Methamphetamine and the Courts: Treatment as a Sentencing Consideration

2015

Although substance abuse in general and methamphetamine abuse in particular have given rise to sentencing enhancement rather than leading to a primary focus on recidivism prevention, the importance of intervention has not been lost in the criminal justice system. Toward that end, as was seen in the review of court cases above, recommendations for treatment as part of probation or conditional release are not uncommon. However, reaching a goal of reducing addictive behavior and the crime that is associated with it depends on having adequate treatment modalities.

Treatment for chemical dependency in general and specifically for methamphetamine has not been uniform around the country. There have been a number of attempts through the National Institute on Drug Abuse (NIDA) and American Society for Addiction Medicine (ASAM) to develop standardized treatment protocols that would act as guidelines to programs that treat addiction. However, the penetration of these algorithms in the provider community has been at best sporadic and fragmented. Many providers continue to use a traditional approach to treatment that is primarily based on the disease concept and follows the Hazleton model. This approach, although effective for many, is more than 30 years old and it has not integrated some of the more recent scientific understanding of addiction and addiction treatment. There continues to be a primary substance-based understanding of addiction as opposed to a more complex model.

A more modern, scientific approach considers addiction as a disorder of activation. Based on this model, there are genetic predispositions to addiction. Those who begin to use mood altering substances activate the addictive tendencies. With frequent and chronic use this pattern becomes solidified and can create major changes in the brain chemistry and the way in which the individual responds to non-drug-induced pleasurable stimuli. The addict will require mood-altering substances to activate certain processes in the brain in order to experience pleasure. With chronic use, there is a shift from attempting to create pleasure (the high), to avoidance of pain, which is caused by withdrawing from the substance. To avoid pain the addict will use whatever means necessary to obtain drugs and the compulsion to use will control multiple aspects of his or her life. Prolonged drug use will affect the physical, social, and psychological functioning of the addict and will result in a downward spiral. The addicted individual who is fortunate enough will “hit bottom” before causing permanent destruction in his or her life; compelled by a sense of desperation, along with external pressures (such as the carrot and stick of court-mandated treatment), the addict may then seek help.

There is a great deal of variability in addiction treatment around the country. If a treatment program is part of a larger behavioral health provider, it is highly likely that it provides a wider range of services than is found as part of a general hospital setting. Such multifactor programs include detoxification and some form of rehabilitation above and beyond simple discharge into a 12-step community-based program.

Comprehensive addiction treatment needs to be multidimensional. This approach to treatment can be highly effective but it tends to be more costly than the more traditional interventions. Because prolonged addiction can create problems in a number of areas, treatment planning needs to consider the various aspects of the individual’s adjustment that are affected. A multi-layered approach, which allows intervention into physical, social, psychological, and psychiatric problem areas in individually tailored fashion, is necessary.

In the ideal situation, the addict is followed through varying levels of care in the same organization and there is familiarity with the case. However, effective communication between agencies with a consistent treatment philosophy can achieve the same result.

The most acute level of care in addiction treatment is medical detoxification. During this phase the addict is abstinent from drugs of dependency and a state of withdrawal will ensue that must be medically managed. Treatment during this phase often requires medication that reduces withdrawal symptoms by acting on the brain in similar ways as did the substance of abuse. These medications are generally slow-acting substances and do not result in drastic changes in mood.

For most substances, the acute phase of this process lasts less than 4 days. However, there are certain mood-altering substances that tend to have longer-lasting half-lives and can continue to create discomfort and problems associated with withdrawal. Heavy methamphetamine use can result in prolonged chronic withdrawal symptoms, which are physiologically based but psychologically expressed, including anxiety, irritability, and anhedonia (loss of pleasure in life). Sometimes, there is progression to a major depressive state.

Care during acute and early chronic withdrawal involves an extensive medical assessment as many addicts have a history of neglecting their health and often suffer from a variety of health-related problems secondary to their drug use and the lifestyle associated with a drug-abusing subculture. Often addicts, particularly those with an extensive history of alcohol use (and most methamphetamine users are polysubstance abusers with alcohol a frequent component), suffer from malnutrition and medical problems related to vitamin and nutritional deficiency.

Shortly after the detoxification is completed, addiction treatment for most patients can be provided on an outpatient basis. Day treatment and intensive outpatient programs are options that are often used. A subpopulation of patients with coexisting mental health diagnoses may require a more structured treatment immediately after detoxification. A large-scale internationally based study of specific interventions into methamphetamine-induced psychoses is currently in the process of development. The researchers hope to identify the best neuroleptic medications as well as other treatment and prevention components (). An adequate treatment program needs to consider external problems in areas of work environment, neighborhood, and family that can create significant problems in recovery. While dealing with relapse is part of a modern treatment program, with addicts who have had repeated relapses after detoxification, more structured and highly supervised modes are indicated. Where individuals have co-morbid psychiatric diagnoses, high levels of family conflict, or have high levels of external cues that trigger addictive behavior, treatment-planning teams need to consider a clinically managed residential program with step down available to a more traditional residential program.

The clinically managed residential program is particularly effective with individuals who require psychotropic medications. Often, extensive education and orientation are indicated to prevent dropout from treatment and early termination of medication use.

Long-term therapeutic communities that focus on providing structure, supervision, treatment, and resocialization can be effective in treatment of the more chronic group of individuals who have had a history of difficulties with issues other than addiction. Some communities have developed and implemented prerelease programs for addicts who have been incarcerated for nonviolent drug-related offenses. These programs are designed for those addicts who are highly vulnerable to relapse and require a high degree of external support and structure.

In these programs, the addict is usually provided with incrementally higher levels of responsibility and moves along the continuum of being closely monitored to rather independent living and working in the community. However, these programs usually have limited direct treatment modules such as group or individual therapy. They rely heavily on peer support and use other community resources for treatment of adjustment difficulties that are often present in addicts who are new in recovery. The length of stay in this type of program is relatively high and can range from 90 to 180 days. It is hoped that with the routines that are established during their stay in such programs, addicts will begin to internalize a more structured lifestyle that is conducive to staying sober. In most of these programs there are daily requirements and each resident is mandated to attend 12-step groups.

Short-term residential programs, on the other hand, are designed to integrate the addict into the recovering community (). During their stay in these programs, clinical staff and peer support focus on helping addicts develop internal coping skills that enable them to live a sober lifestyle. Participants also are presented with alternative approaches to asking for peer support in 12-step recovery meetings and to expand their sober social support systems. Learning leisure activities that are conducive to staying sober is included to assist in prevention of relapse through avoidance of old “traps.”

Generally speaking, an essential aspect of recovery from addiction is active participation in 12-step recovery programs. This process, which includes extensive peer support and following the tradition of using 12 steps in the recovery process, has proved to be relatively effective in promoting and maintaining abstinence in alcoholics and addicts. There is limited scientific scrutiny of the program as it is, by nature, an anonymous group and it does not easily lend itself to empirical investigation. However, intuitively, the values of the 12-step programs are in the structure that they provide for the addict. This type of external sober support is instrumental in relapse prevention and takes the addict out of situations that contain cues that activate drug-seeking desires in the brain and subsequently lead to use.

Effective addiction treatment requires a multidisciplinary team. To be able to perform a comprehensive biopsychosocial assessment of the addict, the team needs to include a physician (an addictionologist or a psychiatrist with addiction treatment specialization), a psychologist, and a chemical dependency counselor. Clinical social workers who provide family and social assessment are essential team members. For treatment to produce optimal results, these professionals must collect data and work together in treatment planning. An attitude of respect for the participant includes an understanding on the part of the treatment team that addicts, like all other patients, are interested in getting better ().

In order for a substance to affect an individual’s mood, it must be able to pass the blood-brain barrier and cause biochemical changes in the brain. The cognitive, emotional, and behavioral effects of these substances mimic those seen in other processes that result from changes in brain chemistry, such as mental illness. It is common that during the active phase of their use, methamphetamine addicts in particular may be diagnosed erroneously as suffering from mental illness. Evaluation must proceed with care or an individual who is abusing substances or addicted to them could be diagnosed with an illness that is chemically induced and may disappear when direct effects of the chemicals dissipate. Kono et al. (2001), in their comparison of individuals who abused nicotine, alcohol, methamphetamines, and inhalants, noted that those who abused methamphetamines displayed a significantly higher intensity of symptoms related to perceptual disturbances, thought disorder, mood disorder, and problems with acting out behaviors, which they categorized as volition disorder.

On the other hand, it is very important to note that there are those addicts or alcoholics who have a coexisting psychiatric condition (patients with dual diagnosis). For individuals who display psychiatric symptoms as a side effect of their substance abuse, there needs to be an active treatment plan for addiction treatment, and a “wait and see” approach toward the psychiatric symptoms. Those individuals who either have a preexisting psychiatric condition or who have developed psychiatric illness during the course of their use of mood-altering chemicals will require a treatment plan that includes psychiatric interventions. Unfortunately, many traditional addiction treatment programs around the country lack appropriate psychiatric services, and this aspect of treatment for those addicts who are most vulnerable is missing. The usual pattern noted in treatment of these individuals is characterized by repeated relapses and the psychiatric symptoms interfering with ability to benefit from the addiction recovery program. Also, shortly after discharge from these programs, the individual is likely to go back to using drugs in an attempt to self-medicate the psychiatric symptoms. Dual diagnosis treatment needs to be provided by a team of professionals who have expertise for both addiction and psychiatric problems.

The opposite case can also occur. There are psychiatric programs that mistakenly attribute drug-related symptoms to psychiatric conditions and often attempt to medicate the addiction problems away. Ignoring addiction-related issues not uncommonly can lead to prescription of addictive medications for what are withdrawal symptoms.

One of the main problems in the field of addiction treatment is blaming treatment failure on the patient with accusations of “poor motivation” and “being in denial.” In making these statements, the clinicians absolve themselves from any responsibility for providing the type of care that is a “good fit” for the patient and thus lose a chance to improve compliance levels. Also, in blaming the patient for treatment failure, a cyclical reward system is set up that promotes the sense of inadequacy and low self-esteem often associated with being an addict. The patient is invalidated and the problem is increased. In research with patients suffering from borderline personality disorder and other patient groups with multiple problems, Linehan (1993) has demonstrated that validation is an effective tool for engaging patients in treatment and therefore obtaining more positive outcomes. The tradition of pejorative labels for patients who have difficulties in navigating a course of treatment has been a significant factor in addiction treatment failures. (For example, a counselor dismissing a patient as a “frequent flyer” is not unknown in the case of so-called resistant participants.) If the patient accepts the view of the counselor, then he or she has incorporated a concept of inability to benefit from treatment. If, on the other hand, the patient disagrees with the assumptions of the counselor, then there is demonstrated “noncompliance,” which can lead to termination of treatment (so-called therapeutic discharge).

In treatment planning for addicts it is important that those who provide the treatment take some responsibility for making sure that the addict is motivated to follow the treatment plan. There are certain commitment strategies that can be quite effective in raising levels of participation. Linehan and colleagues () have demonstrated the effectiveness of these strategies in keeping patients with borderline personality disorder engaged in treatment. Treatment dropout can be reduced dramatically when commitment to therapy is defined as a major objective of therapeutic work rather than as a prerequisite on the part of the patient. Thinking about treatment in this way is especially necessary for individuals who have been referred into treatment by the legal system, rather than presenting themselves for assistance.

Completing a comprehensive program is enhanced through evaluation of prior treatment history. The addict must be asked to outline a history of addiction and psychiatric treatment including the reasons for admission to treatment, the center where treatment occurred, the length of treatment, how long sobriety lasted, and what caused the relapse. A great deal of insight can be obtained if further questions on the course of treatment and its completeness are assessed. As mentioned earlier, there is a great deal of variability in how addiction services are provided; however, there are types of treatment that tend to be offered by certain programs and attended by certain types of addicts in order to pacify certain individuals or institutions. For example, in cases of driving under the influence, many individuals, especially first-time offenders, participate in a weekend program that takes place at a local hotel. Educational offerings are the main aspect of this intervention, along with the brief isolation. There are also many individuals who enter a treatment program and are in the process of withdrawal from drugs and alcohol. These individuals are usually detoxified medically, and are presented with certain educational modules regarding alcoholism and addiction. The assumption is made that these addicts can manage the cognitive tasks involved. After a few short days, they are discharged into the community with no meaningful follow-up treatment and are told that they are in a place where they can benefit from community-based 12-step programs.

Therefore, it is important that during the assessment period, questions regarding the extent and type of treatment are asked to determine whether or not the addict has had a true chance at recovery. Issues related to the type of professional involved in treatment and the programmatic aspect of treatment need to be addressed. This aspect of assessment is even more important in forensic situations, because addicts with legal involvement and criminal convictions tend to have fewer financial resources and it is likely that their treatment was provided in community-based agencies that also have limited resources. It also allows some education of the court regarding those factors that were not under the control of the individual and that favor appropriate treatment options.

Given the extensive damage caused by even short-term use of methamphetamines, the issue of deficits associated with brain injury needs to be addressed directly. Certain aspects of this type of deficit clearly interfere with the addict’s ability to learn and process information. A great deal of programming at most addiction recovery centers is based on a psychoeducation model. It would be safe to assume that chronic methamphetamine users may have a great deal more difficulty with the learning material presented to them than persons without the central nervous system damage. Given that impulse control and inhibition and management of feelings are difficult for these individuals, frustration enhances dropout potentials as well as leads to acting out in ways that disrupt treatment for themselves or others. If cognitive deficits that result in significant interference with learning are noted, appropriate assessment should be undertaken. It may be important to design treatment interventions that are behavioral in nature and do not involve higher-level cognitive work. At the same time, cognitive rehabilitation measures can be included in the treatment plan that will assist in later mastery of more traditional educative aspects. In fact, the 12-step recovery program has a strong behavioral component that is designed to engage participants in the process even if they do not cognitively appreciate more abstract principles.

Educating the addict’s support system can positively affect treatment outcome. Family members, sponsors from 12-step programs, probation officers, and case managers should be informed about the complexities related to how the brain of the addict may be compromised. As a result, the addict’s support system is less likely to engage in blaming  —  and thus unwittingly contribute to treatment failure when cognitive interference leads into treatment lapse.

Individuals with dual diagnosis are significantly more difficult to treat and tend to have a higher rate of relapse in both their psychiatric condition and addiction. This phenomenon generally arises because one or the other aspect of their condition is not treated adequately. As mentioned above, there are major psychological issues and cognitive deficits associated with methamphetamine use. In addition, behavioral problems, often secondary to either premorbid personality or brain damage caused by the destructive force of the substance, make management of these individuals difficult in traditional treatment settings.

The dual diagnosis problem should be assessed prior to making a referral for treatment. Individuals with a history of methamphetamine use and other coexisting conditions require an addiction treatment facility with significant capability to address psychological and psychiatric issues. This combination of expertise is rarely present in even fairly sophisticated treatment settings and is conspicuously absent in programs designed for “treatment” of addicts who have been adjudicated and have been mandated to receive addiction treatment programming as part of their sentencing.

Prerelease programs usually run between 90 to 180 days and are designed to assess the individual’s capabilities to live a sober life outside of the structure of a correctional facility. These programs are not designed to provide primary treatment of any type and are often managed by graduated peers. They are usually found in inner-city locations with access to drug-infested neighborhoods. Given the cognitive, emotional, and behavioral vulnerabilities of chronic methamphetamine users, these programs can represent a major risk for “treatment failure” with subsequent categorization as resistant or non-compliant.

Another aspect of treatment for methamphetamine users is related to how rapidly they become addicted to this drug and how quickly their use results in major impairment and subsequent need for treatment (). Hartz et al. (2001) have reported extensively on the intensity of craving for this drug and the cues associated with relapse because of it. In the long run, the emphasis needs to be on prevention because the prognosis for methamphetamine-addicted individuals, given the brain impacts, can be bleak.