Management of Management of AddictionAddiction

in the in the Criminal Justice Criminal Justice

SystemSystem

Management of Management of AddictionAddiction

in the in the Criminal Justice Criminal Justice

SystemSystem

Dr Oliver AldridgeDr Oliver AldridgeMBBCh, DRCOG, MRCGPMBBCh, DRCOG, MRCGP

Certificant of the International Society of Addiction MedicineCertificant of the International Society of Addiction Medicine

Dr Oliver AldridgeDr Oliver AldridgeMBBCh, DRCOG, MRCGPMBBCh, DRCOG, MRCGP

Certificant of the International Society of Addiction MedicineCertificant of the International Society of Addiction Medicine

Scots Parliament of Scots Parliament of 16171617

Scots Parliament of Scots Parliament of 16171617

...all persons lawfully convicted of drunkenness...

•First offence: £3 or 6 hours in prison

•Second offence: £5 or 12 hours in prison

•Third offence: £10 or 24 hours in prison

•Subsequent offences: "committed to jail until they find security for their good behaviour."

Death Penalty for Drug Death Penalty for Drug OffencesOffences

Death Penalty for Drug Death Penalty for Drug OffencesOffences

High Commitment

•China

•Iran

•Saudi-Arabia

•Vietnam

•Singapore

•Malaysia

Low Commitment

•Indonesia

•Kuwait

•Thailand

•Pakistan

•Egypt

•Syria

•Yemen

•Bangladesh http://www.ihra.net/files/2010/06/16/IHRA_DeathPenaltyReport_Web1.pdf

Symbolic Application Symbolic Application StatesStates

Symbolic Application Symbolic Application StatesStates

•Oman

•Qatar

•India

•Bangladesh

•UAE

•Sri Lanka

•Bahrain

•USA

•Gaza

•South Korea

•South Korea

•Myanmar

•Lao

•Brunei-Darussalam

•Cuba

Scotland's Prison Scotland's Prison PopulationPopulation

Scotland's Prison Scotland's Prison PopulationPopulation

•Per 100,000 population

•www.prisonstudies.org/info/worldbrief/wpb_country.php?country=171

Reconviction Rates - 1 year

Reconviction Rates - 1 year

http://www.scotland.gov.uk/Topics/Statistics/Browse/Crime-Justice/TrendData

The Road to Recovery: The Road to Recovery: 20082008

The Road to Recovery: The Road to Recovery: 20082008

•"People who use drugs undermine their potential to lead rich and fulfilling lives"

•"...one third to over a half of all acquisitive crime is related to illegal drug use"

Drug use and offendingDrug use and offendingDrug use and offendingDrug use and offending

•High rates of drug problems in prison:20-50%

•DTTO: Reduction in drug use - the primary focus of work to reduce offending behaviour

•Offending substantiates diagnosis of addiction (eg TOPS)

Hierarchical Hierarchical RelationshipRelationshipHierarchical Hierarchical RelationshipRelationship

Drug Use

Criminal Justice System

QuestionsQuestionsQuestionsQuestions

•Coercion: not in Rx for the right reasons?

•Hobson's choice?

•Committing crime to gain access to a service?

•Why not access regular drug treatment?

Initiation of Drug UseInitiation of Drug UseInitiation of Drug UseInitiation of Drug Use

•Age 11/12: Nicotine and Alcohol

•Teenage Years: Benzodiazepines, Cannabis, "PartyDrugs", Hallucinogens, Gas, Dissociatives

•Heroin: later onset drug, around 19 yrs.

•25% first use Heroin in custody

Involvement with the Involvement with the Criminal Justice SystemCriminal Justice SystemInvolvement with the Involvement with the

Criminal Justice SystemCriminal Justice System

•Adult convictions from age 16

•Children's Hearing System

Acquired Brain InjuryAcquired Brain InjuryAcquired Brain InjuryAcquired Brain Injury

•Contact sports

•Domestic violence

•Adolescent males who drink

•Falls

•Fights

Incidence of TBIIncidence of TBIIncidence of TBIIncidence of TBI

•8.5% of General Population

•71% of DTTO audit had experienced at least one episode of traumatic loss of consciousness

•Majority as teenagers (age range 5 - 31).

•Mostly as a result of fighting or assault

•As a group had had very little, if any, follow up

FrankensteinFrankensteinFrankensteinFrankenstein

•Mary Shelley

•Adapted by Nick Warburton 2000

FrankensteinFrankensteinFrankensteinFrankenstein•"I came across people, other beings which I

could see were almost like myself. Or so I thought at first when I approached them, though, I found that they did not consider me as one of their own kind. As soon as they saw me, their faces became twisted with fear. They shouted at me and threw things and ran away from me, just as my own maker had done. So this is what I learned about myself - that I was a disgusting creature. Even though I had given them no cause, all men hated me."

Childhood TraumaChildhood TraumaChildhood TraumaChildhood Trauma

• Violence in the home

• Parental substance misuse (including alcohol)

• Care system

• Bereavement

• Poverty

• Abuse: sexual/physical/emotional

• Stigmatisation: eg parental imprisonment

• Learning disability

• Traumatic brain injury

• Poor nutrition

• Difficulty managing contrasting school vs home vs street environment

Social ExclusionSocial ExclusionSocial ExclusionSocial Exclusion

•"... is about more than income poverty. It is a short hand term....combination of linked problems...unemployment, discrimination, poor skills, low incomes, poor housing, high crime and family breakdown. These problems are linked and mutually reinforcing." Mooney et al 2010

AlienationAlienationAlienationAlienation

•Jimmy Reid (1932-2010)

•Rector of Glasgow University 1971

•New York Times: "the greatest speech since President Lincoln's Gettysburg Address"

"People feel alienated by "People feel alienated by society"society"

Jimmy Reid 1972Jimmy Reid 1972

"People feel alienated by "People feel alienated by society"society"

Jimmy Reid 1972Jimmy Reid 1972

•"It is the cry of men who feel themselves the victims of blind economic forces beyond their control....excluded from decision making. The feeling of despair and hopelessness that pervades people who feel with justification that they have no real say in shaping or determining their own destinies."

Addiction FactoryAddiction FactoryAddiction FactoryAddiction Factory

•Bruce Alexander

•Psychosocial dislocation

Alienation SyndromeAlienation SyndromeAlienation SyndromeAlienation Syndrome

•"Alienation expresses itself in different ways in different people....criminal antisocial behaviour....drop outs.....so called maladjusted....who seek to permanently escape from the reality of society through intoxicants and narcotics."

•"It is a much greater factor in all of them than is generally recognised"

Addiction becomes Addiction becomes pre-eminentpre-eminent

Addiction becomes Addiction becomes pre-eminentpre-eminent

•Drug use cements people in the criminal justice system

•Failure to address addiction fatally undermines other rehabilitative attempts

•"A particular form of ill-treatment and possibly torture of drug users is the denial of opiate substitution treatment" UN Special Rapporteur 2013

Prison as gold Prison as gold standard??standard??

Prison as gold Prison as gold standard??standard??

•400 years later, instinct is still to punish

•Good at keeping people alive

•Poor at fostering recovery

http://www.scccj.org.uk/wp-content/uploads/2012/08/SCCCJ-Report-on-Addictions-Recovery-Prisons-210512-

Narcotics FarmsNarcotics Farms1935 - 1960's1935 - 1960's

Narcotics FarmsNarcotics Farms1935 - 1960's1935 - 1960's

•$4M institution on 1000 acres of farmland

•Relapse rate on release "close to 100%" - NIH consensus statement 1997

Problem Solving JusticeProblem Solving JusticeProblem Solving JusticeProblem Solving Justice

•Drug courts

•DTTO's

•Combine high quality drug treatment with wraparound care and resolution of criminal justice system issues

•Focused on empathic, rehabilitative response

California Civil Addict California Civil Addict Program Program

California Civil Addict California Civil Addict Program Program

•1962 onwards

•Long term, heavily addicted, criminally active drug users

•Randomised by a "fluke"

•Treatment reduced drug use

•Legal pressure promoted treatment entry, retention and compliance

•The legal system at the service of treatment

•http://www.findings.org.uk/docs/Ashton_M_25.pdf

ConclusionsConclusionsConclusionsConclusions•Drug use and imprisonment are symptoms of alienation

•High quality drug treatment essential and can be effective within the criminal justice system

•Denial of opiate substitution treatment is torture (UN Special Rapporteur 2013)

•Prison is not the gold standard criminal justice disposal for drug problems

•Rehabilitation and empathy, not punishment

•Challenge is to move towards prevention: dismantling the addiction factory