DRUG ABUSE TREATMENT WITHIN THE CRIMINAL JUSTICE SYSTEM: ADDRESSING OUR NATION'S PUBLIC HEALTH NEEDS
Timothy P. Condon, Ph.D.
National Institute on Drug Abuse
Redonna K. Chandler, Ph.D.
National Institute on Drug Abuse
An estimated 6.7 million people are involved with some aspect of the criminal justice system; nearly 2.1 million are in prison or jail and 4.8 million are participating in community-based supervision. The drug abuse, mental health, and HIV treatment needs of this population are tremendous. Among individuals incarcerated in State and Federal prisons, 69% were involved in drug or alcohol related offenses, and 56% reported using illicit drugs in the month prior to committing the offense for which they were incarcerated. In addition, a recent survey found that within jails, 52% of the women and 44% of the men met diagnostic criteria for alcohol and/or drug dependence.
Epidemiological studies have found high rates of mental health disorders and co-occurring mental health and drug abuse disorders among individuals in the criminal justice system. A survey of individuals entering the Washington State prison system found that 84% of the men met criteria for Axis I or Axis II mental health disorders and substance use disorders. Similarly, researchers found that 80% of probationers sentenced to participate in substance abuse treatment had serious mental health problems.
Finally, those involved in the criminal justice system are far more likely than the general public to have infectious diseases including HIV, AIDS, hepatitis C, and tuberculosis. In 1997, individuals passing through correctional facilities constituted 20-26 percent of people living with HIV in the United States, 29-43 percent of those infected with hepatitis C, and 40 percent of those with tuberculosis. Effectively reducing HIV and hepatitis C infection and providing treatment and services to individuals struggling with these serious health conditions are critical areas of intervention.
Research is currently underway to address the complex medical, psychosocial, and behavioral needs of individuals involved in the criminal justice system. This symposium examines the current state of scientific knowledge and findings from studies seeking to develop interventions and services to effectively address drug abuse, mental health disorders, and HIV among this population.
Findings From a National Survey of Correctional Agencies on Substance Abuse Treatment and Health Services: Who Can Get Served?
Faye S. Taxman, Ph.D.
The National Criminal Justice Treatment Practices Survey (NCJTPS) is designed as the first national survey to systematically describe the prevalence of substance abuse treatment programs across all correctional settings—prisons, jails, probation and parole offices, and other local community correctional agencies—for juvenile and adult offenders. The survey provides a picture of the substance abuse treatment programs that exist for different types of offenders and how these programs operate.
While our national strategy includes drug treatment as a method to control crime and to reduce the demand for drugs, the survey findings illustrate that substance abuse treatment services are not widely available for offenders in all phases of the correctional system (prisons, jails, and community correctional programs), and that the available services are not likely to change behavior. The survey found overall that:
As the first national survey of its kind, these findings raise question regarding the capability of the adult and juvenile correctional system to address effectively the drug use and criminal behavior of offenders—far too few programs and services exist and those that do exist are only offered to a small percentage of offenders and often do not incorporate the core principles of effective programs. The number and capacity of the services available indicates that access to needed services is a significant concern across all categories of adult and juvenile offender programs. Many of the services that are available are education-based substance abuse programs, which are useful, but are not a substitute for clinical services that can guide offenders through the behavior change process. Unless drug-dependent offenders or sufficient numbers of offenders are participating in substance abuse treatment programs, then it is unlikely that States will realize the reductions in recidivism that are desired and are often demanded to justify sustained funding for programs. The survey findings can be used strategically to improve services for offenders.
- Access to treatment services within correctional settings is minimal—less than 10 percent of adult offenders and about 20 percent of juvenile offenders across all settings receive the treatment that they need;
- Less than half of the administrators report using a standardized tool to screen for substance abuse disorders;
- Less than half of the correctional administrators report using an actuarial-based risk tool, despite the fact that research supports that high-risk offenders should be placed in more structured programs;
- Inadequate numbers of treatment staff, and types of training for the staff, makes effective implementation of programs and services difficult;
- Substance abuse treatment services are reported to be offered in 65 percent of the adult correctional programs (e.g., work release, intensive supervision, etc.), but the most frequently provided services are educationally oriented or low-intensive group therapy (less than four hours a week), which are unlikely to facilitate behavior change;
- Most of the substance abuse services are less than the 90 days recommended by the literature; and
- Treatment providers report using some of the consensus-driven, evidence-based practices, but in general, correctional administrators are unaware of these practices occurring in the programs offered to offenders.
The Long-Term Effectiveness of Corrections-Based Treatment for Drug-Involved Offenders
James A. Inciardi, Ph.D.
With growing numbers of drug-involved offenders coming to the attention of the criminal justice system, substance abuse treatment has become a critical part of the overall correctional process. The therapeutic community appears to be a treatment modality especially well suited for correctional clients because its intensive nature addresses their long-term treatment needs. A multistage therapeutic community treatment system has been implemented in the Delaware correctional system. The centerpiece of the treatment process occurs during work release—the transitional stage between prison and the free community. When evaluating this program, 690 individuals in four research groups were followed: treatment graduates with and without aftercare, treatment dropouts, and a “no treatment” comparison group. At 5 years after release, treatment graduates, with or without aftercare, had significantly greater probabilities of remaining both arrest-free and drug-free than did those without treatment. Treatment dropouts were slightly, though not significantly, less likely to be arrested on a new charge as those without treatment, but were significantly more likely to be drug free. These outcome data suggest that the widespread implementation of such treatment programs would bring about significant reductions in both drug use and drug-related crime.
Mental Health and Co-Occurring Treatment Needs of Individuals in the Criminal Justice System
Roger H. Peters, Ph.D.
In this presentation, I review the mental health and co-occurring treatment needs of individuals in the criminal justice system. There are a number of challenges in providing services for this population, including the high risk for relapse, deficits related to educational and job skills, scarce prevention and treatment resources, and stigma related to co-occurring disorders and offender status. The prevalence of mental and substance use disorders are higher (approximately 15 percent) in criminal justice settings than in the general population. Unique areas that need to be addressed among this population include ingrained criminal belief systems and related behaviors, the interrelated nature of mental and substance use disorders, and managing the transition from institutional to community settings. Key features of evidence-based offender treatment programs include use of a highly structured approach, focus on symptom management vs. cure, basic life management and problem-solving skills, and “criminal thinking” groups. These programs feature isolated treatment units often situated within therapeutic communities, and provide several phases of treatment that include orientation/assessment, intensive treatment, and relapse prevention/reentry.
Meeting the Medical Needs of Offenders
Peter D. Friedmann, M.D.
The jail and prison populations are drawn from underserved communities, to which the great majority will return. The high prevalence of medical conditions in the correctional population stems from current or past risk behaviors, including parental drug use; tattoos and unsafe sex; direct toxic effects of illicit drugs or adulterants; impoverished living conditions; and poor access to routine medical care in the community. Combined with high turnover rates in jails and prisons, the constitutional right to medical care for inmates provides an opportunity to improve public health through prevention and treatment of drug abuse and overdose; infectious diseases, including HIV/AIDS, hepatitis C, and hepatitis B; homicide; mental illness and suicide; motor vehicle accidents; cardiovascular disease and cancer.
Pharmacotherapy in Correctional Settings for Addictive and Other Mental Disorders
Robert P. Schwartz, M.D.
Medication therapy for psychiatric and addictive disorders is part of the standard of care in community settings and should be a part of such care in correctional settings as well. The lack of access to medications for the treatment of psychiatric disorders has been the subject of class action litigation. There are several unique aspects of providing psychopharmacologic treatment in correctional institutions. These include avoiding the use of medication as a form of restraint, dealing with formulary restrictions, avoiding neuroleptic malignant syndrome, and attending to discharge planning. Opioid agonist therapy, with methadone or buprenrophine, is the most widely used and effective treatment in the community for heroin addiction. It has been used widely outside of the United States in correctional institutions but has been rarely available to U.S. inmates. This lack of access to treatment exists, despite evidence of methadone treatment’s efficacy obtained in a study of pre-release jail inmates in New York City conducted nearly 40 years ago, and despite more than 20 years of clinical experience in that jail with providing methadone detoxification from heroin addiction, initiating methadone maintenance, and continuing methadone maintenance for individuals enrolled in treatment at the time of arrest. An ongoing randomized clinical trial of methadone as a pre-release strategy for addressing heroin addiction, and a recently completed pilot study of buprenorphine in a pre-release prison in San Juan, show the ability of opioid agonist treatment to increase treatment enrollment and reduce heroin use after release from prison.