The Science of Substance Abuse

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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

Phillip Barbour: Peter, I want to go back to something when you first asked the question. Not only do I work in the field and I have now for more than 25 years, I’m also a hair club client. I came through the criminal justice system just as Jac described. I was on probation, I used heroin for a little over 12 years. And through the court system, I was offered the opportunity to get treatment. Well, it didn’t feel like an opportunity at the time. It was do the treatment or go to jail. So, obviously I chose to go into treatment. And if I had known half of what Josh just talked about, I probably never would have started. But like I say, I came up during an era where getting high was fun. Cheech & Chong movies, the High Times magazine, those kind of things. I didn’t know any better. But as Josh mentioned, it didn’t take long for me to develop that tolerance and to actually develop a heroin addiction that lasted for a dozen years.

Peter L. Salgo, MD: Well, first of all, I don’t want to go any further before saying, congratulations. I’m glad you did that, and you’re here today, because a lot of people just aren’t. A lot of people died.

Phillip Barbour: I guess I mentioned that because I wanted to dispel a little bit of the myth behind what a heroin addict looks like. I’m a United States military veteran, and I didn’t start using heroin until after I got out of the military. I always had good jobs, had a good childhood. So, stereotyping bothers me a little bit because I wasn’t the guy who was supposed to be a heroin addict, but that’s exactly what happened.

Jac A. Charlier, MPA: I wanted to cut in on something earlier to tie in a question that you asked Phil and then Josh about; so addiction and then the neuroscience. From the criminal justice side, my background, we understand addiction as being criminogenic. This is important for the medical community to know. What we mean by that is we accept a statistical linkage between drug use because of the addictive elements or qualities of drug use and crime. For example, on CNN, Fox News, where some shooting happens, everyone wants to know if the person is mentally ill.

Mental health is not criminogenic, which means there’s no statistical link between having a mental health disorder and committing crimes. This is really important. It is why getting at the root of addiction and treatment by the medical community is so important to crime reduction and to neighborhood safety—because there is a statistical link between drug use and committing crime.

Joshua D. Lee, MD, PhD: However, a lot of that is self-fulfilling because we have made drug use illegal.

Jac A. Charlier, MPA: Yes.

Peter L. Salgo, MD: And then they wind up in the criminal justice system.

Jac A. Charlier, MPA: That’s right.

Joshua D. Lee, MD, PhD: But it’s important to point out that a lot of violent crimes—property crime, not a drug crime—are committed while people are under the influence, intoxicated, most of which lead to violence, homicide.

Jac A. Charlier, MPA: And it’s very high. In over 75% on many of the things Josh just said, there’s drug use, drug involvement somewhere. So, absolutely.

Peter L. Salgo, MD: Well, if we believe Josh, the addiction is physiologic. There are receptors and then these receptors need to have a drug. So, why is it in the popular press over and over again don’t talk about this as a medical problem, but we talk about it as a psychosocial problem? Again, I come back to just saying “no.” You can’t just say “no” if your brain is addictive, right? Am I wrong?

Joshua D. Lee, MD, PhD: It’s psychosocial in that we can try and influence the high school kids to just say no.

Peter L. Salgo, MD: That would be a “don’t start.”

Joshua D. Lee, MD, PhD: There’s prevention messaging. And in recovery and in treatment, it’s not just about what’s going on in my brain as opposed to social networks, community standards—moral influences. I wouldn’t say that’s completely unimportant or out of place. But it’s really a brain disorder in terms of which one of the 10 people winds up being a smoker for the rest of their life, and how we successfully get that person to stop smoking or put down heroin or alcohol? And the most successful treatment techniques tend to then get away from the “Just say no” messaging, and really have a neurobiological basis.