that only about 21 and a half percent actually receive treatment. For adolescents, I often say that this is a little bit false, because I believe that every adolescent in the juvenile justice system can benefit from some type of a substance abuse intervention. Because they are such a high-risk group of individuals, their risk of using drugs and of developing some kind of an addictive disorder at some point within their lifetime is much greater than adolescents in the general community. At the very least, they could benefit from some kind of an indicated prevention intervention, if not full blown treatment.

We're aware of the fact that there are a lot of individuals who are involved in prisons, who have a substance use disorder and could benefit from treatment, and yet very few of them are actually receiving any kind of treatment services. If you look, you see that what's most commonly available, about 20 percent is some type of a drug education or a self-help program. That might be a nice adjunct to treatment, but our research has indicated that that is not sufficient enough to be considered an evidence-based treatment for an addictive disorder. When you look at what we might consider to be an evidence-based treatment, less than 10 percent are actually being able to receive those types of services.

Then how do we propose going about trying to think about addressing this particular problem? Well since I've been at NIDA for the last decade, we have been thinking about how to come together and integrate public health and public safety. Because when you look at traditionally what we've done, we've had these very siloed approaches. Public health has viewed addiction and substance abuse as a disease and has sought treatment. Public safety has often viewed the use, particularly of certain drugs, as an illegal behavior, and punishment has been the approach that's been taken. But both of these suffer from their own problems. From the public health perspective, we have high rates of attrition. It's very difficult often to get people engaged in treatment and to keep them in treatment for a long enough period of time to really deal with and address the underlying root causes of their addictive disorders. Public safety has suffered from high rates of recidivism because as I said before, we know that punishment alone is not a solution; that's not a treatment approach for an addictive disorder. You've not taught people how to manage their underlying addiction. You've not helped them to deal with some of the hallmark features that I'll be talking about later on of an addictive disorder.

So what we're trying to do is find a way to blend the functions of both, to optimize what both brings to the table, including when possible, to have treatment that's community based, so that the opportunity to avoid incarceration or to deal with a criminal record can be used as an incentive for participating in treatment. Through the criminal justice system we have the opportunity for close supervision and so that there are sanctions, and I would also say, incentives that can be used to shape behavior and that consequences for noncompliance are certain and immediate.

This is a conceptual framework that I've used at NIH and that Dr. Volkow, another colleague Bennett Fletcher and I put forward in a publication in JAMA a few years ago, where we were trying to help folks who were in the public health sector and treatment providers to begin thinking about when and where and how you might intervene within criminal justice. There's not always an appreciation for the complexity of the criminal justice system. There's not always an understanding of all of the different types of organizations and individuals and unique roles that each play. We tried to break this down in a way that could help them to think about intervention opportunities as well as research. It just starts here when someone would enter the system on arrest and then moves through to prosecution, adjudication, sentencing, corrections, and community re-entry. Now we realize that this is not a linear process, that some people cycle in and out, that some people may never progress from one point to another, but it is a way for me to communicate with my public health colleagues and help them understand that there are key participants or stakeholders that are involved with all of these different points along this continuum and that they have unique roles, and that they present one of two things. They're either your collaborators if you're trying to integrate treatment or you're trying to conduct research, or they're an actual target, they're the individuals whose behaviors you're trying to shape and change, they're the place in which you're trying to implement or test some type of an intervention and conduct a research study. Then there's lots of different unique intervention opportunities. What we try to do is think about what's happening within the system at that particular time and match the intervention opportunity onto a knowledge of the reality of what's going on within the system. So when somebody's arrested and they're first entering into the system it's a great time for a really quick screening, which is just simply a way to get an indicator of whether or not the individual has a substance abuse problem; [Inaudible] can take as few as a couple of minutes in time. Then if you have any reason to believe that there's a signal, then you would refer them on perhaps for more in-depth counseling or in-depth assessment.

Likewise, when someone's in a correctional phase and they're going to be detained for a long period of time, that's when you might be able to offer them some kind of an intensive, residential treatment, especially if it's determined that they have a serious addictive disorder, and that is a part of their criminal activity. Then there's lots of work that needs to be done around community re-entry, including even if someone has participated in drug treatment while they're incarcerated. We know from our research that it's very important to continue and have ongoing care within the community, and there's lots of other needs that individuals have that support recovery, that support abstinence from drug use, including stable housing, employment, dealing with mental health issues.

Now I'm going to talk a little bit about what is addiction and move into a discussion about some of what we've learned with regard to the neurobiology of addictive disorders. What is addiction? Well, addiction is first and foremost a brain disease. Our science is teaching us more and more about the impact that drugs of abuse have on the brain, both how they change the neurobiology, and also how that is manifested in behaviors that some of you all see with the individuals that you work with. One of the hallmark behavioral features of addictive disorders is the compulsive and continued use of drugs in spite of negative consequences. And that addiction is often chronic with a very high potential for relapse.

What do I mean when I say addiction is a brain disease? Well, at its very simplest form, when you think about a disease of the body, you're looking at tissue and tissue that's been compromised or how tissue functions. At the top of this slide you'll see images of a human heart, and to the left is a very healthy heart, all of this bright orange and red denotes the metabolism of glucose within a healthy heart with no damage. To the right you'll see a human heart that has sustained a blockage where tissue has been damaged. You'll note that there's much less of this bright orange and red, so this heart has been compromised. Its ability to properly metabolize glucose has been shifted and altered. In the same way we see that with substance abuse. Our new imaging techniques have allowed us to actually see what's going on inside the brains of individuals, and to compare those who have never been substance abusers to those who have been.

So this particular view is if you cut the top of my head off and you look down in on top of my head, and this is the front part of the brain and you can see here in this person who has never used cocaine a lot of the bright yellow and orange color denoting normal metabolism of glucose, but in the cocaine abuser you see far less of that. So you can see that the brain of this individual because of ongoing exposure to cocaine has actually been changed.

Then the key question we often get is, well why can't addicts just quit? It's a very complicated question with very complicated answers, but I'm going to spend a couple of minutes talking to you about some of what we've learned about how the brain is altered and changed because of repeated exposure to drugs of abuse, and how that leads to their inability to stop using, even though, and I'll repeat this again, even though they know that the stakes are really high. They know that there are lots and lots of serious consequences.

Addiction's a brain disease and it develops over repeat exposure due to the laying down and strengthening of memory connections across various circuits of the brain. I'm only going to talk about a couple of different key circuits of the brain this morning. I don't have time to go through all of them, but there are long lasting changes that occur and that are responsible for what you all may witness: distortions in thinking, difficulty with dealing with emotions and functioning and then particularly that compulsive use of drugs over time.

I'm going to start by talking a little bit about the reward circuitry. The reward circuitry in the brain is very important in motivating us to engage in behaviors that historically have been very important for our survival as a species. This reward circuitry and these motivational pathways actually get hijacked by drugs of abuse. I'll present you with a little bit of information about how that occurs and what we've learned about that.

This is an image of the brain, this is if you slice my head in half and you're looking in this particular direction. What you see here are all of the different circuits that we think have a key role in the development of addictive disorders, but I'm going to focus right now just on the motivational pathways. Today I'm only going to talk about the motivational pathways and a little bit about memory and learning. I'm not going to hit on any of these other parts of the circuitry because I don't have time to do that. But let's focus on the pathways that have to do with motivation. Here's another slice that's a little bit cleaner and a little bit easier to see. These are three key parts of the brain that are connected by neurocircuitry. This is what we call the reward pathway or the pleasure pathways in the brain, and it is where we experience intense feelings of pleasure, self-satisfaction and relaxation. That occurs because of a neurotransmitter called dopamine. Dopamine has a very important role within the human brain. Dopamine is involved in the coordination of movement, it's involved in motivation and motivating us to engage in certain behaviors, it's involved in our feeling of reward and well-being, but it is also involved in the development of addictive disorders.

Dopamine's the brain's primary pleasure chemical. As I said earlier, dopamine is the neurotransmitter that's responsible for that feeling of pleasure, that feeling of well-being, it's also been implicated in the high that you hear drug addicts talk about, and in the craving that accompanies the withdrawal from the use of drugs, and it plays a really important role in attention. The intense feelings of pleasure that we experience because we participate in activities, some of those have been very important to our survival as a species, things such as eating, things such as participating in sexual activity, things such as drinking. We needed to do those things, we needed to find a way for those to be really important activities, so that we would continue participating in them, so that we would be motivated, so that we would pay attention to those things, so that we would solve problems in order to engage in those behaviors, and so that we could even anticipate how great we would feel if we engaged in those behaviors, so we would do them again, and again, and again.

Natural reinforcers exist in our environment. There are activities that we participate as human beings that are naturally rewarding and that lead to the release of dopamine. You can see in these slides, these are actually slides of data that were taken from animal studies where animals were presented with cues for food and then cues that related to sex. You can see here an increase in the release of dopamine in this particular part of the brain associated with the anticipation of the satisfaction of food and the anticipation of the satisfaction or the reward of engaging in sexual activity.

But all drugs of abuse also work on the same neurocircuitry and also lead to an increase in the release of dopamine. What's really important about drugs of abuse though is that they are much more efficient in their ability to release dopamine into the brain than our natural reinforcers. You will see that there are spikes of dopamine release in the case of methamphetamine that are much higher than what you see from natural reinforcers. Not only are they more efficient in the release of dopamine, sometimes leading to a greater release of dopamine, they also often affect the brain in such a way that dopamine is available within those parts of the brain for a longer period of time. Our brains are very efficient. Their natural reinforcers, we release just enough dopamine to experience the pleasure, but then the brain will take that dopamine up again and reuse it again. Drugs of abuse blunt the ability to do that and actually mean that dopamine is available to continue that pleasurable feeling for a longer period of time. All of them do this. We could have had alcohol up here, we could have had any of the different addictive substances.

What you see is that over time this exposure to dopamine actually changes the structure of the brain. This is a control subject here on the left and you can see that there are normal levels of dopamine receptors that's denoted by all of the orange and red and bright coloring, but for those who are addicted to heroin, alcohol, methamphetamine and cocaine, there are lower numbers of D2 receptors. The brains of these individuals have been changed over time because of their exposure to these particular substances. What does that mean to have a lower density of D2 receptors? Well, if you have a lower density of D2 receptors, remember I talked about the fact that naturally occurring events are also rewarding and that they're also pleasurable? But if you have fewer D2 receptors, the value of that reinforcement, the ability of those natural activities to reinforce the brain is changed and compromised and it's lessened. It's part of the reason why addicts report the need to use more and more drugs to experience a high, but it's also why as you work with individuals, some of the things that would be reinforcing to you, that you think should mean a lot to that individual, may not mean that much to them because those natural reinforcers have been usurped, or as we say, hijacked by drugs of abuse.

The last part of neurocircuitry that I'm going to talk about has to do with memory; it's all about people, places and things. This is the part of the brain, the amygdala and the hippocampus, that play a key role in memory and learning. Learning and memory is a part of why addicts relapse and a part of why they will continue to use over periods of time.

This particular study was conducted by our institute director Dr. Volkow a number of years ago. She was seeking to determine whether or not you could induce craving from simply showing people images of cocaine use. She showed videos to people who were in treatment for cocaine addiction. First were some nature scenes, just pictures of trees and grasses and rivers and very calming. Here's a scan of their brains when they were looking at these nature scenes, and you can see here that there's no significant release of dopamine, they weren't reporting craving, they weren't really thinking about drug use. But then she showed them a series of videos that had images, drug paraphernalia, even people who were using drugs, and what happened? The dopamine systems of these brains lit up. They didn't have to use the drug; all they had to do were to see images that reminded them that cued them up, that led them to begin to expect how rewarding it would be to use cocaine. You could see changes that were taking place within their brain. Also their self-reported craving went up as a result of seeing these different images.

This is another study that built on that work. What they were doing here was comparing control subjects to those who were addicted to cocaine and they were looking both at natural reinforcing activities as well as memories and images that were associated with cocaine use. This is just looking at stimulation of three different parts of the brain. What you can see is that for control subjects, there was no indication that there was any stimulation of the brain that was recurring as a result of showing them images associated with cocaine use. But for the cocaine addicts you can see that there's high levels of stimulation that's occurring in these three different parts of the brain when they saw images associated with cocaine use.

What happens with the naturally reinforcing activity? Well, then they went on to show erotic videos to the control subjects and to the addicts because what's more motivating to human beings and more stimulating to our brains than sexual activity? It's highly, highly stimulating. What they found that were for the control subjects in all three parts of their brain there was a high level of stimulation that was occurring when they saw the erotic videos. But what about the cocaine addicts? No, not so much. They were far more stimulated by the cocaine images than they were by the erotic videos, than they were by that naturally reinforcing event. That's what leads us to talk about the fact that the brain actually is hijacked by addiction through the process of addiction.

Then this is my final brain slide. This is looking at trying to understand craving and trying to understand how people in environments that are rich with cues that are associated with their drug use, the impact that has. This investigator determined that she put people into an imaging machine and she flashed images in front of them of lots of different things, including nature scenes, but also of things that were intended to elicit cocaine response or cocaine cues. But she did this at such a rapid pace that it wasn't even registering consciously. They weren't able to describe what these images looked like; they weren't able to even report what they had seen. But she found that for the cocaine addicts, key parts of their brain that is associated with craving lit up, even when they were unconsciously experiencing these cues. Now the importance that has for everyone who's working with individuals with addictive disorders is that they may not have any idea why they're craving drugs. They may not have any idea what within their particular environment is going to be a cue that is going to lead them to be vulnerable to relapse. Often they really don't know. They may not be able to tell you why they can't stop using, they're not trying to fake you out, they're not always trying to lie or be dishonest. Sometimes they really and truly don't understand and aren't sure of themselves.

There's lots of different neurocircuits that are involved in drug abuse and addiction and all of them need to be attended to when we think about treatment. Development of effective treatments needs to take into consideration biology, behavior and the social context. We've done a lot of work to try to develop medications that are effective in dealing with drug abuse, everything from interfering with drugs' rewarding effects, to helping to strengthen executive functioning and inhibitory control, strengthening prefrontal and striatal communication, interfering with memories, teaching new memories and counterbalancing stress. We've also done a lot and developed several behavioral therapies that can effectively be used in these different areas, and to target all of these different key issues, including contingency management, which is providing reinforcement for someone doing activities that are related to abstaining from drug use, whether it's reinforcing them and providing them with some kind of a reward for not using drugs, or whether it's providing reinforcement for some type of improvement or participation in treatment or achievement of a goal that's related to abstinence, cognitive behavioral therapy that helps improve executive functioning and decision making, and inhibitory control to enable someone to have the skills that they need to stop themselves from doing things like using drugs, motivational therapies intended to motivate them to participate in treatment, biofeedback and desensitization, and relaxation.

I'm going to talk a little bit in the remaining time that I have about a few of our key principles of treatment. A number of years ago I had the pleasure of co-authoring a publication at NIDA that you see here, "The Principles of Drug Abuse Treatment for Criminal Justice Populations." It's available on the NIDA website; you can also go there and order copies of it. We have new hard copies if you're interested in that. It was intended to take the last 25 years of science and distill them down in a user friendly way, to help people who are involved with addicts in the criminal justice system think about key overarching principles and approaches. I'm only going to pick out a few of those; I don't have time to go over all 13 of them.

I'm going to start by building on what I've already said, which is that addiction is a brain disease, but I'm going to focus more on the fact that it's a chronic brain disease that affects behavior, where relapse often occurs and is actually expected, but relapse rates are similar to other chronic medical conditions. Here you see drug dependence and relapse rates of patients compared to type I diabetics, folks with hypertension and asthma. You can see that comparatively drug dependence is not that much worse. Relapse and return to drug use is not that different than relapse for these other conditions. What often is different though is our approach to treatment. We typically think of providing treatment in an acute form where we give people one course of drug abuse treatment and then we expect them to change all of their behaviors related to drug use for the rest of their lives. But we don't do that with diabetes, we don't do that with hypertension, and we don't do that with asthma. What we've learned from a scientific perspective is that it's important to reshape the way that we think about treating addictive disorders, to think of it more as a chronic condition that is going to require some of the same types of intervention that we use for other chronic conditions, including multiple episodes of care, including multiple forms of treatment, including teaching the individual how to manage their disorder over time, and how to eventually, when they're ready, become an active part of their care and a collaborator in their treatment and care.

What does recovery look like on average? This is helpful in thinking about a chronic disease management approach. Within the first 12 months of abstinence you start to see some things happen and behaviors begin to change. You start to see less illegal activity and incarceration, less use of drugs, homelessness, violence and victimization, and people have more clean and sober friends. But you've got to really get out to one to three years of abstinence to see the virtual elimination of illegal activity and illegal income, better housing and living situations, and increased employment. When you get to four to seven years of abstinence you really see individuals begin to develop and maintain a stable lifestyle within the community. That includes very importantly a dramatic rise in employment and income, and a big increase in their mental health.

The other principle I'm going to talk about very briefly is that assessment is the first key step in treatment. One of the things that we think about and that we have spent time researching at NIDA is looking at assessment that incorporates things that are important for criminal justice goals and treatment targets as well as addiction. This is a conceptual framework that we used in one of our large multi-site research collaboratives called CJ DATS, where we wanted to really try to do a better job of integrating assessment that focused on key criminal justice targets as well as public health types of targets. Looking at assessment over time and assessment that could be used to measure both risk, including criminogenic risk, treatment needs and then progress that was being made in treatment over time.

You see instruments down here that were developed to target things like treatment readiness including motivation, anger hostility, and co-occurring disorders, early engagement in treatment including participation in the therapeutic relationship, early recovery that occurs during treatment including changes in thinking and behaving, and then discharge planning. These are different instruments that were developed. I'm going to spend a little bit of time talking about the CEST. These instruments are publically available. They're free. You can find them either at the CJ DATS website or Texas Christian University, their website, which provides a lot of information for those who are working with offender populations, has these particular instruments available as well.

The criminal justice CEST was developed to be able to measure over time key domains, including looking at treatment needs and motivation, and you can see the different subscales, psychological functioning, social functioning, treatment progress, but also an area that traditionally wasn't being measured within substance abuse treatment and that's criminal thinking, which is a really important target for intervention, for those who are working with offenders, and it's also an important consideration and something that you need to assess and be aware of when you're trying to do release planning back out into the community. This is a profile; this instrument was administered to thousands of offenders who had substance abuse problems, some that were participating in treatment, some that were not across the country. They established cut points at the lower 25^th and upper 75^th percentile for all of these subscales. The lower 25^th is in the red, the upper 75^th is in the blue. What people who were using this instrument can do is they can give this assessment battery to an individual and then they can map that person onto and see how they're doing with regard to the 25^th and 75^th percentile of individuals who took this particular assessment instrument. It helps you to determine targets for treatment.

For example, this person says that they have a high need for treatment. Well, that's a good thing. They're aware of the fact that they have a lot of problems and that they need to be participating in treatment. However, here's maybe a red flag that's not so good, they're very high in hostility. Here is something that might or might not be good, they claim they have a lot of peer support and that will of course depend on whether or not they have antisocial peers or pro-social peers from which they're gaining support. So this instrument can help individuals to determine treatment targets and then to begin to think about tailoring treatment. You can also give this assessment to individuals as they're going through and participating in drug abuse treatment or other forms of treatment to see how much progress they're making, to change treatment plans, or to tailor after care services.

Another thing that they learned when they were administering the CEST to individuals was the real importance of looking at hostility if you're involved in trying to intervene with those in criminal justice. High hostility rates were associated with higher levels of criminal thinking, lower levels of treatment readiness, lower levels of psychological functioning and lower levels of engagement in treatment. As a result of this, they started thinking about specialized interventions that might be used to target and change hostility, which leads to the second principle, that it's really important to tailor treatment. It's important to tailor treatment for those in criminal justice in two distinct areas. The first of course has to do in my case with their substance abuse treatment needs, but the second also has to do for you all with what that means for their supervision needs, because one type of treatment doesn't necessarily serve all well and one type of supervision doesn't necessarily serve everyone well.

Within CJ DATS building on the CJ CEST there were a series of brief interventions and manualized treatments that were developed to target things like understanding and reducing angry feelings, which focused also on hostility, building social networks, unlocking your thinking, opening your mind, focused on criminal thinking, better communication, getting motivated to change, and also looking at HIV and sexual health and infectious disease. There were actually 10 of these modules that were developed, if anybody's interested. Again, they're all publically available and free and you can find those on either the CJ DATS or the TCU website.

This is just one of the worksheets to kind of give you an idea of what some of the activities look like. It's intended not just to simply provide information and education on a topic like HIV, but really to get the individual engaged and involved in thinking about the different issues and topics and to begin discussing that. So in this activity, the person's being asked, suppose you learned that you were exposed to HIV, who would be the first person you'd tell? What would you do next? Who else would you talk to? Then getting them to think about what it might be like to have to live with AIDS.

When we talk about tailoring supervision we actually have funded some work. Doug Marlowe and some of his colleagues have been working in drug courts in Delaware. They've been trying to determine what do we need to do to be able to match judicial supervision to offender needs. He looked at data of those who were participating in this drug court to try to decide, who's doing the poorest? Who's having the most difficult time with staying drug-free, with staying in the drug court program, and with not participating in criminal activity; and labeling those individuals as high risk. What he found was that those with antisocial personality disorder and a long history of participation in drug treatment were having a really hard time in this particular drug court. Those folks were labeled as high risk. So then the question came about of, well, what's the appropriate level of supervision that these people need, especially when it comes to judicial status hearings, which are very resource intensive? This particular court gave everybody, regardless of risk, a judicial status hearing every four to six weeks. After some pilot work they determined that biweekly sessions were really what were important if you matched those that were high risk to the optimal level of supervision. But that for those who were low risk maybe they didn't even need to come in every four to six weeks, maybe they could just come in as needed, as their probation officer said they should come in, as their treatment provider said they should come in, or certainly if they delivered a positive drug screen.

They set up a study where they were randomly assigning people to the appropriate match level of services. If you were at high risk you were either matched biweekly or every four to six weeks. If you were at low risk you were either matched to as needed or the standard of every four to six weeks. What did they learn? They learned that for high-risk offenders, matching of supervision really matters. For those individuals who were high risk that were matched to coming in for judicial status hearings every other week they were much more likely to deliver drug-free urines than those who were not appropriately matched. For your low-risk folks, it didn't really seem to matter that much. This has led, he and of course his colleagues at the Drug Court Institute to begin thinking more and more about high-risk individuals and how to begin to appropriately match treatment.

The last thing I'm going to say and the last principle I'm going to talk about is on the role and the importance of medication-assisted treatment. I'm doing this in part because I have so many of my colleagues from the Friends Research Institute who are here and this is actually their data. We have a lot of different medications that have been developed and are effective in treating everything from smoking cessation to alcohol addiction to opiate addiction. Yet the uptake within criminal justice is very small, very few individuals are ever able to use medication as a part of their treatment when they're involved in the criminal justice system and there are certain jurisdictions that forbid it altogether.

This study was conducted in Baltimore where they had a huge heroin problem and where they were aware from their prior research that people, even those who had been incarcerated for many, many numbers of years and long periods of time were relapsing and returning to heroin use when they got back to the community within the first couple of weeks of returning to the community. They wanted to look at the role that medication could play in helping an individual who had a prior history of opiate addiction successfully transition from prison back out into the community. At that time the medication that they chose to use was methadone. They had three different treatment conditions. The first condition A was simply people were provided with information about methadone and resources where they could go to enroll in methadone treatment when they were released from prison. The second treatment condition was that they were given a little bit of what I call a more active referral. They were told about methadone, but they actually had an appointment that was set up for them at a particular methadone treatment program within the community upon their release. The third condition were individuals that were started on methadone while they were incarcerated. They were stabilized on methadone and then they followed up for their methadone treatment the next day after they were released when they went into the community. What did they learn? Well they learned that the group that initiated methadone prior to release while incarcerated was much more likely to participate in treatment, much less likely to use drugs, including both opiates and cocaine, and less likely to participate in criminal activity than either one of the other groups. Even, and this is data from 12 months post-release. So medications can play a really key and very important role in helping individuals with their addictive disorders, and especially helping those who are involved in criminal justice.

CJ DATS is a research cooperative that I mentioned earlier. We have 12 different research organizations across the country that are partnered with criminal justice organizations that are involved in conducting different scientific research projects. We are now going into our ninth year of funding. This is the website where you can find information about all the prior studies and current studies. Right now CJ DATS is focused on implementation research, which means we're not trying to develop new interventions; we're trying to actually take interventions that we've learned actually work and are effective in addressing addictive disorders and related problems. We're trying to learn more about how to intervene with the system or with criminal justice organizations so that they can use these interventions. That includes an HIV continuum of care, medication-assisted treatment and implementing screening and assessment for substance abuse.

CJ DATS is going to be continuing and we will have a funding announcement that will be coming out in the next year. CJ DATS now is going to focus on adolescents. We're going to move to the juvenile justice system. Previously our research has focused on adults within the adult system, but we feel that there is a huge need; as I indicated earlier many adolescents have substance abuse problems serious enough to warrant some type of intervention and all of them could benefit at a minimum from a prevention intervention. We've developed many effective prevention and treatment interventions for high-risk adolescents, including those who are involved in criminal justice, but we haven't figured out how to help the criminal justice system take those to scale and be able to use those, so that's the likely focus for our next iteration of science. You can see there a little bit more about the need and about treatment opportunities. And I'm going to stop. Thank you.

[Applause]

Katrina Baum: Good morning. I'm Katrina Baum from the National Institute of Justice. Thank you for your really fascinating presentation. I want to pick up on a few of the points that you raised, at the beginning of the slide and towards the end. One was that you had a depiction of the two silos where the research is and then you had a next slide where it was blending those two. Then at the end you spoke about the need for assessments in the criminal justice system, that that's an opportunity where we're really poised to intervene and to make a difference. My question to you is a little bit broader. I just want to challenge you about what your thoughts are about where the areas of synergy are for your field of addiction and our field of criminal justice in research?

Chandler: Not as interest in the criminal justice system comes from the fact that a large percentage of our patients can be found there. When we talk about trying to address the public health problem of addiction, to leave out criminal justice means that our public health impact is going to be seriously diminished, both when we talk about addressing addictive disorders, but also when we talk about addressing things like HIV. To neglect the criminal justice system means that we're not going to be able to ever reap the full public health benefit.

From a research perspective, we fund things across the full spectrum of the institute that I showed you, and we've worked actually and partnered with NIJ on funding everything from epidemiological studies that look at the drug trade to treatment studies. BJA is a co-funder of CJ DATS, for example, in implementation science. I think whereas you all of course are interested in lowering recidivism, to the extent to which you have people with addictive disorders involved in your system you've got to figure out how to be able to address their addictive disorders. We are interested in being able to find ways to treat substance abuse, wherever substance abusers are found, to the extent that they're found within criminal justice our interests naturally come together. In my area of science and what I'm most involved in has to do not only with the development of evidence-based practices, but also in trying to see how those need to be adapted and changed to go into non-treatment environments. Something like contingency management, for example, we've looked at how to take contingency management and adapt it for criminal justice settings because that's very foreign typically from the criminal justice approach. That's all based on reinforcement, not just on consequences. I think that's a place where our common interests come together and intersect.

Stefan Lobuglio: Good morning. I'm Stefan LoBuglio. I'm the Division Chief at the Pre-release center in Montgomery County and two questions for you. Often in our jurisdiction we're confronted with the choice of whether or not to keep an individual who has a drug abuse history in a therapeutic community in our jail for a minimum of eight weeks, or to have that individual participate in a very intensive community-based treatment program. I've used Steve Aos's compilation of evidence-based research to bias myself towards community-based treatment and I'd like to hear your comments on that. The second question if I may add that is, do we over-rely on AA and self-help groups and how does NIDA view these type of groups that are widespread and used in our field?

Chandler: Because of the recent [Inaudible] I'm going to answer your last question first, and I have some data that can speak to that. We have a group of investigators that are in Illinois, Mike Dennis and Chris Scott, that have actually followed people with addictive disorders who have participated in different types of treatment, and that's very broadly defined, to see what leads them to move from one point to another. So what leads someone who's in the community actively using, what leads them to move to being in the community not actively using? What you find is that some form of professional treatment is the most likely pathway that an individual will follow if they're going to move from being in the community using drugs to being in the community not using drugs.

In treatment broadly defined they also looked at 12-step and self-help programs and they found that you weren't as likely to move from using to non-using if you just were participating in some type of a 12-step program. But when you're not using and you're in the community, what's going to keep you in that box? They found that the thing that was most associated with keeping you in that box was participating in some type of 12-step or self-help program. While for people who have severe addictive disorders that might not be enough to get them sober and abstinent, they may need some type of treatment to help them really address those underlying causes of addiction. It is really important and it's a critical adjunct to help them to maintain their recovery after they're abstinent.

Your first question, therapeutic communities versus intensive community-based treatment; I don't know your two programs, so I can't tell you which one of them is the best.

Lobuglio: They're both excellent.

Chandler: What I can say is that again, treatment has to be individualized; it has to be tailored to meet the needs of the individual. Some people have to have residential treatment; that is essential to helping them to stop using drugs. Their life is in such chaos they may not even have a stable place to live, so going into some kind of a residential setting where they don't have to worry about where they're going to sleep, where they don't have to worry about any type of abuse, where they don't have to worry about if they're going to be able to eat is really critical. Other people who have a more stable living situation may be able to participate in an intensive outpatient program and be very successful. So you really have to look at, and that's where that principle about treatment matching comes into play, and know the individual person.

Jose D. Saavedra: Good morning. My name is Jose Saavedra. I work with the Juvenile Justice Monitoring Unit in Maryland, so I pretty much monitor detention centers, group homes, and shelters throughout the entire state of Maryland, me and my team, so I see a lot of symptoms of what you were talking about in your presentation. They talk about where to place kids within the timeframe so it can be the most effective at the right time, individualized, things like that. First of all, thank you. This was very eye-opening. It's something that can be used immediately, so I think I'm going to take it back to the office and say, hey I talked to a lot of other folks about it. But my question is about — or I wanted to know if you can talk about maybe the family angle, the angle of where the family might be able to come in at what point. In fact, my focus is on juvenile justice, so the criminal justice system is adults and the adults should know what to do and how to get through their process through their addiction and get treatment, things like that. But a lot of parents don't even understand that lifestyle and their kids are going through a lot of things that they really don't understand. I was wondering if you could just talk about any point on the family side of the whole issue, but more so on what we should look at as far as something that's effective, something that's proven or something that could just be helpful overall?

Chandler: Sure. Let me say three things; the first is that we are in the process of writing and finalizing what I call the baby blue book, which is — it's similar to the principles book for criminal justice, but it's focused on adolescents and youth. That should be hopefully coming out sometime during the summer. We will work with our partners at Justice as we did when the criminal justice principles book came out to make sure that they're aware of that and that they can send that out and widely advertise it. That will provide some additional information for people who are working with adolescents whether they're in juvenile justice or not. There's one principle that's going to focus specifically on juvenile justice and part of what we've learned about what works. The second thing I'll say is that on the NIDA website currently there's a new publication that speaks to families specifically and helping them to understand about treatment and about what kinds of questions they should be asking substance abuse treatment programs to try to determine whether or not their family member is getting good quality of care. Then the third thing related to the role of family is that many of the evidence-based interventions that we currently have that we've tested with high-risk kids who are involved in criminal justice are family-based interventions. They're things like functional family therapy, multi-dimensional family therapy, and multi-systemic therapy. So all of those three family-based interventions really focus on integrating family members into helping the adolescent navigate their way through treatment and then become a part of their ongoing recovery.

We haven't necessarily looked a lot at adapting those particular interventions to use them widely across the juvenile justice system; that may be a part of what we're going to do with the next iteration of CJ DATS, which is going to focus specifically on adolescents. But all of those interventions have been used with high-risk kids, not necessarily with criminal justice settings in particular, but with high-risk kids who were involved in criminal justice. You can find, there are a couple of adolescent interventions that were tested through CJ DATS and the website that I provided on the CJ DATS research cooperative, you can find that information there too.

David Marimon: Good afternoon. David Marimon, National Criminal Justice Association. My question is, does the work of Angela Hawken from Pepperdine and the success of the whole program at all change how you view individuals with substance abuse and their ability to control their addiction? Because they've had a lot of success just with swift and certain sanctions regardless of treatment or no treatment.

Chandler: I'm very familiar with Angela's work and with the HOPE model. We talk about that as a promising practice; there's a lot of underlying questions that we still have about the HOPE model. For example, we don't really know when you put someone's addiction on a continuum of severity, we don't know where on that particular continuum HOPE would be effective. As you progress upward in your severity, we don't know if just the HOPE model of sanctions alone would work. We are very interested in, and I've talked to Angela and other people about developing research applications to help us answer some of the questions that we have about HOPE. We haven't really done the study that would randomly assign and compare a HOPE model to another type of treatment matching approach yet. I do know that they have experienced success in Hawaii. I think NIJ and BJA are funding some more demonstration projects with accompanying evaluations as well. Hopefully all of that will help us to really tease apart and understand both what the mechanisms of action are that are working and who that intervention will work for and who might benefit from different types of approaches.

Carol Wild Scott: I'm Carol Scott. I'm with the Veterans Consortium Pro Bono Program and I'm also Chair of the Veterans Law Section of the Federal Bar Association. With both hats, I am much concerned with the plight of hundreds of thousands of returning vets who have underlying posttraumatic stress disorder as well as in many instances undetected early on these guys have, and women, with undetected traumatic brain injuries, which have vastly affected their behavioral, social and industrial capabilities. Consequently in many instances in an attempt to avoid or evade the symptoms and effects of posttraumatic stress disorder, they slip into self-medication and then slip into the addictive cycle and breaking that is extremely difficult. I'm interested in what partnerships you have formed with the VA and with various organizations that deal with our veterans. As a side issue, in Indian Country particularly this is a tremendous problem. I will let you tell me what you are up to and what resources I can find with you. Thank you.

Chandler: I'll try to answer your question, but I'm also going to put my colleague Geoff Laredo on the spot because I may leave something out and he's also very aware of this. NIH and NIDA in particular is very much aware of the issue of substance use within our military. We have done several things; we've had meetings, we've had funding announcement where we set aside funding to have people apply for monies to be able to study issues related to the development of addictive disorders among those who are involved in the military, particularly focusing on trying to develop effective treatment interventions that would address co-occurring problems, things like substance use and traumatic brain injury, or substance use and PTSD, or substance use, especially prescription opiate addiction and chronic pain. All of those are issues. We partner with the VA significantly around different research initiatives. I have someone who works directly with me that the NIH developed a set of instruments that are patient-based reporting tools so that they could report on their experiences with different types of health conditions, including mental health. We've developed some tools within substance abuse pain, called the Promise Measures, and he's negotiating actually with the Joint Chiefs to have the Promise Measures to be used across all of the military and VA facilities for the collections of data. Geoff probably can tell you even more than I can.

Geoff Laredo: There's also some — I'm Geoff Laredo from NIDA's Office of Science, Policy, and Communications. There's also a lot of work that's gone on with the Department of Defense, both from NIDA and our colleagues at the National Institute of Mental Health. I couldn't see who asked the question. Let's be sure that we talk before we finish today. There are some resources both on our website and for NIMH that, there's been tens of millions of dollars of research in intervention research recently that is finally beginning to get at what is specifically effective for members of the military coming back. That's been co-funded by us and the VA and DOD and others, so there's some specific resources that we can get for you.

Chandler: In terms of Indian Country, we also have — there is an effort across all of NIDA to be able to have our portfolio be integrated in addressing the substance abuse problems of Native Americans and we have someone at the institute that actually is responsibility for coordinating our effort and for making sure that we are also not only coordinating our effort internal to NIDA and NIH, but also working with other Federal partners, including the Indian Health Service and other folks, so we can get you her name as well.

Joe Heaps: Joe Heaps. I'm at NIJ. I appreciate your time this morning and I thought your comment about 12-step versus professional was very helpful. My question is, is there any science around faith, religion, God in the program in recovery?

Chandler: We have looked at the role of faith-based organizations as a place to provide treatment and services, but in terms of NIDA funding a study that looks at a particular type of faith or faith practice in addictive disorders, I'm not aware of that. The specific looking at a treatment intervention is not my part of the institute, but I'm not aware of us having funded anything. You can certainly see though when I talked about behavioral interventions that focus on particular targets, and one of those had to do with meditation and relaxation, so for many people prayer is a meditative activity. We're looking at the role that something like meditation can play in helping people deal with stressors and helping people to enhance the connection with their prefrontal cortex and helping them to be able to resist the urge to use drugs. That's the closest that I'm aware of in terms of our current research portfolio.

People need to understand that we are an investigator-initiated institute for the most part, so we study the things for which folks write grants. If someone doesn't write a grant and come in through the peer review process, we may not have research in that particular area. It doesn't necessarily mean that we wouldn't be interested in it, but there's a process that you have to go through where someone writes a grant, they go through a peer review process where scientific experts from across the country will review that application for its scientific merit and then we will make funding decisions depending on the availability of funds. If there are things that you are interested in, in particular that your experience leads you to believe might work and you can find people who are researchers at different organizations and they're interested in writing a grant, then let us know, we'd be happy to talk to you.

Susan Clay: Hi, my name is Susan Clay. I do social work with Alexandria Police Department. I was wondering if you wouldn't mind touching back on the slides that talked about brain functioning, specifically the ones where you talked about drug use and the spikes of dopamine. I was wondering could you touch back on why exactly is there permanent damage over time? Does the body just have a finite ability to release the dopamine in that way? Then also, what is the timeframe, if a person had an addiction or if they experimented with drugs for two weeks probably wouldn't do permanent damage, but after a certain amount of time, is it a couple years, when is it that you see that slide that depicted that permanent damage had occurred?

Chandler: Boy if we could answer that question. What I can say is that it depends. It depends on a lot of things. We know that vulnerability to developing drug addiction is genetic. There is a really strong genetic component, similar to vulnerability for developing other kinds of diseases, but there's also a very important gene/environment interaction that's at play. For example, perhaps I have a genetic predisposition to become a drug addict, but if I never use an illicit substance I won't become addicted to it because I've never been exposed to that. The level of exposure that someone has to have depends on their genetic vulnerability, it depends on whether or not they have other co-occurring mental health conditions, it depends on their age and their developmental stage. Because we know that adolescence is a time when there's a lot of change and a lot of things happening in the brain of these individuals and that developing brains are the ones that are the most vulnerable for developing addictive disorders. So drug use during that critical juncture is more likely to lead to an addictive disorder than drug use that occurs later on in life. So there's lots of different influences and things that come into play that have to do with, well how long and how many times does someone need to be exposed to drugs of abuse in order to develop an addictive disorder?

In terms of your more nuanced question, I'm not a neuroscientist. I have to read and consume a lot of this information myself and be able to talk about it and be able to understand it. It's important in trying to think about how to develop treatment. But at a very basic molecular level inside the cell, we know that there are changes that are occurring, especially because I was talking about the dopamine system. Because illicit drugs affect that system again in a much more efficient way than natural reinforcers. It is because of that and because of repeated exposure that those changes at a molecular level begin to occur and then eventually an individual will cross the threshold and become addicted and will lose the ability to either use or not use. Once you become addicted you no longer have a choice, it's compulsive. It doesn't matter if it's the dead of the darkest wintry night if you begin craving that drug you're going to be propelled to engage in behaviors that will lead to being able to acquire and use that drug, as opposed to being able to say, oh well, I'd like to have a glass of wine tonight with dinner, but I don't have any and it's bad weather and it's cold, and I'm tired, I'm not going to go out and buy it. An addict doesn't have that choice.

Jolene Hernon: Redonna, I have a question that's kind of related to that last one. I'm Jolene Hernon from NIJ. I was fascinated by those brain images that you had and what you just said in response to the last question, does it mean that if an addict stays clean for four to seven to 10 years, the brain image at the end of that 10 years is going to look the same as the brain image did when the addict first started?

Chandler: No, it doesn't mean that. In fact I didn't show those slides and probably should have, but you can see recovery happening after periods of abstinence and after periods of time when an individual is not using drugs. But what does happen is that they are still vulnerable to relapse. You see people that have been abstinent for a number of years and because of events that occur, because a child got sick and died and it created an incredible stressor in their life they may relapse, or because of cue-induced craving and they're not even sure what the cues were that set it off they may relapse. So there is a certain vulnerability to relapse that continues, which is why we talk about that a chronic approach is necessary, it's a chronic disease, and that people who have been most successful in being abstinent go through a course or maybe even multiple courses of treatment, but then they begin to realize what they need to do themselves to manage their addictive disorder. Just like my grandmother who's diabetic has had to learn what she needs to do across her lifetime in order to manage her diabetes.

[Applause]

Chandler: Thank you all.