Addiction is a brain disease, and it doesn't matter: How the aetiology of neurological impairment guides Magistrates’ perceptions of criminal responsibility

This thesis investigates the extent to which addiction and its associated neurobiological impairment are considered as factors in Magistrates' criminal sentencing decisions. Over four empirical studies, Magistrates were presented with sentencing scenarios and their decisions analyzed. Study 1 indicated that addiction can be treated as a disease of the mind, but only in the explicit absence of choice in its initiation. Where normative addiction narratives were confounded by removing choice, leniency was extended in common with similar impairment of alternate origin. This choice component was examined in the context of age of first drug use, maintenance of addiction, and the extent to which addiction might undermine perceptions of intoxication being voluntary. Study 2 found that choice was equivalently inculpating whether made as a juvenile or an adult, but leniency was observed where addiction was accompanied by an acquired (fictional) brain disease, suggesting it was not solely drug-use which set it apart. In Study 3, removing choice from addiction promoted leniency, but only where drug-use was ongoing and uninterrupted. Where it was not, removing choice resulted in harsher sentencing. Study 4 examined addiction as it influenced perceptions of choice in intoxication, finding that, in specific circumstances, intoxication could serve to mitigate, whilst addiction was more commonly seen as aggravating, even in the absence of intoxication. Results are discussed in relation to current legal standards which attach criminal responsibility to acts on the basis of volitional control over behaviour and deny excuse to offenders where they are understood to have created the circumstances of their own defence. These findings demonstrate impairment mediating leniency on the basis of its aetiology. Addiction is understood as a brain disease in theory, but is treated so in practice only where conventional aetiological narratives are confounded by varying perceptions of voluntariness in drug-use

Addiction is a brain disease, and it doesn’t matter: prior choice in drug use blocks leniency in criminal punishment

Our aim was to explore how (neuro)scientific understanding of addiction as a brain-disease impacts criminal sentencing decisions in courts in England and Wales, where legal rules concerning intoxication, prior-fault and mental disease conflict, and sentencing guidelines lack clarity. We hypothesized that despite significant neuropsychiatric overlap of addiction and other brain-disorders, variables in relation to etiology would moderate magistrates’ sentencing decisions in cases involving addicted offenders. Using a questionnaire-based, quantitative design, and combining frequentist and Bayesian analysis approaches, we probed court magistrates’ sentencing decisions, and underlying rationale, for defendants presenting with brain damage resulting from a (fictional) disease, addiction to heroin, or more complex, mixed etiologies. When identical neuropsychiatric profiles resulted from disease, but not heroin addiction, prison sentences were significantly reduced. Study 1 (N=109) found the pivotal factor preventing addiction from mitigating sentences was perceived choice in its acquisition; removing choice from addiction increased the odds of sentence reduction (~20- fold) and attaching choice to disease aggravated or reversed earlier leniency. Study 2 (N=276) replicated these results and found that when heroin use led to disease or vice versa, magistrates found middle ground. These differences were independent of the age of first drug use. Finally, evidence of addiction was more likely to evoke punishment considerations by magistrates, rather than rehabilitation. Consistent with legal rules relating to intoxication but running counter to norms around mental-illness and choice, our results demonstrate the need for greater clarity in sentencing guidance on addiction specifically, and mental disorders more generally

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Harvesting madness: the unintended consequences of cannabis prohibition

The global prohibition of Cannabis was comprehensively enshrined in the 1961 UN Single Convention on Narcotic Drugs, a measure rooted in the unfounded belief that it was a drug with no medical benefit which was known to cause mental illness. This association with insanity was promulgated in significant measure by the US administration during the early 20th century as part of its drive to form international consensus in favour of prohibition. Criminalizing the drug had the inadvertent effect of promoting domestic production over import in Western countries, as clandestine cultivators in these traditionally non-producer nations sought to breed varieties which would flourish in cooler northern climes. Though representing very different interpretations of the 1961 Single Convention, the US and Dutch prohibition regimes acted in concert to accelerate this process, resulting in domestically-produced, hybridized ‘Skunk’ Cannabis variants which quickly found favour throughout the Western world due to the facility of their clandestine domestic production and their markedly increased potency. Cannabis producers in the West have seen the advantage in selectively breeding in favour of significantly increasing the amount of THC present in the plant. However, increasing THC comes at the cost of reducing the amount of Cannabidiol, a potent anti-psychotic, leading to speculation that this changing ratio is impacting the mental health of users. It is this new form of Cannabis which almost exclusively dominates the medical and latterly recreational marijuana market in the US today. It is also this new form of Cannabis which has been the subject of scientific scrutiny for its genuine, demonstrable link to mental illness. Prohibition, founded in large part on the false association of Cannabis with mental illness, is directly responsible for its metamorphosis into a drug which genuinely merits this association. Any move to revisit Cannabis regulation must take account not only of the increased potential for harm emerging from its modern guise, but, crucially, also consider that the one thing guaranteed to perpetuate the trend is continued criminalization

Sentencing addicted offenders: how the pattern and consistency of drug-use influence magistrates' perceptions of responsibility

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