Association of alcohol and drug abuse and violence among prisoners

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1 Association of alcohol and drug abuse and violence among prisoners Hannu Lauerma, MD, PhD, Med Finnish-German Media Seminar, Bad Ems, Germany, 7-10 Sep 2006

2 Substance abuse and violence in Finland The rate of violent deaths/population is threefold to the European average. More than 70 % of violent crimes are committed under the heavy influence of alcohol, and about 90 % of prisoners get a diagnosis of a substance use disorder. Most of them are alcoholics who also use various other intoxicants.

3 Prisoners and intoxicants About 50 % of prisoners seem to have a viral hepatitis associated with intravenous drug use. Alcoholism type 2 with special features of serotonin and glucose metabolism, usually associated with asocial personality disorder, is very strongly overpresented among violent criminals.

4 ADHD as a background of asocial personality Attention Deficit Hyperactivity Disorder. A developmental disorder with inadequate habituation, restlessness, impulsive behaviour and poor harm avoidance. Prevalence in general population 2-5 %. A tenfold overpresentation in prisons in all studies conducted so far, however, there are some methodological problems.

5 ADHD (the upper case) and ADD (the lower one)

6 ADHD and substance abuse % of those with a substance use disorder may have also ADHD, and the lifetime prevalence of substance use disorders among those with ADHD may be 20-40%. Intoxicants may be especially rewarding to those who suffer from ADHD.

7 ADHD and substance abuse lead to prison?

8 Typical comorbid disorders with ADHD in adult age Asocial personality Substance abuse disorders Bipolar disorder Sometimes a gradual positive development into adulhood

9 Some ADHD-cases are thrown into a mill, ground up into feed and eaten up by ducks

10 A traditional way to motivate those with ADHD and reading disorders

11 Where words are not enough, the famous NOKIA product is needed. Suomen Gummitehdas Oy. NOKIA. A commercial in the Finnish journal Policeman in 1932

12 Alcohol dependence type II The very first cartoon figure in Finland, Tommi Turmiola in 1858

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19 Biologic phenomena associated with abnormal violence Asocial personality and type II alcoholism - weak serotonin metabolism. An extreme form of asocial and narsissistic personality, psychopathy: problems with alertness, slow wave-forms in the EEG, high proportion of NREM S4-sleep, prefrontal cortex and posterior part of the hippocampus-amygdala slightly undeveloped, weak responses of sympathetic neural system. => Need of extra stimulation?

20 The role of early experiences and expression of genes which regulate serotonin?

21 Problems of drug treatment among substance abusing ADHD-patients Methylphenidate may be used as an intoxicant. Illicit drug use may continue. There may be a chemicalisation of life style. Hate propaganda against treatment which seems to diminish the probability of abuse disorders.

22 ADHD- medicalisation of social problems or a neuropsychiatric disorder?

23 Scientology...

24 Diagnosis of ADHD among adults is difficult Self-rating scales are of no use among people who have comorbid or other diagnoses: brain contusions, anxiety disorders, depressive disorders, personality disorders, dissociative disorders, posttraumatic stess disorders, history of psychosis etc. Heavy use of cannabis alone may lead to cognitive disorders which simulate ADD/ADHD. Simulation and dissimulation is common among asocial drug-dependent patients. The role of lacking motivation may play a role in difficulties of everyday life.

25 Treatment Diagnosis, psychoeducation and practical training may be sufficient. Sometimes psychotherapy for comorbid disorders. Antidepressants like nortriptyline and venlafaxin. Stimulants: methylphenidate (Ritalin), slowrelease methylphenidate (Concerta), occasionally dextroamphetamine (Dexedrine). Atomoxetine (Strattera).

26 Medication for substance abuse - help or iatrogenic problems?

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28 Medication or intoxicant? Alcohol given as decreasing doses was once the best treatment for delirium tremens, which is often a lethal disorder. Benzodiazepines and opioids are really useful medications, and do not typically cause euphoria when used appropriately. The criterion is not based on molecules but how they are used: to whom and when, dosage and indication.

29 Addictions and neurobiology Addictions are based on neurobiology which was there at least 300 million years ago. Mesolimbic dopamine system, nucleus accumbens. There are anticraving medications but their clinical role is minor so far - NNT:s are far higher than with antipsychotic and antidepressive medications.

30 What to do when motivating is not enough?

31 Whom should we treat with medication: a concervative view Only motivated patients with no illicit drug use and a very clear diagnosis of ADHD. These three criteria do not overlap very often in prison setting. Should we loosen the criteria?

32 Current ADHD treatment in prisons Stimulants are used extremely restrictively. Antidepressants are used with a low threshold The role of atomoxetine remains to be clarified. Cowork with representatives of social work and education are sparse but being developed.

33 Do we act rationally? ADHD-patients with substance abuse suffer often from really severe ADHD-symptoms. This makes it difficult to give up illicit drugs => there will be no treatment for ADHD. Do we possibly neglect the most difficult ADHD-patients because of narsissistic motives and disciplinary pseudoreasoning?

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