Nora D' Volkow, M'D'

1
Effectively Breaking the Cycle of
RESEARCH and TREATMENT Provide the Answers
Nora D. Volkow, M.D. Director National Institute
on Drug Abuse
2
ADDICTION IS A DISEASE OF THE BRAIN As other
diseases, it affects tissue function
Decreased Heart Metabolism in Heart Disease
Patient
Healthy Heart
Diseased Heart
Sources From the laboratories of Drs. N. Volkow
and H. Schelbert
3
Relapse Rates Are Similar for Drug Dependence
And Other Chronic Illnesses
Addiction Treatment Does Work
100
90
80
70
60
Percent of Patients Who Relapse
50
40
30
20
10
0
Drug Dependence
Type I Diabetes
Hypertension
Asthma
Source McLellan, A.T. et al., JAMA, Vol 284(13),
October 4, 2000.
4
Evaluation of A Hypothetical Treatment
HYPERTENSION
During
Pre - - Post
Symptom Severity
Just Like Hypertension, Addiction Is A Chronic
Disease That Requires Continued Care
ADDICTION
Pre - - - - - - - - - - - - Post
Symptom Severity
Stage of Treatment
Source McLellan, AT, Addiction 97, 249-252, 2002.
5
Time in Treatment (Retention) Is the Most
Reliable Predictor of Post-Discharge Outcomes
Legal Pressure Was the Strongest Predictor Of
Remaining in Treatment
80
Treatment Works Even If Its Not Voluntary
Low Pressure
70
Moderate-to-High Pressure
60
55
52
50
40
39
Retained 90 Days
40
28
30
25
20
10
0
Program A (42)
Program B (69)
Program C (88)
Three Programs (with of Caseload CJ Supervised)
Source Hiller, et al., Legal Pressure and
Treatment Retention in DATOS (ASC Meeting, San
Diego, Nov 1997)
6
In 2003, An Estimated 21.6 Million
Americans Were Dependent On or Abused Any Illicit
Drugs or Alcohol ButOnly 3.3 Million (15)
of These Individuals Had Received Some Type
of Treatment In the Past Year
7
Drug Use Connected to Criminal Activity
In 2003, the combined federal, state, and local
adult correctional population reached a new
record of almost 6.9 million (Bureau of Justice
Statistics, 2004).

• 64 jail, state/federal inmates report regular
  drug use (BJS, 1997)
• Drug use involved gt 50 of violent crimes and
  60-80 of child
• abuse/neglect (NIJ, 1999)

8
Minorities are Disproportionately Impacted by
Incarceration and HIV/AIDS
6
4
3
1
100
12
15
18
23
80
11
16
Other
60
43
Hispanic
50
Black
40
70
White
65
20
35
26
0
Prisoners
Population
IDUs w/ HIV-AIDS
Abuse/Dependent
9
(No Transcript)
10
NIDA Response

• Research Portfolio
• Integrating Treatment into CJ Settings
• Drug Courts
• Prisons/Jails
• Probation/Parole
• HIV/AIDS
• Re-entry
• Translating Research
• Principles of Effective Treatment with
• Drug Abusing Offenders
• Judicial Training

11
Criminal Justice Drug Abuse Treatment
Studies(CJ-DATS)
To improve outcomes for offenders with substance
use disorders by improving the integration of
drug abuse treatment with other public health
public safety systems
12
Delaware Work Release TC (Crest)
Aftercare Drug-Free an Arrest-Free 3 Years After
Release (N448)
AFTERCARE is Indispensable
Arrest-Free
Drug-Free





Martin, Butzin, Saum, Inciardi (1999), The
Prison Journal
p lt .05 from Comparison
13
Amity Prison TC 3-Year Outcomes Reincarceration
Rates (N478)
AFTERCARE is Indispensable
Percent Reincarcerated
Wexler et al., Three-year reincarceration
outcomes for Amity, Prison Journal 79321-336,
1999.
14
Components of Comprehensive Drug Abuse
Treatment

A Variety of Ancillary Services are Key to
Successful Transition into the Community
Child Care Services
Vocational Services
Family Services
Housing / Transportation Services
Mental Health Services
Behavioral Therapy and Counseling
Substance Use Monitoring
Clinical and Case Management
Medical Services
Financial Services
Pharmacotherapy
Continuing Care
Legal Services
Educational Services
AIDS / HIV Services
NIDA Principles of Drug Addiction Treatment A
Research-Based Guide (2000)
15
What Are the ROADBLOCKS ?

• Lack of Methadone Treatment Access

Availability of BUPRENORPHINE may facilitate more
widespread use of pharmacological treatments

• Changing the Culture

Education of judges Secondary CJ-DATS goal to
help change the culture by embedding research
into existing settings

• Infrastructure to Support Transition to the
  Community

Ancillary services are critical to successful
transition
16
Where Do We Need to Go From Here?
We Need to
Advance the SCIENCE
17
Dopamine Neurotransmission
1100
AMPHETAMINE
1000
900
800
700
600
500
of Basal Release
400
300
200
frontal cortex
100
0
0
1
2
3
4
5 hr
Time After Amphetamine
FOOD
200
nucleus accumbens
VTA/SN
150
of Basal Release
100
Empty
50
Box
Feeding
0
0
60
120
180
Time (min)
Di Chiara et al.
18
Brain Dopamine System
DA Transporters
DA Receptors
DA
Anatomy
DA
DA
DA
DA
DA
DA
signal
Dopamine Cell
Metabolism
19
Dopamine D2 Receptors are Lower in Addiction
Cocaine
DA
DA
DA
DA
DA
DA
DA
DA
DA
DA
DA
DA
Meth
Reward Circuits
Non-Drug Abuser
DA D2 Receptor Availability
Alcohol
DA
DA
DA
DA
DA
DA
Heroin
Reward Circuits
Drug Abuser
control
addicted
20
Effects of a Social Stressor on Brain DA D2
Receptors and Propensity to Administer Drugs
Individually Housed
Group Housed
Dominant
Subordinate
50
Becomes Dominant No longer stressed
40
30


Reinforcers (per session)
Isolation Can Change Neurobiology
20
10
Becomes Subordinate Stress remains
0
S
.003
.01
.03
.1
Cocaine (mg/kg/injection)
Morgan, D. et al. Nature Neuroscience, 5
169-174, 2002.
21
Criminal Justice Involvement of Patients in
Community-Based Drug TreatmentTREATMENT WORKS
EVEN WHEN ITS NOT VOLUNTARY
Simpson et al. (1997), Psych Addictive Behaviors