A Changing View of Drug Addiction

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Drug-related convictions place a substantial burden on the criminal justice system and on society. The MD Magazine Peer Exchange “Medication-Assisted Treatment in Drug Abuse Cases: A Path to Success” features a panel of experts in the criminal justice field who provide insight on medication-assisted re-entry programs.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Phillip Barbour, master trainer with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jac Charlier, director for consulting and training, also with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jonathan Grand, MSW, LICSW, senior program associate at the Advocates for Human Potential in Sudbury, MA
• Joshua Lee, MD, MSc, associate professor in the Department of Population Health, and a research clinician at Bellevue Hospital Center, NYU Langone Medical Center, and the New York City jails

Peter L. Salgo, MD: When people think of drug addicts, I think that the common perception is that it’s opioid related. How much of the criminal justice issue is opioid related?

Jonathan Grand, MSW: We know that approximately two-thirds of the inmates in the United States have been diagnosed with substance abuse disorders. So, that’s a major player in our criminal justice system. And the system is just exploding with people who have substance abuse problems to the point where we now have drug courts—and we have over 3,000 drug courts in the country—to relieve the prisons and the jails of the nonviolent folks who have addiction problems.

Peter L. Salgo, MD: And how many of the folks who are suffering from addiction problems in the criminal justice system turn out to be repeat offenders?

Jonathan Grand, MSW: Of the people with diagnosed substance abuse disorders, about 50% of them relapse within 1 month after discharge. And there’s another number that’s really dramatic. In addition to that, within 2 weeks of inmates being discharged, there’s 129 times more of a chance of them dying from a drug overdose than the average person.

Peter L. Salgo, MD: I was going to ask that. The science behind that sounds pretty clear to me—they go to prison. One thinks, one hopes, they’re not going to get drugs in prison, although that may not be true. But they come out clean. They go back and take a drug dose that they previously were taking because they were tachyphylactic to that dose; they were used to it. The dose is now a massive overdose, right?

Jonathan Grand, MSW: Yes.

Joshua Lee, MD, PhD: As well as mixing drugs and alcohol, which is a typical experience with people when they get out of an institution or controlled environment, and that’s also a risk factor for overdoses.

Peter L. Salgo, MD: What have we learned about addiction over the years that we’ve been studying it? When I was a kid, it was all injectable heroin. These were the bad people and they were in the bad neighborhoods, and good people never saw these drugs. We didn’t have to worry about it. That’s changed, hasn’t it?

Jac A. Charlier, MPA: Sure. I’ll tell you just from experience. Josh is going to chime in on the neuroscience, so I’ll leave that to him. I know when I started out, and my background is actually from law enforcement, the view of addiction was very much the lay view of the moral issues around it. You use because you fail morally, you don’t have the right upbringing.

Peter L. Salgo, MD: “Just say no.”

Jac A. Charlier, MPA: Exactly, “Just say no.” And from when I first came out onto the streets working as a state law enforcement officer to now, the understanding of addiction as a chronic relapsing disease of the brain has been astounding. What it means for the practice in the field of behavioral health, medicine, but also for criminal justice and the implications for how we supervise people, and how we handle people when they do things that we don’t like or shouldn’t be doing is just massive. Because we now understand it from a very different point of view.

Peter L. Salgo, MD: You applied their science here.

Joshua Lee, MD, PhD: We have a pretty good understanding of addiction as a brain disorder, not unlike depression or other mental health diagnoses or other chronic diseases like hypertension or diabetes, that is an interaction between a human being and their environment. But as far as we can tell, people have been experimenting with and abusing or misusing naturally occurring substances they could make in the kitchen for neuropsychiatric purposes, for intoxication, for relaxation, or for pain control. And then some of these substances turned out to have side effects. They’re addictive. They’re deadly, and you’re left with the burden of disease that we have today. It has to do somewhat with your individual vulnerability. And if your dad was an alcoholic, that definitely impacts your own personal risk. But in the end, you’re just talking about a naturally occurring problem within the human population.

Peter L. Salgo, MD: Is this a biochemical receptor issue? Some people use a drug—for the sake of argument, oxycodone, or say heroin—they use it a few times, they never use it again. Some people use it once, ballgame over. What’s the difference?

Joshua Lee, MD, PhD: Most people’s experience with any drug, even if it’s the most addictive drug or the least on your ladder of risky potential, will not develop a drug problem. We’ve probably all used alcohol or tobacco or other potentially addictive substances in our life and didn’t graduate to more problems. So, there’s something about each particular person in terms of their vulnerability and reasons they might be using it. But, some agents are more physically addictive, and opiates are a good example.

If I put us all on opiates for a couple of days, we would develop a physical tolerance, period. It’s universal; it’s how the brain works; it’s how opiates work in our opiate receptor system. In the brain, you’ll develop physical tolerance. That’s then reinforcing. If you stop the oxycodone after knee surgery all of a sudden, you’ll have some withdrawal symptoms. That’s, again, universal; it happens to everybody. Some of the agents like opioids are so universally physically dependent after a pretty short amount of time and in pretty low doses that no human being escapes that effect.

And that’s part of why people become addicted to opiates in particular. But, again, most people will be prescribed opiates. And we’re going to talk about how we’re in the midst of a United States opiate epidemic and that one will probably not get addicted after their surgery or their wisdom teeth get pulled. But enough people do, and we’re becoming much more sophisticated about our understanding of the rates of the spinoff of addiction from opiate prescribing in general. Those rates of people that do become addictive, while low in the overall number of people that get these drugs, are much higher than we ever thought. Now, we’re totally rethinking how we prescribe opiates.