The Driving Force Behind Crime: Alcohol and Other Drugs

1. The Driving Force Behind Crime: Alcohol and Other Drugs What’s New in Pharmacology?Hon. Peggy Fulton Hora , Judge of the Superior Court of California (Ret.)Andrea Grubb Barthwell, M.D., FASAMAmerican Judges Association Sept. 24, 2013 .Kohala Coast, Hawai’i

2. Objectives • To understand the connection between substance abuse and crime • To discuss the benefits of providing substance abuse treatment to individuals in the criminal justice system • To list existing and upcoming medications that allow (or will allow) addicted individuals to achieve and maintain sustained recovery

3. Disclosures • Sativex • Vivitrol • Probuphine

4. The Connection between AOD use and crime

5. Costs of alcohol • Median of $2.9 billion in 2006, ranging from $420 million in North Dakota to $32 billion in California • Binge drinking = 70% of the cost • Includes criminal justice expenses and motor vehicle crash costs • State Costs of Excessive Alcohol Consumption, CDC (Aug. 13, 2013)

6. Alcohol and Crime • 36.8% Violent • 29.1% Property • 21.4% Drug • 41.2% Public order • 41.0% Other BJS “Alcohol and Crime: 2002-2008” • DWI 1,112,384 arrests • Domestic violence (93% in one study) • Child maltreatment

7. Drug Use and Crime • Well-known and well-documented connection between criminal activity and substance abuse • Three types of offenses • drug possession or sales • related to drug abuse (e.g., stealing to get money for drugs) • related to a lifestyle that predisposes the drug abuser to engage in illegal activity • Many offenses, including violent crime, are committed by people who have substance abuse disorders

8. Substance Abuse in the Criminal Justice System • Drug law violations are the most common type of criminal offense (Glaze and Bonczar2009) , 1,305,191 arrests (FBI’s Uniform Crime Reporting (UCR) Program 2009) • Only a small percentage of offenders has access to adequate services, especially in jails and community correctional facilities (Taxman et al. 2007; Sabol et al. 2010)

9. Breaking the Cycle • Offenders who are left untreated for substance abuse disorders often relapse and return to criminal activity • Re-arrest and re-incarceration 66% of the time • Treatment offers the best alternative for interrupting the drug abuse/criminal justice cycle.

10. Treatment in Criminal Justice System • Cross-agency coordination and collaboration of criminal justice professionals, substance abuse treatment providers, and other social service agencies • Examples: • treatment in prison followed by community-based treatment after release • drug courts that blend judicial monitoring and sanctions with treatment by imposing treatment as a condition of probation • treatment under parole or probation supervision

11. ADAM II 2012

12. Heroin use almost doubled • Number of people who were past-year heroin users in 2011 (620,000) vs. 2007 (373,000) 2011 National Survey on Drug Use and Health • More than half of the 36,450 overdose deaths in the United States in 2008 involved a prescription drug • July 16, 2012 The New York Times • Heroin is often cheaper than marijuana, selling for as little as $5 a hit

13. Overdose deaths • Overdoses have increased almost six-fold in the last 30 years. • Leading cause of accidental death in the United States overting motor vehicle crashes for the first time • The New York Times, Jan. 1, 2012 • It is estimated 6.2 million Americans– that is 2.5% of the US population- is abusing prescription drugs • NBCLatino Aug. 12, 2013

14. More than half of the 36,450 overdose deaths in the United States in 2008 involved a prescription drug. The New York Times , July 16, 2012 • Treatment admissions for abuse of prescription pain relievers have risen 430percent from 1999-2009 • SAMHSA, 2011

15. 10% taking meds not theirs

16. 2.2 million American withopioid dependence • 2.2 million people with opioid dependence in the U.S. • Approximately 20 percent of this population is addicted to illicit opioids, such as heroin • The other 80 percent to prescription opioids, such as oxycodone, hydrocodone, methadone, hydromorphone and codeine

17. Opiate Addiction • Currently, approximately 1 million people in the United States are addicted to heroin1 • More than 3 million people over the age of 12 have used heroin at least once2 • An estimated 1.4 million people are dependent on or abusing other opiate drugs, including prescription painkillers3 • Office of National Drug Control Policy, 2000 • National Survey on Drug Use and Health (NSDUH), 2004 • NSDUH (Ibid).

18. FAX CESAR August 6, 2012 Vol. 21, Issue 31 A Weekly FAX from the Center for Substance Abuse Research U n i v e r s i t y o f M a r y l a n d , C o l l e g e P a r k Estimated Number of Buprenorphine- and Hydromorphone-Related ED Visits More Than Doubles from 2006 to 2010 The estimated number of emergency department (ED) visits related to the nonmedical use of opioid pain killers increased 79% from 201,280 in 2006 to 359,921 in 2010, according to the most recent data from the Drug Abuse Warning Network (DAWN). The greatest increases were seen in buprenorphine- and hydromorphone-related ED visits. In 2006, the nonmedical use of buprenorphine was involved as either a direct cause or a contributing factor in an estimated 4,440 ED visits, compared to 15,778 in 2010—an increase of 255%. The estimated number of visits related to the nonmedical use of hydromorphone increased 161% over the same 5-year period (see figure below). While the number of ED visits for the nonmedical use of buprenorphine and hydromorphone is relatively small compared to other opioid pain relievers, the magnitude of the increase suggests that there may be emerging problems with the nonmedical use of these drugs that warrant the monitoring of their use and related consequences. Estimated Number of U.S. Emergency Department Visits Related to the Nonmedical Use of Opioid Pain Relievers, 2006 to 2010 NOTES: Nonmedical use includes taking more than the prescribed dose; taking a drug prescribed for another individual; deliberate poisoning by another person; and documented misuse or abuse. Five categories of opioid pain relievers (dihydrocodeine, opium, pentazocine, phenacetin, and all other narcotic analgesics) were not included in the above table because the estimate for either 2006 and/or 2010 did not meet standards of precision (relative standard error greater than 50% or an unweighted count or estimate less than 30). SOURCE: Adapted by CESAR from Substance Abuse and Mental Health Services Administration (SAMHSA), National Estimates of Drug-Related Emergency Department Visits, 2004-2010 - Nonmedical Use of Pharmaceuticals, 2012. Available online at http://www.samhsa.gov/data/DAWN.aspx#DAWN%202010%20ED%20Excel%20Files%20-%20National%20Tables. 

19. 85% Ohio drug court clients

20. Rx drugs and heroin

21. Drug-exposed infants

22. “Sharp Rise in Women’s Deaths From Overdose of Painkillers” The New Your Times, July 2, 2013

23. Prosecutors file against supplier

25. What’s New in Pharmacology?

26. What are Substance Abuse Disorders? • Drug addiction is a complex illness—characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that persist even in the face of devastating consequences. • Addiction produces far-reaching health and social consequences: • increases a person’s risk for a variety of other mental and physical illnesses • interferes with a person’s normal functioning in the family, the workplace, and the broader community • Effective treatment programs typically incorporate many components, including pharmacotherapies.

27. Pharmacotherapies • Medications can be an important component of effective drug abuse treatment for offenders. • By allowing the brain to function more normally, they enable the addicted person to leave behind a life of crime and drug abuse. • Addiction medications are underused in the treatment of drug abusers within the criminal justice system, despite evidence of their effectiveness.

28. Opiate Addiction • Heroin, morphine, and some prescription painkillers (e.g., OxyContin, Vicodin, and Fentanyl) are all opiates. • They act on specific (opiate) receptors in the brain • Interact with naturally produced substances known as endorphins or enkephalins– important in regulating pain and emotion • Opiates as a general class of drugs have significant abuse liability.

29. Narcotic Agonists: Methadone • Methadone maintenance therapy: • In the 1960's, methadone gained recognition as an effective treatment for heroin addiction. • Administered daily, methadone treatment is currently regulated so that only specialized clinics can provide it. •  Patients’ illicit opioid use declines, often dramatically, during methadone maintenance treatment1. 1. Condelli WS, Dunteman GH. Exposure to methadone programs and heroin use. American Journal of Drug and Alcohol Abuse 1993;19:65-78.

30. Narcotic Agonists: Buprenorphine • Buprenorphine • Long-acting partial agonist that acts on the same receptors as heroin and morphine • Relieves drug cravings without producing the same intense “high” or dangerous side effects. • Abuse-deterrent formulation with naloxone • Naloxone has no effect when Suboxone is taken as prescribed, but if an addicted individual attempts to inject Suboxone, the naloxone will produce severe withdrawal symptoms • Currently available in two formulations that are taken sublingually: • a pure form of the drug • a more commonly prescribed formulation called Suboxone (a combination with naloxone)

31. Narcotic Agonists: Buprenorphine • NIDA-supported basic and clinical research showed that, alone or in combination with naloxone, buprenorphine significantly reduced opiate drug abuse and cravings and was a safe and acceptable addiction treatment.

32. Trading one drug for another? • Simply substituting one addictive drug for another? • Taking these medications as prescribed allows patients to • hold jobs, • avoid street crime and violence, • and reduce their exposure to HIV by stopping or decreasing injection drug use and drug-related high-risk sexual behavior. • Patients stabilized on these medications can also engage more readily in counseling and other behavioral interventions essential to recovery.

33. U.N. Report Criticizes Harsh, Unhelpful Addiction Treatment • Condemns denying patients long-term maintenance treatment with methadone or buprenorphine • “A particular form of ill-treatment and possibly torture of drug users is the denial of opiate substitution treatment” • Considered a human rights violation when it occurs in jails and prisons • UN General Assembly Feb. 1, 2013

34. Narcotic Antagonists: Naltrexone • Naltrexone • an opioid receptor blocker, or antagonist—it blocks opioids from binding to their receptors and thereby prevents their euphoric and other effects. • Highly effective in reversing the effects of opiate overdose • No potential for abuse, and it is not addictive • Noncompliance is a common problem • Best suited for highly motivated, recently detoxified patients who desire total abstinence because of external circumstances

35. Narcotic Antagonists: Naltrexone • Revia • Daily pill • Problem is medication compliance • Subject to diversion

36. Naltrexone, cont. • Vivitrol • long-acting injectable version of naltrexone, called Vivitrol, was approved to treat opioid addiction. • Because it only needs to be delivered once a month, this version of the drug can facilitate compliance

37. Naltrexone, cont. • Offers an alternative for those who do not wish to be placed on agonist/partial agonist medications • Side effects such as injection site reactions

38. Alcohol • Intoxication can impair brain function and motor skills. • Heavy use can increase risk of certain cancers, stroke, and liver disease. • Alcoholism or alcohol dependence is a diagnosable disease characterized by • a strong craving for alcohol, • and/or continued use despite harm or personal injury. • Alcohol abuse, which can lead to alcoholism, is a pattern of drinking that results in harm to one's health, interpersonal relationships, or ability to work.

39. Alcohol (cont.) • Acamprosate (Campral®) • acts on the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems • Reduces symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria. • Has been shown to help dependent drinkers maintain abstinence for several weeks to months, • May be more effective in patients with severe dependence.

40. Alcohol (cont.) • Disulfiram (Antabuse®) • Interferes with degradation of alcohol, • Causes accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if a person drinks alcohol. • Utility and effectiveness are limited because compliance is generally poor. • Can be effective among patients who are highly motivated • Some patients use it episodically for high-risk situations • It can also be administered in a monitored fashion, such as in a clinic or by a spouse, improving its efficacy.

41. Alcohol (cont.) • Naltrexone • blocks opioid receptors that are involved in the rewarding effects of drinking and the craving for alcohol. • It has been shown to reduce relapse to problem drinking in some patients. • Vivitrol also FDA-approved for treating alcoholism, and may offer benefits regarding compliance.

42. Alcohol (cont.) • Topiramate • Is thought to work by increasing inhibitory (GABA) neurotransmission and reducing stimulatory (glutamate) neurotransmission • Precise mechanism of action is not known. • Although it has not yet received FDA approval for treating alcohol addiction, it is sometimes used off-label for this purpose. • Topiramatehas been shown in studies to significantly improve multiple drinking outcomes, compared with a placebo.

43. What’s new? Roadside devices, CBT, brain imaging

44. The State of the Science: New Medications Possibilities for Drug Abuse • Genomics and epigenetics • High resolution mapping of targeted brain areas • Anti-addiction vaccines • Medication combinations

45. Medicines Under Development: Vaccines • Anti-drug vaccines seek to induce antibodies that bind their target drugs and drug metabolites • Results in drug-antibody complexes that are too large to cross the blood-brain barrier • In effect, keep drug from reaching brain The vaccine makes oxycodone visible to the immune system by linking it to the highly immunogenic protein keyhole limpet hemocyanin (KLH). Antibodies formed in response to the vaccine “see” and bind to oxycodone as if it were part of the KLH molecule.

46. Medicines Under Development: Heroin Vaccine • Developed at the Scripps Research Institute  • Creates antibodies against heroin and its psychoactive metabolites • Causes effective and continuous sequestration of brain-permeable constituents of heroin in the bloodstream following vaccination. • Efficient obstruction of heroin activity in treated rats • Still in preclinical trials Joel E. Schlosburg, Leandro F. Vendruscolo, Paul T. Bremer, Jonathan W. Lockner, Carrie L. Wade, Ashlee A. K. Nunes, G. Neil Stowe, Scott Edwards, Kim D. Janda, and George F. Koob. Dynamic vaccine blocks relapse to compulsive intake of heroinPNAS 2013 : 1219159110v1-201219159. From: http://www.pnas.org/content/early/2013/05/02/1219159110.abstract

47. Medicines Under Development: Cocaine Vaccine • Developed by researchers at Weill Cornell Medical College • Researchers tested the anti-cocaine vaccine in primates • Vaccine prevented cocaine from reaching the brain and producing “high” • Vaccine is designed to induce anti-cocaine antibodies that isolate cocaine, preventing access to the central nervous system • Still in preclinical trials

48. Medicines Under Development: Oxycodone Vaccine • Developed by researchers at the University of Minnesota • Vaccine as a potential aid in the treatment of oxycodone and hydrocodone abuse and dependence • Vaccine aims to lower motivation to take prescription opioids by blocking rewarding and reinforcing effects • Vaccinating rats before injecting them with oxycodone or hydrocodone reduced the amount of drug reaching the brain by an average of 86 percent after a 0.1 mg/kg dose, and 54 percent after a 0.5 mg/kg dose.

49. New meth med? • Ibudilast reduces craving and improves cognitive functioning • Small study at UCLA • FDA approval in future • Huffington Post, April 3, 2013

50. Medicines Under Development: Methamphetamine • AV411 (also called ibudilast) reduced methamphetamine seeking in animal models of stress- and drug-induced relapse • AV411 affects the brain's glial cells rather than neurons, may avoid side effects caused by other anti-addiction medications