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Drug Treatment Programs:
Policy Implications for the Judiciary
Arthur H. Garrison
Drug use in the United States has been cited for the drugs.3 The impact of this increased drug use can be seen in
growth in American prisons over the past decade.
the fact that the number of Americans incarcerated (prison Heroin, once considered a drug to be avoided and only) reached more than one million (1,078,542) in 1995 for scorned, has had resurgence in use by middle-class youth and the first time in U.S. history.4 According to the Bureau of white-collar professionals due to the increased purity of the Justice Statistics, the percentage of prisoners in federal prison drug and the lack of need to use needles for ingestion.
incarcerated for dugs increased from 57.9% of the total popu- Naltrexone has been used as a method of helping heroin lation in 1991 to 62.6% in 1997 and the percentage of drug addicts to end their drug dependency, but such programs have offenders in state prisons decreased from 21.3% of the total limitations in their use and effectiveness. This paper is drawn from an evaluation of a drug treatment program in “The majority of heroin users are still older, chronic users Wilmington, Delaware. The goal of this paper is to review the who inject the drug. At the same time, the number of new, factors that lead to successful drug treatment and the limita- young users who snort or smoke the drug continues to rise.”6 tions on the success of drug treatment that the judiciary According to the DEA, the “typical heroin user today con- should consider when sentencing drug addicts. sumes more heroin than a typical user did just a decade ago, More than 13 million Americans used an illicit drug at least which is not surprising given the higher purity currently avail- once in 1998, and 977,000 Americans classified themselves as hardcore heroin users in 1999.1 The growth of increased drug venously, subcutaneously (under the skin), or intramuscu- use has impacted the criminal justice system. “In 1997, over larly8 but due to the high level of purity (as high as 98%), it one third of prison commitments involved drug offenses, com- can be snorted or smoked. The purity of the heroin now pared to only 7% in 1980. In 1980, about half of all commit- makes heroin snorting possible, and makes heroin more ments were for violent offenses; by 1997, only about one third “appealing to new users because it eliminates both the fear of were.”2 In 1999 Americans spent an estimated $63.2 billion acquiring syringe-borne diseases . . . and the historical stigma for cocaine, heroin, methamphetamine, and other illicit The author would like to thank Janice Hunter, Medical Librarian, In 1999, approximately 6.3 million adults—3.1% of the Delaware Psychiatric Center, Delaware Department of Health and Nation’s adult population—were under correctional super- Human Services for her help in securing articles and citation correc- vision (that is, incarceration, probation or parole). Drug tions. Her help was invaluable for the preparation of this paper. offenders accounted for 21% (236,800) of the State prisonpopulation in 1998, up from 6% (19,000) in 1980, and 59% This paper is based on a study supported by grant No.
(55,984) of the Federal prison population in 1998, up from 98–DD–BX–0022 awarded by the Bureau of Justice Assistance. For 25% (4,749) in 1980. Also, in 1998, an estimated 26% the full report, see ARTHUR H. GARRISON, SODAT–DELAWARE, INC., (152,000) of all inmates under local supervision were NALTREXONE ALTERNATIVE PROGRAM (SNAP), A HEROIN ADDICT incarcerated for drug offenses. This increase in the drug OUTPATIENT TREATMENT PROGRAM: AN OUTCOME EVALUATION (1999).
offender prison population mirrors the steady increase inarrests for drug offenses.
An earlier draft of this paper was presented at the 29th Annual OFF. OF NAT’L DRUG CONTROL POLICY, DRUG TREATMENT IN THE Meeting of the Society for Police and Criminal Psychology, Canton, CRIMINAL JUSTICE SYSTEM FACT SHEET (March 2001) at 1. Ohio, and was awarded the 2000 C. Edward Shaffer Memorial 3. OFF. OF NAT’L DRUG CONTROL POLICY, supra note 1, at 114.
Research Award for Best Research Paper.
4. BUREAU OF JUSTICE STATISTICS, SOURCEBOOK OF CRIMINAL JUSTICE Footnotes
5. Id. at 513. See also NELS ERICSON, SUBSTANCE ABUSE: THE 1. OFF. OF NAT’L DRUG CONTROL POLICY, NATIONAL DRUG CONTROL NATIONS’S NUMBER ONE HEALTH PROBLEM.(OJJDP Fact—Sheet #17) STRATEGY 2000 ANNUAL REPORT (2000) at 115–116. Seventy-four million Americans have tried an illicit drug at least once in their 6. OFF. OF NAT’L DRUG CONTROL POLICY, PULSE CHECK: NATIONAL lifetime; 2.4 million have tried heroin at least once, 22.1 million TRENDS IN DRUG ABUSE (Summer 1998), at i.
have tried cocaine at least once, and 4.6 million have used crack 7. DRUG ENFORCEMENT ADMIN. & THE NAT’L GUARD, DRUGS OF ABUSE at least once. OFF. OF NAT’L DRUG CONTROL POLICY, DATA SNAPSHOT–DRUG ABUSE IN AMERICA 1998 (1998) at 32-33. In 1999, 1,254,577 Americans were in federal and state prisons. OFF. OF 9. Id. The DEA estimated that purity levels of heroin in 1981 were NAT’L. DRUG CONTROL POLICY (March 2001), infra note 2 at 1. 7%, and in 1998 the average purity rate was 41 % nationwide.
2. OFF. OF JUSTICE PROGRAMS, U.S. DEP’T OF JUSTICE, CRIME AND JUSTICE Estaban Parra, infra note 18. The ingestion of heroin either by ATLAS 2001 UPDATE (2001) at 5. The Office of National Drug smoking or snorting has increased from 55% in 1994 to 71% in Control Policy recently reported the following: 1997. OFF. OF NAT’L DRUG CONTROL POLICY, supra note 6 at 30.
24 Court Review - Winter 2002
In Newark, Delaware, the purity of heroin has been found [B]etween 1993
to range from 20% to 90%.10 The New Castle County Police have reported that purity levels have been found to be as high and 1995, 88%
of new heroin
National Drug Control Policy, Newark, Delaware sources users were
report that there has been a “‘definite increase in teenage users’. . . dealers, some from nearby Philadelphia, are making between the
a clear attempt to establish a new market. For example, by A BRIEF REVIEW ON THE USE
ages of 18 to
encouraging young females to begin use, dealers hope to OF HEROIN AND
25 years old.
attract older male users. In that area, users start at around 13, NALTREXONE
and the source reports that there are ‘chronic’ users aged 15 - 17.”12 It has recently been reported that between 1993 and derivative of opium prepared from morphine.19 Heroin was 1995, 88% of new heroin users were between the ages of 12 to first introduced into medicine in 1898 and was used as a pain 25 years old.13 The “average age of addicts seeking treatment medication until the addictive nature of opioids in general was is getting younger. In 1993, only 17.2 percent of heroin found.20 Heroin is classified as a narcotic due to its ability to addicts who reported for treatment were 24 or younger. By produce mood and behavior changes, potential for dependence 1997, the percentage had climbed to 31.7 percent.”14 and tolerance following continued use, and derivation from number of people who are treated for heroin addiction in In 1914 the Harrison Act was passed, which is Delaware has increased from 336 in 1991 to 1,767 in 1997, an “interpreted as excluding the provision of opioids to addicts as increase of 426%.15 The impact of the increase in heroin usage a legitimate medical use.”22 Although the use of opiates was can be seen in the number of heroin-related deaths. Deaths illegal, “heroin addiction persisted and its prevalence rose fol- related to heroin have increased from 14 in 1991, to 29 in lowing World War II [and by] the early 1960’s [many recom- 1997.16 The national average of heroin purity is 35%.17 The mended] remedicalizing heroin distribution as a way to reduce average purity level for heroin in Delaware is 85%.18 crime associated with heroin addiction.”23 In an effort to deal with the growing heroin use problem in With the increase of heroin addiction in the U.S. Military Delaware, SODAT-Delaware, Inc., received more than during the Vietnam War and in society as a whole, federal $1,650,000 over a three-year period (1995–1997) to imple- funds were expended for both research and treatment of heroin ment an intensive outpatient therapy program (SNAP), which addicts.24 Over the past 30 years, various techniques have 10. OFF. OF NAT’L DRUG CONTROL POLICY, supra note 6 at 4. between South American (high purity white) and Mexican (lower 11. New Castle County Police Heroin Alert Task Force, “Heroin: The purity “black tar”) heroin is the Mississippi River. OFFICE OF NAT’L New Serial Killer That Is Stalking Our Children,” presentation DRUG CONTROL POLICY, supra note 2 at 31. 19. STEDMAN’S MEDICAL DICTIONARY (25th ed.1990). HAROLD KAPLAN 12. Supra note 6 at 3. “The hub of the area heroin trade [is in] the & BENJAMIN SADOCK, COMPREHENSIVE TEXTBOOK OF PSYCHIATRY (6th Kensington section of Philadelphia. That’s where many Delaware ed. 1995). Joseph Ternes & Charles O’Brien, The Opioids: Abuse addicts go to get [their heroin]. Through the first 10 months of Liability and Treatment for Dependence, in ADDICTION POTENTIAL OF 1998 [there were] 716 arrests for heroin” of which 30 were peo- ABUSED DRUGS AND DRUG CLASSES (Barry Stimmel ed., 1990) ple from Delaware. Tom Feeney & Esteban Parra (1998). Hooked 20. Kaplan & Sadock, supra note 19 at 844.
on Heroin: Police Sound the Alarm, SUNDAY NEWS JOURNAL, Nov. 29.
21. Id. “Heroin crosses the blood-brain barrier more rapidly than morphine and produces greater euphoric effects when given in 13. New Castle County Police Heroin Alert Task Force, supra note 11.
equal doses. Once in the brain, heroin is hydrolyzed to morphine 14. Feeney & Parra, supra note 12.
almost immediately.” Id. at 31. Both heroin and morphine are derivatives of opium and as such are considered opiates.
Opiates attach to the opioid receptors of the brain and produce 17. DRUG ENFORCEMENT ADMIN. & THE NAT’L GUARD, supra note 7 at similar euphoric and pleasure reactions to natural occurring pain suppressants in the brain (endorphins and enkephalins) which 18. New Castle County Heroin Alert Task Force, supra note 11. DEA also attach to the opioid receptors of the brain. SUBSTANCE ABUSE investigations have discovered that heroin sold in Dover and Kent AND MENTAL HEALTH SERVICES ADMIN. (SAMSHA), NALTREXONE AND County originates in New York City. The heroin market in the ALCOHOLISM TREATMENT: TREATMENT IMPROVEMENT PROTOCOL U.S. is dominated by two sources, Columbia and Mexico.
(TIP) (1998), series #28 at 28. Both endogenous opioids (endor- Columbian heroin is dominant along the east coast in cities like phins and enkephalins) and exogenous opiates (heroin and mor- Boston, New York City, Newark, N.J., and Philadelphia.
phine) act as neurotransmitters that transfer information through Columbian heroin averages at almost 68% pure, but the the nervous system. In the case of opioid neurotransmitters, the Columbian heroin in Dover has been found in the high 90% information is pain relief and pleasure responses. See infra note range. The heroin purity rate in Dover has been found to be 32 for discussion on the cycle of addiction theory.
higher than in Philadelphia, which is about 80%. The combina- 22. Kaplan & Sadock, supra note 19 at 844.
tion of the high purity rate of heroin in Delaware and the low cost is blamed for the increase of heroin use in suburban areas in 24. Id. See also, infra note 25, and Robert Greenstein et al., Methadone Delaware. Estaban Parra, Purity Is Part of the Local Problem, and Naltrexone in the Treatment of Heroin Dependence, 7 SUNDAY NEWS JOURNAL, Jan. 21, 1999, at A7. The dividing line PSYCHIATRIC CLINICS OF NORTH AMERICA, 671 (1984). Winter 2002 - Court Review 25
by preventing the reestablishment of physical Early studies and addicts. One of the treatment
dependence, treatment with antagonists also leads theoretical use
to the eventual extinction of conditioned with- drawal phenomena. Recently, . . . empirical and lab- of naltrexone
oratory observations [show] patients taking nal- proposed that
trexone experience less craving in the presence of naltrexone
opioid-related cues, presumably because, on a cog- nitive basis, they are aware that they are unable to effective in
dealing with
Early studies and theoretical use of naltrexone proposed that impulsive and
naltrexone would be effective in dealing with impulsive and compulsive heroin use in addicts who are in treatment.30 Early compulsive
researchers of heroin addiction recognized that recovering heroin use in
heroin addicts could recidivate and develop full addiction due addicts who are
to impulsive heroin use by environmental stimuli. The stimuli could be an interaction between the recovering addict and a in treatment.
friend, whom the addict had a history of heroin use with, or being in a neighborhood in which heroin is used. The stimulus “blocks or reverses the physiologic and psychological effects of causes a craving for the heroin that could cause readdiction.
opioids by binding opiate receptors” in the brain.26 Goldstein explained that “naltrexone can protect against impul- Naltrexone “prevents or reverses opioid effects [and] will pre- sive use and can prevent the consequences of impulsive use.
cipitate abstinence . . . in narcotic addiction.”27 The use of nal- The protective medication, [the naltrexone], is taken at a time trexone is based on “the assumption that classically conditioned when motivation [to end the addiction] is high, then later, if withdrawal symptoms and operantly reinforced drug seeking circumstances arise that would typically lead to use the agonist behaviors contribute to high relapse”28 in heroin addicts. drug [heroin], there is a strong reason to avoid that behavior” Theoretically, by blocking the euphoric effects of because the subject knows the heroin will not have any effect.31 opioids, treatment with antagonists would lead to Naltrexone can also aid in the reduction of compulsive addic- the extinction of operantly reinforced drug seeking; tion. The cognitive knowledge that the use of the heroin will 25. Kaplan & Sadock, supra note 19 at 844. For a review of early Kassenbaum eds., 1965) at 85 for early work on the use of nar- research on naltrexone in heroin addiction, see Richard Resenick cotic antagonists for treating heroin addiction. See also, Karen et al., Narcotic Antagonists in the Treatment of Opioid Dependence: Allen, Essential Concepts of Addiction for General Nursing Practice, Review and Commentary, 20 COMPREHENSIVE PSYCHIATRY, 116 33 NURSING CLINICS OF NORTH AMERICA 1.
(1979). See also, DEMETRIOS JULIUS & PIERRE RENAULT, NARCOTIC 29. Kaplan & Sadock, supra note 19 at 857. See also, Charles O’Brien ANTAGONISTS: NALTREXONE (National Institute on Drug Abuse et al., Use of Naltrexone to Extinguish Opioid-Conditioned Research Monograph # 9, 1976),which encompasses 25 articles Responses, 45 J. CLINICAL PSYCHIATRY 53.
on naltrexone treatment studies for the first half of the 1970s that 30. See Avram Goldstein, Naltrexone in the Management of Heroin were funded by the National Institute on Drug Abuse, U.S.
Addiction: Critique of the Rationale, in NARCOTIC ANTAGONISTS: Department of Health, Education, and Welfare.
NALTREXONE (National Institute on Drug Abuse Research 26. Robert Greenstein et al., supra note 24 at 675; Joseph Ternes & Monograph # 9) (Demtrios Julius & Pierre Renault eds., 1976) Charles O’Brien, supra note 17 at 43. See also, Vis Navartnam et 158, 159. See also, Richard Resinick, et al., supra note 25, and al., Determination of Naltrexone Dosage for Narcotic Antagonist Richard Resnick & Elaine Schuyten-Resnick, A Point of View Blockade in Detoxified Asian Addicts, 34 DRUG AND ALCOHOL Concerning Treatment Approaches with Narcotic Antagonists, in DEPENDENCE, 231 (1994), which found naltrexone to be effective NARCOTIC ANTAGONISTS: NALTREXONE 84 (1976).
in blocking the physiological and psychological effects of heroin 31. Avram Goldstein, supra note 30 at 159. “Relapse to heroin use in for at least 48 and 72 hours, respectively. Opioid antagonists like abstinent ex-addicts is rarely cogitated and planned in advance.
naltrexone “block opioid receptors and reverse the effects of Conditioned abstinence (‘craving’) can be elicited by accidental endogenous opioid peptides as well as exogenous opiates [and it encounters with active addicts . . . or other major stress.” Id. On is theorized that] these agents may prevent the reinforcing effects” the issue of behavior, Goldstein noted that humans have the abil- of consumption of heroin. SAMHSA, supra note 21 at 32. ity to “anticipate consequences and to modify our behavior 27. DRUG FACTS AND COMPARISONS (1998) at 3579. See also, Joseph accordingly. In this connection, the observation that naltrexone Volpicelli, Naltrexone and the Treatment of Alcohol Dependence, 18 can diminish ‘craving’ is entirely understandable, since ‘craving’ is ALCOHOL HEALTH & RES. WORLD: JOURNAL NAT’L INST. ON ALCOHOL generally elicited by the possibility of obtaining a drug rather than by its unavailability. It follows from this analysis that naltrexone 28. Kaplan & Sadock, supra note 19 at 857. See, Abraham Wikler, can only work if the patient understands how it works and Dynamics of Drug Dependence: Implications of a Conditioning believes that it will work.” Id. at 159–160. Goldstein also asserted Theory for Research and Treatment, 28 ARCHIVES OF GENERAL that because the patient knows that the naltrexone will block the PSYCHIATRY 611 (1973), and Wikler, Conditioning Factors in Opiate affects of heroin and thus taking the drug will be futile, “it is not Addiction and Relapse, in NARCOTICS (Daniel Wilder and Gene surprising that many subjects taking naltrexone may not use 26 Court Review - Winter 2002
not have an effect reduces the obsessing over the craving for the The SNAP program
heroin. Thus naltrexone will assist the addict in developing behavior re-enforcers to resist the thoughts and desires for the was based on the
drug, in turn reducing compulsive addictive behavior.
theory that the
Although use of naltrexone has been found to block the heroin addict (once
effects of heroin, one of the biggest problems in heroin addic- tion32 treatment, along with heroin detoxification of addicts, is detoxification is
low compliance in taking the naltrexone by the addicts and completed) will be
their high dropout rate.33 Kaplan and Sadock noted that in one assisted in ending
study, “the dropout rate was quite high: 25 percent of subjects who started treatment dropped out within two weeks; 94 per- his or her heroin
cent stopped by nine months.”34 In a study in Israel, the aver- addiction if
age retention rate for program participants was 56.3 days.35 medication was
Out of a total of 32 patients, 58 percent completed the pro- provided that
gram.36 Forty percent of the patients dropped out of the pro- gram within two weeks, and 60% of the patients who dropped blocked the effects
out did so within the remaining ten weeks of the program.37 of the heroin.
PROGRAM THEORY DESCRIPTION
The SNAP program was based on the theory that the heroin addict (once detoxification is completed) will be assisted in end- METHODOLOGY
ing his or her heroin addiction if medication was provided that Between October 7, 1993, and July 22, 1998, the SNAP pro- blocked the effects of the heroin. The heroin-blocking medica- gram provided 73 participants naltrexone as part of their treat- tion provided was naltrexone. Naltrexone is an orally adminis- ment for heroin addiction. Data was collected from the case tered medication, which prevents the uptake and effects of opi- files of all 73 participants, which included basic demographic oid compounds. Thus, when taking this medication, any person information (age, gender, race), employment status, history of heroin to test and verify the protection.” Id. at 159. For research receptor blocking pharmacological agents in the battle to reduce showing that heroin addicts will test the blocking ability of nal- relapse in early recovery.” Id. See also, D. Colin Drummond.
trexone, see infra note 40. For a study looking at impulsive heroin Theories of Drug Craving, Ancient and Modern, 96 ADDICTION 33 addicts and self-control, see Gregory Madden et al., Impulsive and (2000). For a discussion on opiate receptor sites within the brain, Self-Control Choices in Opioid-Dependent Patients and Non-Drug- see Roy Wise, Opiate Reward: Sites and Substrates, 13 Using Control Participants: Drug and Monetary Rewards, 5 NEUROSCIENCE AND BIOBEHAVIORAL REVIEW, Summer-Fall 1989, 129, EXPERIMENTS IN CLINICAL PSYCHOPHARMACOLOGY 256 (1997). For a and Jane Stewart, supra note 31.
study looking at compulsive use of heroin and the opioid recep- 33. High dropout rates can be partially explained by the nature of tors and naltrexone, see Jane Stewart, Conditioned and addiction. As noted in footnotes 21 and 32, the consumption of Unconditioned Drug Effects in Relapse to Opiate and Stimulant Drug heroin produces a pleasurable experience that can be stronger Self-Administration, PROGRESS IN NEUROPSYCHOPHARMACOLOGY & than natural pleasurable experiences. The experience in turn pro- duces chemical reinforcers to the use of heroin. The reduction or 32. In the development of the cycle of addiction, the intake of heroin stopping of the behavior (heroin use) produces the chemical rein- leads to an increase in opioid receptor activity. “Once opioid forcers in the brain, which in turn produce craving for the behav- receptor activity has been primed, more [heroin] is needed to ior (heroin use). The craving in turn produces the continuation of ensure continued opioid receptor activity. Therefore, a cycle may the behavior (heroin use). Negative reinforcement and addiction ensue during which the desire to increase or recapture feelings of are achieved. Treatment programs using naltrexone block the pleasure or euphoria is translated into cravings for [the heroin].
pleasure reaction of opiates and opioids in the brain. But the psy- The loss of control that follows the initial consumption of a rein- chological desire for the heroin and the resulting pleasure from forcing agent [the heroin] may provide the root mechanism for using the drug causes the person to stop taking the naltrexone in . . . addictive behavior.” SAMHSA, supra note 19 at 31–32. Thus order to have the heroin have its desired effect. It is here that the use of heroin can have a “priming” for additional use. The use treatment modalities like cognitive therapy and group therapy can of heroin, even a small amount, can effect a release of endorphins have an effect, for therapy addresses the emotional need for the (which produce feelings of pleasure), which in turn increase the desire for more heroin, which in turn produce more release of 34. Kaplan & Sadock, supra note 19 at 857. See also, Emi Shufman endorphins. Addiction research has found “that opiates can have et al., The Efficacy of Naltrexone in Preventing Reabuse of Heroin an effect equal to that of having an appetizer before dinner. A after Detoxification, 35 SOCIETY OF BIOLOGICAL PSYCHIATRY 935 small dose of a substance that effects the opiate receptor sites can increase the drive to consume more of the same.” The first inges- 35. Emi Shufman et al., supra note 34 at 939. “In this study, 75% of tion of the heroin increases the motivation to have another.
the patients stayed in the program after 1 month, and 58% com- Alfred Turner, Naltrexone: The Magic Bullet for Alcoholism (1995), pleted the 3 months treatment period.” Id.at 942.
available at www.enteract.com/~alturner/neltrexo.html. “This appetizer or priming effect provides good reason to look at opiate Winter 2002 - Court Review 27
single SNAP population. Those who were married and failed to The majority of
complete treatment accounted for 93.3% of the married SNAP SNAP patients
population. Those participants who were single and failed to SUMMARY OF FINDINGS
complete treatment accounted for 80.7% of the single SNAP did not test
population. Thus, a higher percentage of those who were single positive for
successfully completed treatment than those who were married, drugs while in
and a higher percentage of those who failed treatment were mar- the program.
ried than those who failed and were single. The data may sug- gest that there may be an inverse relationship between success- ful completion and being married. An alternative theory could majority, 81%, began drug use before the age of 18. The main be that these married addicts had unstable marriages or were two introduction drugs were alcohol and marijuana. More married to addicts. If so, these negative relationships could be than 70% of SNAP participants used at least one of these drugs decreasing the opportunity for the SNAP participants to take as the first drug in their drug use histories. The median age for advantage of the program and successfully complete treatment.
first drug use was 15, and 14 years old was the mode.
Being employed was associated with program success. Those The majority of SNAP patients did not test positive for participants who were employed and successfully completed drugs while in the program. More than 75% of the participants treatment accounted for 21% of the employed SNAP population.
remained drug free. But there was not a corresponding result Those participants who were unemployed and successfully in successful treatment by SNAP participants. The majority of completed treatment accounted for 3.4% of the total unem- SNAP participants did not successfully complete the program.
ployed SNAP population. Those who were employed and failed While the majority of participants did not use drugs, only 13% to successfully complete treatment accounted for 76% of the successfully completed the treatment. These results may sug- employed SNAP population. Those participants who were gest that drug treatment success may not be related to remain- unemployed and failed to complete treatment accounted for ing drug free during treatment. The majority of participants 93% of the unemployed SNAP population. Thus, a higher per- who entered the SNAP program did so unemployed (52%). At centage of those who were employed successfully completed time of discharge, the majority of participants were employed treatment than those who were unemployed, and a higher per- centage of those who failed treatment were unemployed than Previous drug treatment histories did not provide an increased chance of successful completion in the SNAP pro- The majority of the SNAP patients started to use drugs in gram. Of the 71 SNAP participants who had prior drug treat- their early teen years. Longer periods spent using drugs were ment histories, 84.5% failed to successfully complete treatment.
associated with failure to complete treatment successfully. As would be expected, the longer participants remained in the The SNAP program achieved a 75% negative test for drug use program the higher the rate of program success. Out of the ten and 13.7% treatment success rate. A review of the literature participants who succeeded in treatment, nine remained in the shows that success rates in naltrexone treatment programs for program longer than six months. Conversely, 60.7% of those heroin addicts can range from 12% to 20%.38 who failed to complete treatment remained in the program less O’Brien and Greenstein39 note in their study that only 12% of than six months. The median length of time SNAP participants those who began treatment remained in the program beyond six remained in the program was almost five months. months. In a study conducted by Tennant and his colleagues, Being married did not prove to be a positive factor in suc- only 16% of the program participants completed the program cessful treatment. Participants who were married and success- successfully. D’Ippoliti and his colleagues conducted a study on fully completed treatment accounted for only 6.7% of the mar- treatment retention in Italy and found that after one year, the ried SNAP population. Those participants who were single and retention rate among 1,503 heroin users using naltrexone was successfully completed treatment accounted for 15.8% of the 18%.40 Some of the results of the SNAP program showed better 38. See Michael Stark & Barbara Campbell, Personality, Drug Use, and in Suburban Opioid Addicts, 45 J. OF CLINICAL PSYCHIATRY, Sept.
Early Attrition from Substance Abuse Treatment, 14 AM. J. DRUG & 1984, 42; Miguel Gutierrez et al., Retention Rates in Two ALCOHOL ABUSE 475 (1988); Charles O’Brien et al., Clinical Naltrexone Programmes for Heroin Addicts in Victoria, Spain, 10 Experience with Naltrexone, 2 AM. J. DRUG & ALCOHOL ABUSE 365 (1975); Steven Sideroff et al., Craving in Heroin Addicts Maintained 39. Charles O’Brien & Richard Greenstein, Treatment Approaches: on the Opiate Antagonist Naltrexone, 5 AM. J. DRUG & ALCOHOL Opiate Antagonists, in SUBSTANCE ABUSE: CLINICAL PROBLEMS & ABUSE 415 (1978); Richard Greenstein et al., Naltrexone: A Short- PERSPECTIVES (Joyce Lowenson & Pedro Ruizeds, 1981) 403.
Term Treatment for Opiate Dependence, 8 AM. J. DRUG & ALCOHOL 40. Forest Tennant et al., supra note 36; Daniella D’Ippoliti et al., ABUSE 291 (1981); Len Derogatic & Nick Melisaratos, The Brief Retention in Treatment of Heroin Users in Italy: The Role of Symptom Inventory: An Introductory Report, 13 PSYCHOL. MEDICINE Treatment Type and of Methadone Maintenance Dosage, 52 DRUG & 595 (1983); Richard Greenstein et al., Naltrexone: A Clinical ALCOHOL DEPENDENCE 167 (1998). See also, George W. Joe et al., Perspective, 45 J. OF CLINICAL PSYCHIATRY, Sept. 1984, 25; Herbert Recidivism Among Opioid Addicts After Drug Treatment: An Analysis Kleber & Thomas R. Kosten, Naltrexone Induction: Psychological by Race and Tenure in Treatment, 9 AM. J. DRUG & ALCOHOL ABUSE, and Pharmacological Strategies, 45 J. OF CLINICAL PSYCHIATRY, Sept.
1984, 29; Forest Tennant et al., Clinical Experience with Naltrexone 28 Court Review - Winter 2002
results than some of the work in the literature. The research There are
literature suggests that patients in a naltrexone program will “test naltrexone’s opiate blockade at least once during treat- different types of
ment.”41 The results of this program show that the patient on heroin addicts
naltrexone may not test the blocking effect of the drug. The with different
large majority of patients, 75%, did not test positive for any drugs during their participation in the program. expectancy rates
The program achieved other measures of drug treatment of successful
success noted in the literature, including employment status treatment
change and post-program arrest history. The majority of SNAP program participants left the program employed, regardless of completion.
their discharge status. Those who were employed at time of discharge had a higher rate of successful treatment than those that the program is designed to handle the type of who were not employed. Additionally, the percentage of those who were employed and who failed the treatment program wasless than those who were unemployed and failed the treatment There are different types of heroin addicts with dif- ferent expectancy rates of successful treatment com- Other observations about drug addiction in the literature were confirmed, specifically that “softer” drugs serve as an with addicts who have a stable family structure; are introduction to “harder” drugs and that drug use starts in the married to a nonaddicted mate; are highly motivated to early years of adolescence. Alcohol and marijuana proved to stop using heroin; have good jobs; have minimal anti- be the two introduction drugs to the SNAP patients. Heroin social behavior; have low drug craving/addiction; or proved to be a distant third. Drug use of SNAP participants have high professional, social, or economic status.43 began in their teen years. A majority of the SNAP patients Programs with addicts who use heroin as a “self-med- were between 13 and 18 when they first began using drugs.
ication” have a higher rate of program discontinuation These results support the general belief that drug use begins in the early years of the addict’s life, and if a person can remaindrug free through these early years the chances of becoming an II. Assessment of success of drug treatment programs should be made using multiple measures, includingabstinence rates, improvement in employment sta- POLICY IMPLICATIONS FOR THE JUDICIARY
tus, success in therapy treatment, reaching of social ON THE DESIGN AND UTILITY OF DRUG
goals, positive behavior changes, and the level of TREATMENT PROGRAMS
involvement in criminal activity, rather than onretention rates alone. The court should not assume The judiciary should assess what type of addict is that failure to complete the program is analogous to before the bench before ordering the addict to a 41. Robert Greenstein et al., supra note 24 at 677. See also, Robert 43. See, Augusta Roth et al., Naltrexone Plus Group Therapy for Greenstein et al., supra note 38 at 27. See supra note 31 to the Treatment of Opiate-Abusing Health Care Professionals, 14 J.
SUBSTANCE ABUSE TREATMENT, 19 (1997); Walter Ling & Donald 42. See, Jonathan Rabinowitz, et al., Compliance to Naltrexone Wesson, Naltrexone Treatment for Addicted Health Care Treatment After Ultra-Rapid Opiate Detoxification: An Open Label Professionals: A Collaborative Private Practice Experience, 9 J.
Naturalistic Study, 47 DRUG & ALCOHOL DEPENDENCE, Aug. 1997, CLINICAL PSYCHIATRY, Sept. 1984, at 46; Arnold Washton et al., at 77; Domingos Neto et al., Sequential Combined Treatment of Naltrexone in Addicted Business Executives and Physicians, 9 J.
Heroin Addicted Patients in Portugal with Naltrexone and Family CLINICAL PSYCHIATRY, Sept. 1984, at 39; John Gonzalez & Rex Therapy, 3 EUR. ADDICTION RES., July 1997, at 138; Philip Robson Brogden, Naltrexone: A Review of Its Pharmacodynamic and & Margaret Bruce, A Comparison of “Visible” and “Invisible” Users Pharmacokinetic Properties and Therapeutic Efficacy in the of Amphetamine, Cocaine and Heroin: Two Distinct Populations, 92 Management of Opioid Dependence, 35 DRUGS, Mar. 1988, at 192; ADDICTION, 1729 (1997); Michael Gossop et al., Severity of Richard Resnick et al., supra note 23. See also, OFF. NAT’L DRUG Dependence and Route of Administration of Heroin, Cocaine and Amphetamines, 87 BRIT. J. ADDICTION, 1527 (1992); and Arnold EFFECTIVENESS STUDY (1996); A. Thomas McLellan, Patient Washton et al., Successful Use of Naltrexone in Addicted Physicians Characteristics Associated with Outcome, in RESEARCH ON and Business Executives, 4 ADVANCES IN ALCOHOL AND SUBSTANCE TREATMENT OF NARCOTIC ADDICTION 500 (James Cooper ed., 1983). ABUSE 89 (1984). See also, infra note 41. For the assertion that 44. See, Richard Resnick et al., supra note 25. See also, Richard there is a distinction between compulsive/addictive users of Resnick et al., A Cyclazocine Typology in Opiate Dependence, 126 heroin and nonaddictive, long-term moderate users of heroin see, AM. J. PSYCHIATRY, 1256; Richard Resnick & Arnold Washton, Wayne M. Harding, Controlled Opiate Use: Fact or Artifact?, 3 Clinical Outcome with Naltrexone: Predictor Variables and Follow- ADVANCES IN ALCOHOL & SUBSTANCE ABUSE, Fall-Winter 1983, at up Status in Detoxified Heroin Addicts, 311 ANNALS NEW YORK Winter 2002 - Court Review 29
program. Selection bias produces an outcome, i.e., success or Research on
failure that can be explained as function of individual differ- program treatment modalities as for treatment of
ences among the patients and not the treatment program.
dropouts . . . notes other psychological prob-
Although, the “single most important predictor of success [is] the length of stay in treatment,”48 “the so-called retention that treatment
rate . . . simply measures the length of time an addict stays in programs work
a program,”49 not the change in the addict due to the program.
with patients who
It has also been noted that retention rates can be associated with factors outside of the program, including environmental are future
support for drug addiction, personality characteristics of the oriented, have a
addict, employment status, status and health of the addicts’ positive motivation in treatment because it does
family, psychological status of the addict, criminal history,50 the readiness of the addict to change,51 and multiple drug use to change, and are in the behavior and lifestyle of history.
at a stage in their
addiction when
III. Research shows that more than 80% of the clients preparation for
in a drug treatment program drop out from the pro- gram during a first attempt at drug treatment. The change is
court should determine if the addict is at a point in achieved.
his or her addiction that allows for successful success is vulnerable to selection bias because those who suc-cessfully stay in a treatment program do so because the pro- Research on program treatment dropouts as well as theory gram expels them or they choose to remain in the program.
on behavior change notes that treatment programs work with Thus, the “success” or “failure” of the program based on reten- patients who are future oriented,52 have a positive motivation tion is artificially inflated or deflated by those who are removed to change,53 and are at a stage in their addiction when prepa- from the program either by the participants’ choice or by the ration for change54 is achieved. The future-oriented addict has 45. George DeLeon & Nancy Jainchill, Circumstances, Motivation, see, James Prochaska et al., The Transtheoretical Model of Behavior Readiness and Suitability as Correlates of Treatment Tenure, 18 J.
Change, in THE HANDBOOK OF HEALTH BEHAVIOR CHANGE 59 (Sally Shumaker et al. ed., 2nd ed., 1998), and Neil Grunberg et al., It has been asserted that treatment programs are destined for Biological Obstacles to Adoption and Maintenance of Health- failure because they don’t consider the multifaceted factors of why Promoting Behaviors, in THE HANDBOOK OF HEALTH BEHAVIOR the treatment is being offered, the difference between treatment CHANGE 269 (Sally Shumaker et al. ed., 2nd ed., 1998). and therapy, why an addict is seeking treatment, who is offering 52. Nachman Ben-Yehuda, supra note 46. The future-oriented indi- the treatment, and why the addict has an addiction. Additionally, vidual looks to the future and makes plans to make his or her life the lack of specific and meaningful goal setting for the individual better in the future. Decisions are meant to generate change as addict, the lack of specific diagnosis of the individual addict, the supposed to a past-oriented person who lives from moment to confusion of goals to help the addict become an effective patient moment, who is resistant to change or unwilling to take account with goals to make the patient a better citizen by improving his or of behavior and make decisions that produce benefits in the her lifestyle, and confusing different theories of therapy and treat- future. Id. at 88, 97. “Future-oriented patients apparently benefit ment modalities all help to create program design problems that most from their therapeutic experience in [drug treatment] pro- lead to failure. See, Stanley Einstein, Factors Initiating/Affecting grams.” Id. at 97. This classification as either past or future ori- the Treatment of Drug Use and the Drug User, 15 INT’L J. ADDICTIONS ented can be helpful in the designing and the selection of clients for a potential drug treatment program. “Upon admission . . .
46. Nachman Ben-Yehuda, Success and Failure in Rehabilitation: The patients could be classified . . . as to the behavior expected of Case of Methadone Maintenance, 9 AM. J. COMMUNITY PSYCHOL., 83 them while [in] the program. This information could potentially (1981). It has also been observed that since treatment programs help clinical and administrative personnel working with drug- generally are not evaluated using random selection of patients abuse to better deal with their patients, construct differential and control groups and established baseline measurements and treatment plans for them, and assess success more meaningfully.” have reliability and validity limitations, the fact of high attrition rates should not be the sole assessment of success. William Berg, 53. George DeLeon & Nancy Jainchill, supra note 45. A positive moti- Evaluation of Community-Based Drug Abuse Treatment Programs: A vation is “ a desire to forge a new lifestyle; a belief that one can be Review of the Literature, in THE ADDICTIVE PROCESS: EFFECTIVE successful and have the good things in life; or a desire for per- SOCIAL WORK APPROACHES 81 (E. Freeman ed., 1992). sonal growth, to be a better person . . . as well as to have health- 47. William Berg, supra note 46 at 84.
ier relationships.” Id. at 203.
54. James Prochaska et al., supra note 51. In the preparation stage 48. Nachman Ben-Yehuda, supra note 46 at 85.
“people are intending to take action in the immediate future, usu- ally measured as during the next month. These individuals have 51. George DeLeon & Nancy Jainchill, supra note 45. For two theo- a plan of action. . . . These are the people we should recruit for ries on the readiness to change and its impact on behavior change . . . action-oriented programs.” Id at 61.
30 Court Review - Winter 2002
decided to make a change and end his or her addiction. The Many of those
addict is positively motivated because the change is self- desired—the addict wants a better life. The addict is prepared who enter
to change and demonstrates this preparation by the formation drug treatment
of a plan to end the addiction. The addict enters the program programs have
having decided to enter a treatment program with the desire and expectation to successfully complete it, as compared to moderate to
entering the program to avoid incarceration. severe mental
If the program is servicing addicts who have not reached the illness.
point of having a future-oriented, positively motivated, pre- pared mental state to make a change in their lives (i.e., end their heroin addiction) success rates will be low regardless ofthe value of the program. The nature of addiction has been described as a state in which the addict (1) has a persistent regular use of a drug; (2) IV. The presence of psychological dysfunction on attempts to stop such use leads to significant and painful with- potential clients can affect retention and successful drawal symptoms; (3) continues to use the addictive drug completion rates. The court should determine despite damaging physical or psychological problems, or both; whether the treatment modality can accommodate (4) engages in compulsive drug-seeking behavior; and (5) clients who have psychological problems.
needs a constant increasing level of dosage of the drug to get Treatment programs need to be designed to address the individual addict and quality-of-life issues that Treatment programs should implement program modalities the addict is experiencing, along with the addiction in the light of recent research that has observed that (1) drug use occurs within a broader family of social and psychologicalproblems, (2) cognitive-behavioral abilities are fundamentally Many of those who enter drug treatment programs have psychological in nature, (3) the motivation to change is a cog- moderate to severe mental illness.55 More significant is the fact nitive-behavioral process, and (4) the skills and the relation- that only about half of those addicts who have a mental illness ship between the client and the individual counselor has an receive treatment for the mental illness and the drug addiction together.56 The presence of mental illness and dropout rateshave been shown to be associated.57 Research has also found VI. The court should consider if the drug treatment pro- that mental illness can affect the ability to function and how gram design encompasses the biochemical as well as drugs impact the individual.58 Programs that address both drug the cognitive-behavioral aspects of addiction when addiction and mental illness should design treatment modali- designing drug addiction treatment modalities. ties to take into account the importance of the client’s quality oflife. Recent research has noted that the patients’ quality of life Virtually “all drugs . . . have common effects, either directly (family support, employment, positive self-image, etc.) can pre- or indirectly, on a single pathway deep within the brain.”62 In 55. Peggy el-Mallakh, Treatment Models for Clients with Co-Occurring # 147) (Roa Rapaka & Heinz Sorer eds., 1995), at v. Addictive and Mental Disorders, 12 ARCHIVES PSYCHIATRIC NURSING, 61. William Miller & Sandra Brown, Why Psychologists Should Treat Alcohol and Drug Problems, 52 AM. PSYCHOL. 1269 (1997). James 57. H. Lawrence Ross et al., Retention in Substance Abuse Treatment: drug abuse as overdetermined behavior. That is, physical Role of Psychiatric Symptom Severity, 6 AM. J. ADDICTION 293 dependence is secondary to the wide range of influences that instigate and regulate drug-taking and drug seeking 58. Jennifer Tidey et al., Psychiatric Symptom Severity in Cocaine- behaviors. In the vast majority of drug offenders, there are Dependent Outpatients: Demographics, Drug Use Characteristics cognitive problems; psychological dysfunction is common; and Treatment Outcome, 50 DRUG & ALCOHOL DEPENDENCE, Mar.
thinking may be unrealistic or disorganized; values are mis- shapen, and frequently, there are deficits in education and 59. Joan Russo et al., Psychiatric Status, Quality of Life, and Level of employment skills. [D]rug use is a response to a series of Care as Predictors of Outcomes of Acute Inpatient Treatment, 48 social and psychological disturbances.
PSYCHIATRIC SERVICE 1427 (1997). For research on addressing theemotional and spiritual factors that can affect heroin treatment James Inciardi, “Drug Treatment in Prisons,” presentation at the success or failure see Karen Miotto et al., Overdose, Suicide Summit on U.S. Drug Policy, U.S. House of Representatives, Attempts and Death Among a Cohort of Naltrexone-Treated Opioid Committee on the Judiciary, Washington, D.C. (May 7, 1993), at Addicts, 45 DRUG & ALCOHOL DEPENDENCE Apr. 1997, at 131, and 3–4. See also, Robert Hooper et al., Treatment Techniques in Leslie Green, et al., Stories of Spiritual Awakening: The Nature of Corrections-Based Therapeutic Communities, 73 PRISON J., Spirituality in Recovery, 15 J. SUBSTANCE ABUSE TREATMENT, 325.
60. Rao Rapaka & Heinz Sorer, Introduction, in DISCOVERY OF NOVEL 62. Alan Leshner, Addiction Is a Brain Disease, and It Matters, 278 OPIOID MEDICATIONS (Nat’l. Inst. on Drug Abuse Res. Monograph Winter 2002 - Court Review 31
occurring neurotransmitters in the brain, such as dopamine The use of
and serotonin. Dopamine produces immediate feelings of naltrexone
pleasure and elation that reinforce certain behaviors, such as eating or sex, and motivates repetition of these activities.67 addresses the
Dopamine is believed to be produced with the use of opiates.
results of heroin opiates “can be more powerfully
“Serotonin is associated with the reinforcing effects of many use due to
abused drugs through its mood regulating and anxiety reduc- impulsive and
ing effects. Low levels of serotonin are associated with depres- sion and anxiety.”68 The lack of stimulation by opioid recep- compulsive
tors is believed to be a cause for low levels of dopamine and behavior.
serotonin. The lack of these two chemicals is thought to pro- duce depression, which in turn produces the craving for the heroin to relieve feelings of depression and to restore feeling In studies dealing with positive and negative reinforcement, pleasure or at least feeling “normal.” it is believed that if pleasure responses can be secured artifi- The cycle of addiction and compulsive and impulsive drug cially a person will choose the artificial stimulation even over use is compounded by biochemical change within the brain69 natural positive stimulation such as food or sex.
and cognitive-behavioral cues. The cycle of addiction is [The] process in which a pleasure-inducing started by positive reinforcement and then driven by negative action becomes repetitive is called positive rein- reinforcement. Heroin produces a strong pleasure effect, and forcement. Conversely, abrupt discontinuation of cognitively, the user decides to use the drug again to receive alcohol, opiates, and other psychoactive drugs fol- the same pleasurable effect. The opioid receptors of the brain lowing chronic use . . . results in discomfort and become addicted to the presence of the heroin and then require craving. The motivation to use a substance in order the heroin stimulation continuously. Here is where negative to avoid discomfort is called negative reinforcement.
reinforcement takes control. The user no longer takes the Positive reinforcement is believed to be controlled heroin to feel pleasure, but to feel “normal.” The purpose in by various neurotransmitter systems, whereas nega- taking the heroin is to avoid painful sensations not to enjoy tive reinforcement is believed to be the result of pleasurable sensations. During drug treatment the addict will adaptations produced by chronic use within the desire to take heroin on two levels. Impulsive use will occur due to cues in the environment or by memories of taking thedrug. The addict takes the drug almost without thinking about The use of heroin creates both positive and negative rein- the consequences. Compulsive (craving) drug use occurs due forcement through its processing within the brain. The heroin to the addict obsessing over the pleasure gained by the drug.
acts as an exogenous opiate within the brain and acts as a neu- The addict thinks about the drug, and the thoughts drive the rotransmitter for pleasure within the brain. The heroin pro- duces a stronger pleasure reaction than endogenous opioids The use of naltrexone addresses the results of heroin use due to impulsive and compulsive behavior.70 But the issue The chronic use of exogenous opiates within the pleasure- treatment programs need to contend with is the cognitive seeking system drives the need for the exogenous opiates, and behavior of addicts in that they decide that life without heroin the opioid receptors are now only stimulated by the exogenous is not desirable and simply choose to stop taking the naltrex- opiates, rather than by natural pleasure stimuli. “Natural rein- one so that they can enjoy the pleasure of the heroin. The forcers such as food, drink, and sex [which] activate [pleasure] treatment therapy must create new cognitive pathways within pathways in the brain [are replaced by the exogenous opiates] the brain to allow for controlling the cravings71 for the heroin as surrogates of the natural reinforcers.”66 It is also believed and new behavior patterns to deal with the social factors of that the use of these opiates and the negative reinforcement their lives. Since human beings have the ability to cognitively they produce (the need for the opiates to avoid pain due to choose to do or not do something, drug treatment programs lack of presence of the opiate) are aided by other natural need to focus on how the individual addict handles life stres- 63. See, supra notes 21, 31–33.
for a series of articles on the biochemistry of addiction. 64. SHAMSHA, supra note 21 at 27.
70. See, supra notes 27–32 and accompanying text. 71. For general discussion on craving and drug use see, Raymond Anton, What Is Craving? Models and Implication for Treatment, 23 67. Id. at 28. See also, Robert Swift, Medications and Alcohol Craving, ALCOHOL HEALTH & RES. WORLD: J. NAT’L INST. ALCOHOL ABUSE & 23 ALCOHOL RES. & HEALTH: J. NAT’L. INST. ALCOHOL ABUSE & ALCOHOLISM, 165 (1999); Stephen Tiffany, Cognitive Concepts of ALCOHOLISM, 207 (1999). See also infra notes 69 and 71 for stud- Craving, 23 ALCOHOL HEALTH & RES. WORLD: J. NAT’L INST.
ies dealing with craving and the biochemical dynamics of drug ALCOHOL ABUSE & ALCOHOLISM, 215 (1999); and Mary Jo Breiner et al., Approaching Avoidance: A Step Essential to the Understanding 68. SHAMSHA, supra note 21 at 27. See also, infra notes 69 and 71.
of Craving, 23 ALCOHOL HEALTH & RES. WORLD: J. NAT’L INST.
69. See Neuroscience: Pathways of Addiction, 21 ALCOHOL HEALTH & ALCOHOL ABUSE & ALCOHOLISM 197 (1999).
RES. WORLD: J. NAT’L INST. ALCOHOL ABUSE & ALCOHOLISM (1997) 32 Court Review - Winter 2002
sors and train the addict to resort to socially positive alterna- Although the
tives to reduce stress, rather than resort to the use of heroin. brain, there is some debate on thecause of addiction. For example, literature is
VII. The biochemical and cognitive-behavioral aspects settled on the
of drug addiction present the criminal justice sys- fact that
tem with political as well as social policy issues.
The criminal justice system needs to contend with addiction causes
the implications of the fact that drug addicts have changes in the
altered brain chemistry, while maintaining its brain, there is
inherent purpose of focusing on individual accountability and responsibility. Conversely, drug some debate on
treatment designers and drug addiction scientists the cause of
must contend with the fact that personal responsi- addiction.
bility and accountability will always be a demand of policy makers and the public regardless of the Heyman, while agreeing, “changes in brain function alter Research on addiction shows that prolonged drug use voluntary behavior,” notes that addiction is still a behavior of “causes pervasive changes in the brain [and] the addicted which social and economic costs can persuade addicts to end brain is distinctly different from the non addicted brain” and their addiction.76 Heyman asserts that there are two types of this fact leads to the conclusion that on a general policy level addicts, those who take drugs voluntarily and those who do so “the addicted individual must be dealt with as if he or she is in involuntarily. The former can be persuaded cognitively but the a different brain state.”72 In other words, treat drug addicts as latter will “not be persuaded by costs and incentives to stop those whose minds have been “altered fundamentally by using them.”77 O’Brien asserts that three factors should be drugs.”73 Although the literature is settled on the fact that kept in mind when considering addiction and how to deal with 72. Alan Leshner, supra note 62 at 46. See also, George Koob et al., abnormalities that are shared by all addictive disorders and Neuroscience of Addiction, 21 NEURON 467 (1998). Some recent 2) those that relate to the selection of a particular substance research has asserted that addiction can be traced to genetics, see as the one that is preferred for addictive use. I would add Thomas Kosten, Addiction as a Brain Disease, 155 AM. J.
that each set includes both genetic and environmental fac- tors. Environmental factors in the development of the 73. Alan Leshner, supra note 62 at 46.
underlying neurobiological abnormalities include deficien- 74. Charles O’Brien, Progress in the Science of Addiction, 154 AM. J.
cies in the child’s caregiving environment during the first PSYCHIATRY 1195, 1195 (1997). O’Brien asserted that years of life, when the maturing brain is most sensitive to Drug exposures . . . paired with environmental cues (per- external influences and depends on particular qualities of sons, places, things) . . . acquire the ability to activate the interchange with the caregiving environment for healthy same or complementary brain circuits even in the absence development. Genetic factors in selection include geneti- of the drug. Id. Drug-related cues alone have [been shown cally based variations in 1) the sensitivity of the reward sys- to produce] increases in limbic blood flow in formerly tem to different substances, 2) the body’s sensitivity to dependent cocaine users . . . . Drug cues have also produced immediate aversive consequences of using a substance increases in the metabolism of specific brain areas. Id. at (such as flushing or standing ataxia after ingestion of alco- hol), and 3) the intensity of the individual’s sensitivity tovarious painful effects [which are] associated with . . . neg- This explains why addiction is considered to be a chronic disease.
Although the use of drugs has ended, pathways and brain chem-istry have been altered so as to produce the effects of the “disease” See, Bruce Lawford et al., The D(2) Dopamine Receptor A (1) allele although the agent causing the disease is no longer present.
and Opioid Dependence: Association with Heroin Use and Response Although this chemical analysis may be true, the choice of whether to indulge in an impulse or compulsive need (chemically NEUROPSYCHIATRIC GENETICS 592 (2000), for research showing that created or not) is not destroyed. One still chooses to indulge a heroin addicts that have a certain type of dopamine receptor are desire and one chooses to frequent an area that provides those more likely to drop out or fail a methadone treatment program than those without this variation. The research noted that there 75. Aviel Goodman, Science of Addiction (Letter to the Editor), 155 were significantly more heroin addicts with this variation (TaqI AM. J. PSYCHIATRY 1642, 1642 (1998). Goodman goes on to say A(1) allele of the D(2) dopamine receptor) in a group of addicts that had poor treatment outcomes compared to those who hadsuccessful treatment outcomes. The researchers also found that I would describe addiction as a chronic condition that 19% of the heroin addicts had this variation compared to 4.6% of develops through a process that involves complex interac- a control group of people free from drug and alcohol use and free tions over time between genetic and environmental factors.
from a family history of alcohol and drug use.
More specifically, I would propose that two sets of determi- 76. Gene Heyman, On the Science of Substance Abuse (Editorial), 278 nants are involved in the development of an addictive dis- order: 1) those that concern underlying neurobiological Winter 2002 - Court Review 33
political policy may not be aware or care about the science of [T]he judiciary
addiction, especially if the idea of personal responsibility is not should make
reflected in theories of addiction. For example, Congress has recently restricted social security payments and other social sure that a
benefits from those who have drug addictions.80 Similarly, the proposed drug
judiciary should make sure that a proposed drug treatment treatment
program modality includes personal responsibility and behav- ior modification as one of the tools to address drug addiction.
Both the science of addiction and personal responsibility modality includes biological issue involving brain
add to the understanding of addiction and addiction treatment.
personal
Moral responsibility aside, drug addiction brings serious and responsibility
chronic physical and social consequences.81 Heyman, three factors should be kept in mind when trying to and behavior
understand addiction: “[1] drug use in addicts can be altered modification as
by the proper arrangements of costs and benefits, [2] addictive one of the tools
drugs reduce options but do not eliminate choice, and [3] the biology of addiction is the biology of voluntary behavior.”82 to address drug
addiction.
belittled in some of the litera-ture, there is value in the com- mon belief that human beings think and thus can control their Arthur H. Garrison is the criminal justice plan- behavior. The ability to be responsible for an addiction accom- ning coordinator for research and program eval- panies the power to end addiction. The mere fact that one has uation at the Delaware Criminal Justice damaged his or her brain and formed neuropathways for cer- Council. He is a member of the Society of Police tain stimuli does not mean that the ability to choose has been and Criminal Psychology. Garrison has pub- destroyed. The fact that human beings have the ability to lished articles in various journals, including the think, learn (form new neuropathways), and choose between New England Journal on Criminal and Civil behaviors seems to be acknowledged as an afterthought by Confinement, Journal of Police and Criminal some of the literature on addiction. The political (used here to Psychology, Police Studies, Issues in Child Abuse Accusations, mean philosophical) view that behavior is a cognitively con- American Journal of Trial Advocacy, and Juvenile and Family trolled activity that is at least equal in the cause and mainte- Court Journal. Garrison received his B.S. (1990) from Kutztown nance of addictive behavior needs to be considered by treat- University of Pennsylvania and his M.S. (1995) from West ment program designers and neuroscientists. Those who make Chester University of Pennsylvania. 78. Charles O’Brien, Dr. O’Brien Replies (Letter to the Editor in PSYCHOL. 503 (2001). See also, Yih-Ing Hser et al., A 24-Year Response to Dr. Goodman), 155 AM. J. PSYCHIATRY 1642 (1998).
Follow-Up of California Narcotics Addicts, 50 ARCHIVES GEN.
PSYCHOL. 577 (1993); Edna Oppenheimer & Gerry Stimson, 79. Alan Leshner, supra note 62 at 45.
Seven-Year Follow-Up of Heroin Addicts: Life Histories Summarized, 80. See, Carole Gresenz et al., Supplemental Security Income (SSI), Disability Insurance (DI) and Substance Abusers, 34 COMMUNITY SIMPSON & B. SAUL SELLS, OPIOID ADDICTION AND TREATMENT: A 12 81. For studies on long-term affects of heroin use see, Yih-Ing Hser et 82. Gene Heyman, supra note 76 at 16.
al., A 33-Year Follow-Up of Narcotics Addicts, 58 ARCHIVES GEN.
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