Substance Abuse News

A brief, motivational talk in the emergency room reduced by half the chances that teenagers would experience peer violence or problems due to drinking, according to a study published Aug. 4 in a theme issue of the Journal of the American Medical Association.

The special issue on violence and human rights includes the work of University of Michigan Health System researchers who immersed themselves at the Hurley Medical Center emergency department, in Flint, Mich., for three years.

Researchers offered help to 726 adolescents, ages 14-18, who reported they experienced aggression or had a drink of beer, wine or liquor at least two or three times in the past year.

Reduction in Aggression

A one-on-one talk with a therapist resulted in a 34 percent reduction in peer aggression. Teens who received only a brochure had a 16 percent drop in aggression over the next three months.

The study showed similar drops in alcohol misuse after teens heard prevention messages delivered by a therapist or while using a role-playing computer program.

“Violence and alcohol use are preventable behaviors and the emergency department can be a key location for reaching high-risk teenagers,” says senior author Rebecca Cunningham, M.D., an emergency room physician and director of the University of Michigan Injury Research Center.

Violence and injuries are the leading causes of deaths among adolescents in the United States and the incidents are often fueled by alcohol. The U-M study showed ED interventions can also reduce alcohol-related problems by as much as 32 percent for six months.

The talks with teens were more complex than a parent talking to a child about the dangers of drinking and how to avoid peer pressure.

“Therapists used motivational interviewing which is well-suited for adolescent development,” says study lead author Maureen Walton, M.P.H., Ph.D., research associate professor in the U-M Department of Psychiatry, Addiction Research Center. “It doesn’t preach or tell teens what to do, but allows adolescents to weigh the pros and cons of their choices in reference to their goals.”

The therapists’ talks with teens also included role play exercises and tools to cope with risky situations that involve drinking or violence and referrals to community services.

Motivational Interviewing

“Most of the adolescents had high aspirations – they wanted to go to college, be a good role model for their younger siblings. They didn’t want to make the mistakes they saw happening around them,” Walton explains. “We talked to them about the discrepancies between their behavior and what they wanted to do with their lives.”

Motivational Interviewing, with proper training, can be used effectively by healthcare providers as well those without a professional healthcare background. Study co-author Stephen T. Chermack, Ph.D, a clinical psychologist and addiction specialist at the U-M Health System and the VA Healthcare System in Ann Arbor, is a member of the Motivational Interviewing Network of Trainers (MINT).

Adolescents in the study reported to the emergency department at Hurley Medical Center between noon and 11 p.m., during the three-year period, September 2006 to September 2009.

All patients completed computerized screening questions regarding alcohol use and violence and were randomized into three groups: a control group receiving a brochure, or one of two groups receiving a 35-minute brief intervention delivered by a computer or a therapist in the emergency room.

Authors say the computer screening worked well with teenagers because of their comfort with using technology. The computer program included animated role playing such as how to handle drinking and driving and conflicts with peers.

High-Risk Youth in the ER

“The study tells us that technology can aid in assisting high-risk youth in busy clinical settings, as well as deliver important prevention messages,” says Cunningham who is also an associate professor of emergency medicine at the U-M Medical School and associate professor of health behavior & health education at the U-M School of Public Health. “Emergency staff are busy and not all hospitals have the resource of a social worker or therapist present at all times in the emergency department.”

The ED can be a prime location for reaching high-risk teenagers since many may skip school, consider themselves too old to go to a pediatrician, yet often do not have a primary care doctor.

“We see the consequences our patients face from violence,” says Cunningham who is part of the team of U-M physicians who work in the Flint emergency department.

“But in addition to treating the immediate wounds from violence, the emergency department can offer opportunities to help the teens we see prevent future problems with alcohol and violence.”

HIV disease tends to progress at a faster rate in infected individuals who consume two or more alcoholic drinks a day, according to an important new paper in AIDS Research and Human Retroviruses, a peer-reviewed journal published by Mary Ann Liebert, Inc. The article is available free online.

The article, entitled “Alcohol Use Accelerates HIV Disease Progression,” clearly demonstrates that frequent alcohol use, defined as two or more drinks daily, is associated with declining CD4+ cell counts (which indicate a weakened immune system) in individuals with HIV disease who either are or are not receiving antiretroviral therapy (ART). Based on the results of a 30-month prospective study, the authors, Marianna Baum, Carlin Rafie, Sabrina Sales, and Adriana Campa, from Florida International University (Miami), Shenghan Lai, from Johns Hopkins University, and John Bryan Page, from University of Miami, Florida, conclude that alcohol has a direct effect on CD4 cells and that the accelerated decline in CD4+ cell counts in frequent alcohol users is not simply due to poorer adherence to ART in this population.

Alcohol Consumption and HIV

Another article by Natascha Ching, Karin Nielsen-Saines, Jaime Deville, Lian Wei, Eileen Garratty, and Yvonne Bryson, from the David Geffen School of Medicine at UCLA, Los Angeles, CA, demonstrated that children who were infected with HIV while in utero via maternal-fetal transmission, were subsequently given antiretroviral therapy, and had no detectable HIV in their blood, still produced neutralizing antibodies against HIV, suggesting that low levels of viral replication might still be occurring despite drug therapy. In the article “Autologous Neutralizing Antibody to Human Immunodeficiency Virus-1 and Replication-Competent Virus Recovered from CD4+ T-Cell Reservoirs in Pediatric HIV-1—Infected Patients on HAART,” the authors present data to support their conclusion that the children’s CD4 T-cells may contain latent HIV reservoirs that formed early in life before antiretroviral therapy was initiated.

“It is important that HIV infected individuals make informed decisions relating to alcohol consumption. This article will help to achieve that goal,” says Thomas Hope, PhD, Editor-in-Chief of AIDS Research and Human Retroviruses and Professor of Cell and Molecular Biology at the Feinberg School of Medicine, Northwestern University, Chicago, IL.

Driver’s license suspension has become the most widely used as well as effective method for incapacitating individuals who have been convicted of driving under the influence (DUI). A new study has found that encouraging license reinstatement with continued controls, such as interlocks as a condition of reinstatement, may be effective as long as they do not extend delays.

Results will be published in Alcoholism: Clinical & Experimental Research and are currently available at Early View.

Driver’s License Suspension Reduces Recifivism

“Suspension of driving privileges is the major standard sanction for an impaired driving offense in the western world,” explained Robert B. Voas, senior scientist and director of the Impaired Driving Center at the Pacific Institute for Research and Evaluation (PIRE). “Jail is used in most countries for multiple offenders and problem cases such as involvement in a crash causing injuries. But jail terms are generally too short to significantly reduce the risk the driver presents to the driving public. Research clearly shows that suspension reduces recidivism when compared to not suspending the offender, but it is far from a perfect system since studies show that up to 75 percent of offenders report illicit driving.”

“The value of the sanction partly depends on drivers regarding a proper driving license as having great value,” observed Paul R. Marques, senior research scientist with the Impaired Driving Center at PIRE. “Unfortunately it seems in recent years there are many more drivers who find the benefit of driving unlicensed to be an acceptable low-risk thing to do, probably because the perceived risk of consequences is small. This becomes a public danger for several reasons, not least of which is that an unlicensed driver is usually an uninsured driver. If we cannot adequately enforce license suspension, and if drivers do not feel threatened by loss of their licenses, then suspension cannot serve its intended purpose of restricting road use to those who abide by the laws.”

Researchers analyzed the driving records of 40 million drivers – three million of whom were convicted of DUI – from seven of the largest U.S. states during a seven-to14-year period of time.

“We found that 50 percent of second offenders delay reinstating for more than a year,” said Voas. “Those that delay have higher recidivism rates after they are reinstated, suggesting – but not demonstrated in this study – that they will have higher crash rates. Additionally, one third of second offenders will never reinstate.”

Alcohol-Involved Driving

“Maybe the single most interesting finding from this study is the relationship between risk indicators of impaired driving and the longer time delay in reinstatement after becoming eligible to reinstate,” said Marques. “Drivers with more alcohol citations are less likely to reinstate promptly when eligible. What can we do to reduce the risk these drivers pose to the average road user? We need to either substantially increase monitoring and enforcement, and/or use other ways to control alcohol-involved driving.”

Who are the DUI offenders who delay reinstatement after they become eligible? “It is probable that those who delay may do so because they have not satisfied other requirements such as attending and completing treatment, paying their fine, or meeting with their probation officer,” said Voas. “Research suggests that failure to meet these responsibilities is an indication that they are more likely to resist conforming to rules and regulations generally, including traffic laws. They may also have more serious drinking problems which make it less likely that they can separate their drinking from their driving.”

“The delay in reinstatement is also correlated with having had more prior DUI convictions – multiple offenders are more likely to delay than first-time offenders – and those with more prior convictions generally have more future convictions,” added Marques. “But also, there are usually more conditions placed on reinstatement for those perceived as having higher risk. There may be a break point where some offenders just do not want to bother with the burden of proper relicensing. We should not be making the relicensing process so onerous that we force people out of compliance with the laws.”

Conversely, who are the DUI offenders who do reinstate? “Conforming to the requirements imposed by the courts and motor vehicle departments in a timely manner suggest that these individuals have taken advantage of treatment and other intervention programs provided by the state and have better control over their own behavior,” said Voas. “The fact that first offenders, who have fewer drinking problems, are less likely than multiple offenders to delay suggests that the level of the offenders’ drinking problem plays a role.”

Driving While Suspended

People have different reasons to conform, observed Marques. “If you have a certain satisfaction with your life and want to retain privileges, conveniences, and fulfill responsibilities, then meeting the administrative and legal expectations around reinstatement is a no-brainer,” he said. “Simply enough, those more invested in social norms are more apt to do things that are normative. For those who are more marginalized, whether through choice, income or opportunity, the risk-benefit ratio of either not relicensing, or choosing to drive while suspended, will be different.”

“Our findings suggest that more attention should be given to DUI sanctions that maintain contact with the offender following reinstatement such as vehicle alcohol interlocks,” said Voas. “The results also suggest that offenders who have delayed several months beyond their nominal reinstatement date might be reminded of the importance of reinstating, and of the sanctions for illicit driving.”

“Our roadways are the national commons,” added Marques. “It is silly to imagine that we can bring DUI behavior under control just by making laws that are more punitive or restrictive. The evidence developed by Voas and colleagues provides an estimate of problem magnitude and should ideally form the basis for policy innovations.”

A new study by researchers at the David Geffen School of Medicine at UCLA has found that more than a third of drinkers 60 years old and older consume amounts of alcohol that are excessive or that are potentially harmful in combination with certain diseases they may have or medications they may be taking.

Basing their research on data from 3,308 older patients accessing primary care clinics around Santa Barbara, Calif., the authors report that just as many individuals were at risk from alcohol consumption in combination with comorbidities or medication as from alcohol consumption alone.

The study, published in the current online edition of the Journal of General Internal Medicine, also found that at-risk drinking was associated with being younger, white and less educated.

At-Risk Drinking

“Compared to the U.S. Census population over age 60, the sample studied was more likely to be white, married, well-educated and high-income,” said lead study author Andrew Barnes, a researcher in the UCLA School of Public Health’s department of health services. “However, the adjusted associations of patient demographics with at-risk drinking found in our research should be more generalizable than the descriptive data published previously.”

At-risk drinking was assessed using the Comorbidity Alcohol Risk Evaluation Tool (CARET), which categorizes older adults as at risk if they display at least one of the following drinking behaviors: they consume more than two drinks on most days; they consume one to two drinks on most days and have certain comorbidities, such as gout, hepatitis or nausea; they consume one to two drinks on most days and take select medications, such as antidepressants or sedatives.

The specific findings include:

• 34.7 percent (1,147) of older adults were at risk due to drinking alone or to drinking in combination with comorbidities or medications, and 19.5 percent fell into multiple risk categories.
• Of those at risk, 56.1 percent fell into at least two risk categories, and 31 percent fell into all three.
• Participants who had not graduated from high school had 2.5 times the odds of at-risk drinking as those who had completed graduate school.
• Respondents with annual household incomes between $80,000 and $100,000 had 1.5 times the odds of being at-risk as those with incomes under $30,000.
• Respondents who were 80 or older had half the odds of at-risk drinking as those between the ages of 60 and 64.
• Asians had less than half the odds of at-risk drinking as Caucasians.

Risk varied considerably, depending on patient characteristics. For example, a 62-year-old white male respondent who was married and had an annual household income of $90,000 was estimated to have a 57.1 percent adjusted probability of being an at-risk drinker, compared with an 8.1 percent adjusted probability for an 85-year-old Asian female patient who was widowed and had an annual income of $35,000.

One in Three At Risk

The study does have some limitations, the researchers noted. For instance, it relied on patients’ self-reported drinking frequency and quantity, so some participants may have been misclassified. Also, the sample was more likely to be white, married, well-educated and higher income than the over-60 U.S. population as a whole.

“In summary, even among our relatively advantaged study patients, as many as one in three who continued to consume alcohol into older adulthood were at risk of harm from drinking,” the researchers wrote. “Physicians may be less aware of other alcohol-related risk factors common among the elderly (e.g., interactions with select medications and comorbidities) than the risks associated with heavy drinking. Information suggesting which patients have the highest likelihood of at-risk drinking may assist physicians to better target patients for further screening and intervention.”

Teens with a history of crack or cocaine use are significantly more likely to engage in unprotected sex than youth who have never used these drugs, putting themselves at increased risk for HIV, according to a study in the April issue of the Journal of Child and Adolescent Substance Abuse.

Researchers from the Bradley Hasbro Children’s Research Center report that teens in psychiatric care who used crack and/or cocaine at least once were six times more likely to use condoms inconsistently, which was defined as “sometimes,” “never” or “rarely.” The findings suggest that crack cocaine appears to have more of an influence on risky teen behaviors than other factors, like alcohol and marijuana use, which are more routinely incorporated into adolescent HIV prevention interventions.

Cocaine and Unprotected Sex

The study is one of the first to look at the link between crack and cocaine use and HIV risk behaviors in adolescents. Previous research has demonstrated this association in adults.

“Unprotected sex is the most common way that HIV is transmitted among teens, so if we can develop a clearer picture of why some kids engage in high-risk sexual behaviors, we will be better prepared to educate them about safe sex,” says lead author Marina Tolou-Shams, PhD, of the Bradley Hasbro Children’s Research Center. “Our findings suggest that future HIV prevention interventions should include content specific to crack and cocaine use, just as they do with drugs that are more commonly used by teens, like alcohol and marijuana.”

Overall, nearly 280 teens between the ages of 13 and 18 from therapeutic psychiatric day programs took part in the study. Participants exhibited a range of psychiatric diagnoses, including mood disorders, post-traumatic stress disorder and disruptive behavior disorders. More than half of all adolescents were male, and more than three-quarters were Caucasian. Approximately 13 percent of teens in the study reported trying crack or cocaine at least once.

Not Using Condoms

After controlling for known adolescent HIV risk factors, such as gender, race, age and psychiatric status, researchers found that only 47 percent of teens with a history of crack and/or cocaine use said they used condoms “always or almost always.” In addition, 15 percent of these adolescents have a history of sexually transmitted diseases (STD), nearly three-quarters reported using alcohol at least once and more than half indicated prior marijuana use.

In comparison, 71 percent of teens who never used crack or cocaine reported using condoms consistently.

Tolou-Shams says it was important to look at the association between crack and cocaine use and HIV risk behavior in adolescents with psychiatric disorders, since previous research has shown that teens in mental health treatment have high rates of risky sexual behavior and are more likely to engage in substance use.

“Our study clearly shows that youth in psychiatric treatment are using other drugs – and not just alcohol or marijuana – at high rates and that a history of drug use should alert clinicians to a wide variety of possible behavioral risks in their young patients,” she adds.

Provide Interventions

The authors recommend that all clinicians who treat adolescents – including pediatricians, social workers and psychologists – routinely discuss their patients’ mental health history, lifetime use of all substances and sexual activity, as well as provide appropriate interventions when necessary in order to reduce their HIV risk.

The research is supported by grants from the National Institute of Mental Health and the Lifespan/Tufts/Brown Center for AIDS Research (CFAR).

Tolou-Shams is also an assistant professor of psychiatry at The Warren Alpert Medical School of Brown University. Study co-authors include Larry K. Brown, MD, and Nicholas Tarantino, BS, both from the Bradley Hasbro Children’s Research Center and Alpert Medical School, and Sarah W. Feldstein Ewing, PhD, at the University of New Mexico.

Measuring a set of protein changes in the blood linked to alcohol use may potentially lead to a more accurate diagnostic test than those currently available, according to Penn State College of Medicine researchers.

“The challenge in alcohol abuse as opposed to substance abuse — things like cocaine or heroin or PCP — is that alcohol is a perfectly legal substance for those over 21,” said Willard M. Freeman, Ph.D., department of pharmacology and lead investigator. “Unlike routine testing for illicit drugs, you can’t just look for a trace of alcohol because many people enjoy a drink in a responsible manner and alcohol is very quickly metabolized. Discriminating between excessive and responsible levels of drinking makes this a greater challenge.”

Proteins Predict Alcohol Use

Penn State Hershey researchers, working for two-and-a-half years in cooperation with Kathleen A. Grant, Ph.D., at the Oregon National Primate Research Center, identified a set of 17 proteins in the blood that accurately predicted alcohol usage 90 percent of the time in non-human primates. Researchers were able to separate usage into three categories — no alcohol use, drinking up to two drinks per day and drinking at least six drinks per day.

Protein levels rose and declined depending on alcohol consumption.

“We observed that the levels of some proteins increased or decreased with as little as one or two drinks a day,” Freeman said. “These same changes occurred with heavier levels of drinking. We also found other proteins that responded only to heavy levels of drinking. Combined, these proteins allow us to classify subjects into non-drinking, alcohol-using, and alcohol-abusing groups.”

The researchers are continuing their work, first by determining whether the changes measured return to normal levels with cessation of drinking. Second, they are looking for additional proteins to both increase accuracy and provide alternates if some of the initial 17 do not work in humans.

Working with groups around the world, Penn State Hershey researchers — led by Freeman and Kent Vrana, chair, department of pharmacology — plan to collect blood from people undergoing inpatient treatment for alcohol abuse.

Testing for Abstinence

“We’ll collect blood throughout their stay to see if the patients’ protein pattern reverts from an excessive drinking pattern to a pattern that’s indicative of alcohol abstinence,” Freeman said.

The goal is to create a diagnostic test for alcohol consumption that may be used in areas of public safety like aviation or national security, for parole conditions and for helping physicians determine if a patient may have an alcohol abuse problem. Currently there are tests that try to address this issue, but Freeman said these tests are not sensitive and specific enough to serve as diagnostics.

“Many of these tests rely on just one protein,” he said. “The limitation to this approach is that these tests often look at proteins produced by the liver. While these proteins increase with excessive alcohol intake, they also increase with any type of injury to the liver. For example, a lot of prescription drugs are hard on the liver. These tests let us know that the liver is being stressed but can’t discriminate between excessive drinking and other conditions, which therefore reduces the utility of these tests.

“That’s where we see the promise in this panel of proteins. The proteins are produced by a number of organs including the liver, the muscle, and the brain. This unique fingerprint that is indicative of alcohol abuse is less likely to be produced by unrelated conditions.”

Freeman stresses, a diagnostic test would not be testing for alcoholism, but rather, alcohol intake.

Amount of Drinking Test

“In a strictest use of the words, alcoholism is a psychological diagnosis as opposed to a level of drinking,” he said. “The Diagnostic and Statistical Manual really classifies alcohol abuse and alcoholism based on how alcohol is interfering with your life. Obviously we can’t use a blood test to say yes, your drinking is interfering with your home life. But the amount of drinking and the amount of problems it causes in your life are tightly correlated.

“We envision, a number of years down the line if this becomes a diagnostic test, that if the test indicates that you’re drinking a lot, it would prompt a referral to a specialist in alcohol abuse and alcoholism. This test could provide an objective indicator to help people begin addressing what may really be a problem in their lives.”

Men and women with a history of alcohol abuse may not see long-term negative effects on their memory and thinking, but female smokers do, a new study suggests.

In a study of 287 men and women ages 31 to 60, researchers found that those with past alcohol-use disorders performed similarly on standard tests of cognitive function as those with no past drinking problems.

The findings were not as positive when it came to tobacco, however.

Cognitive Function Impaired

In general, women who had ever been addicted to smoking had lower scores on certain cognitive tests than their nonsmoking counterparts. The same pattern was not true of men, however, the researchers report in the Journal of Studies on Alcohol and Drugs.

The reasons for the disparate findings on alcohol and smoking are not fully clear. Nor do they necessarily mean that serious alcohol problems would not affect long-term memory and other cognitive abilities; most study participants who had ever had drinking problems met the criteria for alcohol abuse rather than the more serious diagnosis of dependence.

Alcohol abuse was diagnosed when people reported one symptom of problem drinking — drinking and driving, for instance, or failing to meet work or school obligations as a result of drinking. Dependence, on the other hand, required people to have at least three symptoms — such as needing to drink more and more to achieve the same effects and experiencing physical withdrawal symptoms when they did not drink.

Alcoholics Not ‘Doomed’

If more study participants had been alcohol dependent, the findings on cognition might have been different, says lead researcher Dr. Kristin Caspers, an assistant research scientist in the department of psychiatry at the University of Iowa in Iowa City.

But the bottom line, she says, is that people with a history of alcohol abuse appear not to be “doomed” to suffer cognitive effects when current levels of drinking are in the light to moderate range.

The findings are based on assessments of 115 men and 169 women with an average age of 43. Overall, 45 percent of men and 37 percent of women met the criteria for lifetime alcohol abuse, and 13 percent and nearly 4 percent, respectively, had a lifetime history of alcohol dependence. One quarter of women and 18 percent of men had a history of tobacco dependence.

Overall, women who reported having ever smoked 20 or more cigarettes a day scored lower than nonsmokers on tests of executive function — that is, “higher-order” brain functions that include the ability to reason, plan and organize. The scores were, however, all within normal range.

Estrogen a Factor?

As for why smoking was related to cognitive scores only among women, it’s possible that there is a role for estrogen, according to Caspers.

Animal research suggests that nicotine lowers blood estrogen levels and may inhibit the positive effects of the hormone on brain cells. Sixty percent of the women in the current study were between the ages of 40 and 54, when menopause usually occurs. In theory, nicotine may exacerbate any brain-cell effects of fluctuating estrogen levels in women as they age, the researchers speculate.

In a study published in the journal Addiction, researchers in the United States have discovered that accidental overdose deaths involving cocaine rise when the average weekly ambient temperature passes 24 degrees Celsius (75 degrees Fahrenheit). Using mortality data from New York City’s Office of the Chief Medical Examiner for 1990 through 2006, and temperature data from the National Oceanic and Atmospheric Association, researchers found that accidental overdose deaths that were wholly or partly attributable to cocaine use rose significantly as the weekly ambient temperature passed 24 degrees Celsius. The number of cocaine-related overdose deaths continued to rise as temperatures continued to climb.

Cocaine Increases Body Temperature

Cocaine-related overdose deaths increase as the ambient temperature rises because cocaine increases the core body temperature, impairs the cardiovascular system’s ability to cool the body, and decreases the sense of heat-related discomfort that ordinarily motivates people to avoid becoming overheated. Cocaine users who become overheated (hyperthermic) can overdose on lower amounts of cocaine because their bodies are under more stress.

The study’s findings correct previous research that associated an increase in cocaine-related mortality with much higher temperatures (31.1 degrees Celsius, or 87.9 degrees Fahrenheit). Because cocaine-related overdose fatalities begin to rise at lower ambient temperatures than was previously thought, it is now apparent that cocaine users are at risk for longer periods of each year. Between 1990 and 2006, the average weekly temperature in New York City rose above 24 degrees Celsius for about seven weeks per year.

Deaths Linked to Temperature Rise

The study showed no difference in the number of drug overdoses in New York City among those weeks where the average temperature was between -10 and 24 degrees Celsius. Above 24 degrees Celsius, however, there were 0.25 more drug overdoses per 1,000,000 residents per week for every two degrees increase in weekly average temperature. Given that over 8.2 million people live in New York City, the study’s findings predict that at least two more people per week will die of a drug overdose in the city for each two degree rise in temperature above 24 degrees Celsius, compared to weeks with average temperatures of 24 degrees and below.

The authors of this study point out the need for public health interventions in warm weather, such as delivering health-related warnings to high-risk groups. Prevention efforts could also include making air conditioning available in locations where cocaine use is common such as urban areas with a known high prevalence of cocaine use, and within those urban areas, particular neighbourhoods with elevated numbers of cocaine-related deaths or arrests. As lead author Dr. Amy Bohnert explains, “Cocaine users are at a high risk for a number of negative health outcomes and need public health attention, particularly when the weather is warm.”

Of the 2.3 million inmates crowding our nations prisons and jails, 1.5 million meet the DSM IV medical criteria for substance abuse or addiction, and another 458,000, while not meeting the strict DSM IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation; or shared some combination of these characteristics, according to Behind Bars II: Substance Abuse and America’s Prison Population. Combined these two groups constitute 85 percent of the U.S. prison population.

The new 144-page report released today by The National Center on Addiction and Substance Abuse (CASA) at Columbia University also reveals that alcohol and other drugs are significant factors in all crime. In 2006, alcohol and other drugs were involved in these inmate offenses:

• 78 percent of violent crimes;
• 83 percent of property crimes; and
• 77 percent of public order, immigration or weapon offenses; and probation/parole violations.

The CASA report found that only 11 percent of all inmates with substance abuse and addiction disorders receive any treatment during their incarceration. The report found that if all inmates who needed treatment and aftercare received such services, the nation would break even in a year if just over 10 percent remained substance and crime free and employed. Thereafter, for each inmate who remained sober, employed and crime free the nation would reap an economic benefit of $90,953 per year.

“States complain mightily about their rising prison costs; yet they continue to hemorrhage public funds that could be saved if they provided treatment to inmates with alcohol and other drug problems and stepped up use of drug courts and prosecutorial drug treatment alternative programs,” said Susan E. Foster, CASA’s Vice President and Director of Policy Research and Analysis.

Joseph A. Califano, Jr., CASA’s Chairman and President and former U.S. Secretary of Health, Education, and Welfare, called the nation’s current prison policies, “Inane and inhuman. Between 1996 and 2006, the U.S. population grew by 12 percent. Over that same period, the number of adults incarcerated grew by 33 percent to 2.3 million inmates and the number of inmates who either met the DSM IV medical criteria for alcohol or other drug abuse and addiction or were otherwise substance involved shot up by 43 percent to 1.9 million inmates. The tragedy is that we know how to sharply reduce the costs of incarceration and the crimes committed by substance-involved offenders.”

The report also noted that in 2005, federal, state and local governments spent $74 billion on incarceration, court proceedings, probation and parole for substance-involved adult and juvenile offenders and less than one percent of that amount–$632 million–on prevention and treatment for them.*

Twelve years ago, CASA released Behind Bars: Substance Abuse and America’s Prison Population. CASA prepared this report to see if any progress had been made in reducing the number of substance-involved offenders behind bars and to examine and identify promising practices for cost-effective investments. To conduct this study, CASA researchers analyzed data on inmates from 11 federal sources, reviewed more than 650 articles and other publications, examined best practices in prevention and treatment for substance-involved offenders, reviewed accreditation standards and analyzed costs and benefits of treatment.

“Despite increased recognition of the problem and its potential solutions, we have made no progress in reducing the number of substance-involved inmates crowding our prisons and jails. The United States has less than five percent of the world’s population and we consume two-thirds of the world’s illegal drugs and incarcerate almost a quarter of the world’s prisoners, more than eight of ten of whom have some substance involvement,” said Califano.

The CASA report also found that compared to non-substance involved inmates, substance-involved inmates are not only likelier to be re-incarcerated, begin their criminal careers at an early age, and have more contacts with the criminal justice system, but they are also:

• Four times likelier to receive income through illegal activity;
• Twice as likely to have had at least one parent who abused alcohol or other drugs when they were children;
• 41 percent likelier to have some family criminal history;
• 29 percent less likely to have completed at least high school; and
• 20 percent likelier to be unemployed a month before incarceration.

Other Key Findings

In 2006, an estimated one million substance-involved inmates were parents to more than 2.2 million minor children. Three quarters of these children were age 12 or younger.
Alcohol is implicated in the incarceration of more than half of all inmates in America; illicit drugs are implicated in three quarters of incarcerations.
Contrary to public perception, only two percent of all inmates are incarcerated for marijuana possession as their controlling or only offense.

A Call for Action

To reduce the number of substance-involved inmates crowding our prisons, improve the health of inmates and reduce crime, the CASA report offers specific recommendations in its call for action by the nation’s criminal justice systems and federal, state, and local governments including these:

• Use trained health care professionals to screen, assess and treat substance-involved offenders and provide care for co-occurring physical and mental health problems.
• Provide comprehensive pre-release planning and aftercare to continue treatment services for inmates with substance use disorders.
• Require addiction treatment for inmates to be medically managed.
• Expand the use of treatment-based alternatives to jail and prison.
• Require accreditation for prison- and jail-based treatment programs and providers.

“This report lays out the steps we need to take to address the treatment needs of offenders while holding them accountable for their crimes,” noted Foster. “We do not as a nation refuse to provide treatment for other chronic ailments like heart disease or diabetes. We should do so for addictive disorders, especially when the added benefits of treatment for offenders include significant reductions in crime and its costs to society.”

A novel technology for delivering nicotine to the lungs may soon give smokers a new way to kick the habit.

When compared to the nicotine vapor delivery system used in the Nicotrol/Nicorette inhaler, the new technology proved more effective at delivering nicotine to the blood stream. As a result, it provides immediate relief of withdrawal symptoms, according to Duke University Medical Center researchers. Users also reported the new nicotine delivery method was more tolerable than the current inhaler because it caused less throat irritation.

Smoking Without Danger?

“We wanted to replicate the experience of smoking without incurring the dangers associated with cigarettes, and we wanted to do so more effectively than the nicotine replacement therapies currently on the market,” said Jed Rose, Ph.D., director of the Duke Center for Nicotine and Smoking Cessation Research where the technology is being developed. He presented the data today at the Society for Nicotine and Tobacco Research (SRNT) in Baltimore, MD.

The Nicotrol inhaler is a smoking cessation therapy that delivers nicotine vapor to the mouth and upper airways, but little of it reaches the lungs.

Duke’s new technology employs a unique method to deliver nicotine to the lungs. In today’s presentation, the researchers show the new lung delivery technology results in rapid absorption of nicotine that provides immediate relief of withdrawal symptoms and also re-creates some of the familiar sensations that are pleasurable to smokers.

Current methods that deliver medicine to the lungs — metered dose sprays, dry powder inhalers or nebulizers that create a fine mist – do not replicate the natural inhalation used by smokers when drawing on a cigarette. And, because medication residue often deposits in the mouth and throat, doses aren’t always high enough to ensure the appropriate amount reaches the lungs.

Combining Two Vapors

Duke’s new technology combines the vapor phase of pyruvic acid, which occurs naturally in the body, and nicotine. “When the two vapors combine, they form a salt called nicotine pyruvate,” explains Rose. “This reaction transforms invisible gas vapors into a cloud of microscopic particles which is inhaled, just like a smoker inhales from a cigarette.”

In a study of the new Duke technology, nine healthy smokers inhaled 10 puffs of nicotine pyruvate in increasing doses, 10 puffs from a Nicotrol/Nicorette inhaler cartridge, and 10 puffs of room air (placebo). Blood was drawn before and after each set of inhalations. When the results were analyzed, the Duke researchers noted rapid increases in plasma nicotine concentrations following the nicotine pyruvate inhalations and less complaints of harshness/irritation when compared to the Nicotrol/Nicorette control cartridge. The smokers also said their cravings for cigarettes were substantially alleviated following the nicotine pyruvate inhalations.

“Compared to the current nicotine vapor inhaler, we are able to give smokers more nicotine, although still less than a cigarette, with less irritation, resulting in reduced cravings,” said Rose. “Thus we are able to achieve a therapeutic effect with greater tolerability.”

More research is needed to examine the safety and effectiveness of prolonged use of the inhalation system, and to assess its role in helping people quit smoking. But, Rose says if all goes well, he anticipates the product could become commercially available within three to five years.

He also says the novel inhalation system may one day prove useful for delivery of other medications. Duke has filed patent applications on the new technology, which was invented by Rose and his colleagues, including his brother, Seth D. Rose, Ph.D., Duke colleague, Thangaraju Murugesan, Ph.D., and James E. Turner, an inventor of the Nicotrol/Nicorette inhaler.