Compared with other nations, the United States incarcerates the largest percentage of its citizens, with close to 7 million adults and 650,000 youth under some form of criminal justice supervision, including prison, jail, and probation or parole supervision in the community. Incarceration in the United States costs nearly $1.2 trillion each year in incarceration and societal costs, and 40%–60% of prison intakes result from failures in community supervision related to drug relapse. Research consistently demonstrates the close connection between drug use and criminal justice involvement, with over 70% of offenders involved with drugs or alcohol at some point in their lifetimes. About 36% of violent crimes involve alcohol and 40% of criminal offenders reported using alcohol at the time of their offense. Many offenders are caught in a cycle of drug use, crime, arrest, and reincarceration. Drug charges account for about one-third of re-arrests following release from prison or jail. Over half of all offenders are re-arrested within 12 months of release and over two-thirds are re-arrested within 3 years of release. Numerous studies have shown that involvement in community alcohol and drug treatment services delays re-arrest and reincarceration. The purpose of this chapter is to provide an overview of the drug and alcohol treatment needs of offenders and the mechanisms available in the criminal justice system to address these needs.
Prevalence of Substance Abuse and Dependence
Substance abuse is four times greater in the offender population than in the general population; 37% of offenders are estimated to have a substance abuse disorder, compared with 9% of the general population. Over 80% of state prisoners reported a lifetime history of drug use and about half of state prison inmates met Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for a substance use disorder.
Compared with the nonoffender populations, offenders are more likely to abuse illicit and prescribed substances. For example, about 11.3% of male and 20.8% of female prisoners reported daily opioid use in the 6 months preceding incarceration; 10% had a history of lifetime opioid dependence and 8% met criteria for current opioid dependence. Abuse of prescribed opiates is a recent phenomenon and, according to the 2015 National Survey on Drug Use and Health, an estimated 3.8 million Americans 12 years of age or older used prescription opiates nonmedically in the past month, which represents three-fifths of all misusers of psychotherapeutic drugs. Among individuals who are 18 years of age or older who were arrested between 2002 and 2004, almost 30% had used prescription drugs nonmedically in the past year. A recent study of prescription drug abuse among a large sample of prisoners found that 34% of male prisoners and 62% of female prisoners reported nonmedical use of prescription opiates. Individuals who abused prescription opiates were more likely to have been involved in criminal activity and reported more drug charges, shoplifting, forgery, disorderly conduct, charges resulting in convictions, number of convictions, months incarcerated, and days incarcerated within the last month than individuals who had never abused prescription opiates.
A recent study concluded that 64.5% of the inmate population in the United States met criteria for a substance use disorder, suggesting a large need for substance abuse services in facilities that are not equipped to offer such services. Because almost all arrestees are initially housed in jails while awaiting trial or sentencing, it is left to the jail facilities to treat the acute effects of drug use and withdrawal. For example, one-fourth (25%) of inmates reported withdrawal symptoms from active drug or alcohol use upon entering jail, but only 16% reported receiving medication for relief of withdrawal symptoms.
Substance Abuse Comorbidities
Smoking is the leading preventable cause of death in the United States, resulting in over 480,000 premature deaths each year and is implicated as a causal agent in an increasing range of cancers. Prisoners, as a class, are especially vulnerable to the negative health consequences of smoking. Smoking rates are 3–4 times higher among prisoners than among individuals in the general population, and smoking is normative and nonstigmatized within the correctional environment. Among male prisoners, smoking prevalence is 70%–80%. Smoking rates among incarcerated women range from 42% to 91%—2–4 times greater than among women in the general population.
Ninety percent of prisons prohibit smoking in medical, chapel, and vocational and educational areas; however, about 40% allow unrestricted smoking in common areas, housing units and cells, or in prison yards. Due to a 2006 policy, cigarettes and other tobacco products are readily available in prison and tobacco products were banned from being sold in prison commissaries. In 2012, 30 states prohibited the use of tobacco inside state correctional facilities to reduce secondhand smoke. [CR] Due to the increase in smoke-free policies in prisons and jails, there has been an increase in tobacco contraband sold among prisoners. Tobacco products are bartered among prisoners and employees and function as a form of prison currency.
In an attempt to return nicotine products for sale in commissaries, electronic cigarettes have recently been developed specifically for use in correctional facilities. If successful, electronic cigarettes will be sold in prisons across all 50 states, with calculated sales of nearly $330,000 per 100 inmates annually. However, because of the high cost of cigarettes in prison, many prisoners purchase loose tobacco that they roll into nonfiltered cigarettes. Thus smoking inside a correctional environment may present a higher risk for tobacco-related diseases than smoking in the community.
In contrast to the enormous literature focusing on smoking prevalence, prevention, cessation, and policies in other populations, smoking among prisoners remains virtually ignored, despite the enormous human, health, and economic costs. Only five published studies have examined smoking interventions for prisoners. All five suggest that prisoners are interested in smoking cessation and able to achieve smoking abstinence, despite pressures within the correctional environment to continue smoking. In the largest study to date of smoking cessation in a correctional setting, Cropsey and colleagues conducted a randomized controlled trial of a combined nicotine replacement and 10-week group smoking cessation intervention for female prisoners. Sustained cessation rates were comparable to cessation rates following smoking cessation interventions in the community.
According to a recent Report to Congress by the National Commission on Correctional Healthcare and National Institute on Justice on the health status of soon-to-be released inmates, rates of psychiatric disorders in US prisons and jails dramatically exceed general population rates. A meta-analysis of 62 studies from 12 Western countries estimated that one in seven prisoners has a psychotic or major depressive disorder. Prevalence estimates for psychiatric disorders among state prison inmates are schizophrenia (2%–4%), major depression (13%–19%), bipolar disorder (2%–5%), dysthymia (8%–14%), anxiety disorder (22%–30%), and posttraumatic stress disorder (6%–12%). Prevalence estimates for psychiatric disorders among jail inmates are similar: schizophrenia (1%), major depression (8%–15%), bipolar disorder (1%–3%), dysthymia (2%–5%), anxiety disorder (14%–20%), and posttraumatic stress disorder (4%–9%). Approximately 50% of female inmates have mental illness. A national study estimated rates of mental illness ranging from 3% to 23% for probationers and 1%–11% for parolees. Finally, 6% of male and 15% of female jail inmates have acute psychiatric symptoms in need of treatment at the time of initial booking.
Inmates with comorbid substance use and mental health problems report more numerous and serious past year and lifetime medical conditions and consume more medical services during incarceration and in the community —underscoring the importance of psychiatric treatment in correctional settings. With the number of prisoners with serious psychiatric disorders exceeding the number of patients in psychiatric hospitals, jails and prisons have become “America’s new mental hospitals” (p. 1612). For many individuals with severe mental illness, most psychiatric care is provided in jails and prisons. The high prevalence of psychiatric disorders in correctional populations is due, in part, to the deinstitutionalization of mentally ill persons, lack of access to community mental health services and the criminalization of the mentally ill. Unfortunately, most prisoners with psychiatric and substance use disorders do not receive adequate care during incarceration and are expected to serve 4 months longer than prisoners without a mental health problem. Although data are limited, most prisons and jails fail to conform to community standards for screening and treatment of mental disorders. For example, 83% of jails offer screening, 60% offer mental health evaluations, 42% provide psychiatric medications, 43% offer crisis intervention, and 72% offer access to inpatient psychiatric treatment. Jails and prisons differ in the type and range of mental health services; jails may provide management of acute symptoms and suicide prevention, whereas prisons may offer a range of services including long-term support and treatment. After incarceration, 34% of state prisoners received treatment, followed by 24% of federal prisoners and 17% of jail inmates. [CR] Medical and psychiatric treatment in criminal justice systems varies from state to state; some contract with independent companies to provide psychiatric and medical services for their populations. Often facilities offer specialized services such psychiatric or sex offender treatment units, although little is known about the types and effectiveness of treatment programs offered.
HIV/AIDS and Sexually Transmitted Infections
The HIV/AIDS epidemic in the United States coincided with a sharp rise in incarceration related to the war on drugs, mandatory minimum sentencing, and truth in sentencing legislation in the 1980s and 1990s. As a result, many substance-abusing individuals at high risk for HIV/AIDS are also at high risk for criminal justice involvement. In 1997, 16% of individuals with AIDS and 22%–31% of individuals with HIV passed through a US correctional facility. Between 1989 and 1999, 32.9% of positive HIV tests in Rhode Island came from the state correctional institution. Between 1995 and 2004, the percentage of known HIV+ prisoners decreased from 2.3% to 1.9% of the prison population. AIDS-related deaths among state and federal prisoners declined from 2001 to 2010 by 16%. Despite that decline, the rate of confirmed AIDS in state and federal prisons was 3 times higher than in the overall US population—0.49% for prisoners and 0.14% for the US population. In 2010, more than 20,000 inmates had HIV/AIDS, with the majority (91%) occurring in male inmates.
Offenders have histories of high-risk sexual behavior and high rates of sexually transmitted infections. High-risk sexual behavior includes inconsistent condom use with multiple sexual partners, history of sexually transmitted infections, exchanging sex for money or drugs, and engaging in sexual intercourse with an injection drug user or under the influence of drugs or alcohol. Rates of chlamydia and gonorrhea are 18–50 times higher in adult prisoners compared with adults in the general population. Left untreated, chlamydia and gonorrhea may result in infertility, pelvic inflammatory disease, cervicitis, and ectopic pregnancy. Rates of syphilis are also high in correctional populations; with 8% of male inmates and 5% of female inmates testing positive for syphilis, compared with less than 0.0001% of adults in the general population. High rates of untreated sexually transmitted infections enhance risk for HIV transmission or infection, —suggesting the importance of addressing high-risk sexual behavior in the context of drug and alcohol abuse among criminal justice populations.
Other Infectious Diseases
Active or latent tuberculosis infections are higher among correctional populations than in the general population, with 20%–25% of prisoners testing positive for tuberculosis compared with 0.0048% of the general population. Multidrug-resistant tuberculosis has become epidemic in prison institutions around the world, where high rates of HIV facilitate transmission of multidrug-resistant tuberculosis. About one-third of prisoners test positive for hepatitis C, compared with general population rates of 2%. The convergence of high rates of sexually transmitted infections, hepatitis C, HIV/AIDS, and tuberculosis among prisoners is not a coincidence; these diseases act synergistically in their infection rates and disease progression, making them more challenging to treat and highlighting the importance of addressing them in the context of alcohol and drug abuse among correctional populations.
Pharmacotherapies for Substance Use
A review of the literature shows a dearth of research on pharmacological treatments for substance abuse among criminal justice populations, particularly in the United States. Providing effective treatment for opioid dependence decreases relapse to active substance use upon release from prison and prevents recidivism. Despite this, very few correctional facilities provide methadone or other detoxification or maintenance for opioid-dependent prisoners. A recent study demonstrated that initiating methadone maintenance therapy for prisoners with histories of opioid dependence prior to release facilitated entry into community treatment. However, a primary disadvantage of methadone maintenance therapy is that the individual has to be treated at a methadone maintenance clinic after release from prison and waiting lists for such treatments in the community are long, providing the opportunity for a recently released offender to fall between the cracks and miss the opportunity for immediate entry into methadone maintenance therapy upon release from prison.
An alternative treatment, oral naltrexone, an opiate antagonist, has been available for 20 years but has not been widely used, primarily due to problems with medication compliance. One review noted that less than 20% of recipients continued to take oral naltrexone 4 months after treatment was initiated. Depot naltrexone has recently received US Food and Drug Administration (FDA) approval for use in treating alcohol dependence but does not have an indication for treating opioid dependence and is unlikely to be adopted by criminal justice authorities until FDA approval is obtained. However, studies are under way to investigate the use of depot naltrexone with individuals in community corrections, which may provide another option for pharmacotherapy for individuals under criminal justice supervision in the community.
Buprenorphine, a thebaine derivative, is a mu opioid partial agonist with a pharmacological profile that makes it attractive as a pharmacotherapy for the treatment of opioid dependence. Buprenorphine, like other full mu agonists, produces opioid-associated subjective and physiological effects, but its maximal effects are less than those of a full agonist such as morphine. This property contributes to its utility in the treatment of opioid dependence in that buprenorphine is effective in preventing the onset of the opioid abstinence syndrome in opioid-dependent individuals. With escalating doses, buprenorphine produces less effect than full mu agonists and exhibits a ceiling effect at which further dose increases produce no additional effects. In addition, buprenorphine has high affinity for the mu receptor, a property that produces blockade of the effects of full mu agonists, should these be administered during buprenorphine maintenance.
The safety of buprenorphine in nontolerant individuals (such as those exiting a controlled environment) was demonstrated by Walsh and colleagues, where a plateau on subjective and respiratory dose effects resulted in sublingual doses up to 32 mg (2–4 times the recommended treatment dose) being well tolerated. Thus the ceiling effect associated with buprenorphine administration provides a wide margin of safety. Buprenorphine has fewer restrictions on its use for treatment of opioid addiction and provides an attractive alternative to methadone. In comparison with methadone and oral naltrexone, buprenorphine treatment demonstrated lower overall mortality related to its use. Thus buprenorphine appears to have advantages over other opioid therapies, including better acceptance and compliance, a favorable safety profile, and the ability to deliver the medication by prescription in a general clinic practice after release from prison. A recent review concluded that the efficacy of buprenorphine has been firmly established for treatment of opioid dependence. A cost-effectiveness study embedded in a randomized controlled trial of buprenorphine versus methadone concluded that buprenorphine is no more expensive than methadone maintenance therapy. Buprenorphine has not been widely investigated with a corrections population, and adoption of this medication by criminal justice administrators has been nonexistent, despite the well-demonstrated efficacy of buprenorphine in noncriminal justice populations. One study found that providing buprenorphine to women prior to release from the criminal justice system, reduced opiate use as they transitioned back into the community. [CR]
The community corrections population has quadrupled over the past 25 years (1.12 million in 1980 to 6 million in 2006) and comprises the largest segment of the criminal justice population. The increase in criminal justice sanctions has been attributed to a change in US policy in the 1980s to “get tough on crime” and led to the war on drugs that continues today, with drug-related arrests skyrocketing over the past 35 years (322,300 drug arrests in 1970 to 1.65 million in 2005) ; driving under the influence continues to be the largest arrest category in the United States, with over 1.8 million arrests a year.
Probation and Parole
At the end of 2006, there were over 6 million offenders on probation or parole in the United States (about 5,237,000 on probation and 798,200 on parole). Over half of these offenders have orders for substance abuse treatment services in the community, and providing care to these offenders is a challenge given the dearth of treatment services available in the community. For example, a recent survey of correctional agencies in the United States found that less than 10% of the offender population can participate in treatment services on a daily basis, due to the size of the population and the lack of availability of treatment services for offenders. The majority of treatment services available to offenders are drug and alcohol education (53.1%), group counseling for less than 4 hours a week (47.1%), substance abuse counseling for 5 or more hours a week (21.2%), and therapeutic community or residential services (3.7%) (see Table 47.1 ). Even more revealing is that the most commonly offered services do not incorporate evidence-based treatment strategies such as cognitive behavioral therapy, motivational interviewing, and therapeutic communities.
|Specialized Facilities||Generic Prisons|
|Type of Service||% With Service||Estimated # of Offenders||% of ADP (Median)||% of Programs >90 Days||% of ADP (Median)||% of Programs >90 Days|
|Substance abuse group counseling: up to 4 h/week||47.1||141,263||4.8||90.9||3.3||62.8|
|Substance abuse group counseling: 5–25 h/week||21.2||37,090||1||87.9||2.7||92.9|
|Substance abuse group counseling: 26+ h/week||1.5||2,449||<1||71.8||1.1||24.2|
|Relapse prevention groups||34.3||43,740||<1||91.5||1.3||57.4|
Over the last three decades, different strategies have been used to address the large percentage of offenders that need treatment services. Most community correctional agencies use referrals to existing programs and services in the community to provide treatment for offenders. The referral process, generally referred to as the brokerage model, relies on the probation/parole officer giving a referral to the offender for a public health clinic(s) or a specific program. The success of the model relies on the offender obtaining services. Other variations to bridge the correctional and drug treatment systems have evolved over the past two decades to provide more direct access to treatment services by offenders. These variations include the Treatment Alternatives to Street Crime (now called Treatment Accountability for Safer Communities), drug treatment courts, “break the cycle” or seamless systems of care, or on-site treatment services. Studies vary considerably on these different mechanisms, but generally research demonstrates that more offenders have access to treatment services and increased participation in treatment services when these options are available
Another model is to train the probation/parole officer in a new role, which involves engaging the offender in the change process by utilizing clinical skills such as motivational interviewing and addressing the offender’s ambivalence toward involvement in treatment services. Studies of this approach have demonstrated that the altered role of the probation officer reduces technical violations compared with traditional intensive supervision programs where the parole officer’s focus is solely on monitoring the offender after release.
The drug court, a postadjudication sentencing program, was first established in 1989 and designed to reduce criminal involvement among drug-addicted offenders. By 2007 there were over 890 drug courts operating in the United States. The theory that led to the formation of drug courts is that many drug-addicted offenders engage in criminal behavior as a means to acquire drugs; therefore, to reduce crime among drug-addicted offenders, the addiction must be treated. The basic components of most drug courts include assessment of substance abuse disorder, assimilation of substance abuse treatment and criminal justice supervision through case management and weekly status hearings with judicial oversight, a continuum of care in which offenders have access to multiple services, frequent drug and alcohol screening, and continuous interactions between the offender and the criminal justice system (e.g., judges, case managers, and so on). Drug treatment courts have revolutionized treatment for the criminal justice offender in that they provide a mechanism to ensure that monitoring, supervision, and treatment are intertwined. However, only about 3% of substance-abusing offenders have access to drug treatment courts.
A number of studies have been conducted to determine the effectiveness of drug courts; findings are generally positive but mixed. Several studies have shown that participants in drug courts show diminished drug use and criminal activity and higher treatment retention rates compared with offenders in traditional treatment settings. Belenko reviewed evaluations of 37 drug courts nationwide and found that 47% of participants graduated successfully and that drug use and recidivism were low while clients were enrolled in drug court. However, most studies did not include long-term follow-up data, making postprogram outcomes unclear. An empirical study of drug treatment courts found that treatment participation (29%–88%) and program graduation rates (29%–50%) varied considerably.
A recent meta-analysis by Wilson et al. revealed that although individuals graduating from drug court have significantly lower arrest rates than nonparticipants, most drug court participants did not attend the minimum number of required treatment sessions and more than half were not given the minimum number of drug tests. Taxman and colleagues report that treatment participation varied from 35% to 80% across drug courts. In addition, none of the programs reviewed by Wilson and colleagues was based on a formal theory of the causes of addiction and most were using a mixed bag of therapeutic approaches without focusing on any one treatment method. For example, some programs used 12-step approaches, which require addicts to turn over their addiction to a higher power in conjunction with cognitive-behavioral therapy, which focuses on thoughts and feelings and emphasizes learning new skills to change addictive behaviors. Unfortunately these two therapeutic approaches are incompatible in their views on the origins of addiction. In addition, although cognitive-behavioral therapy is widely considered one of the best approaches for treating substance abuse, it was used in only about 22% of therapy sessions.
There also appears to be a dearth of family involvement and minority or culture-specific treatment in drug courts, all of which are important treatment components. Many researchers have suggested that the lack of evidence- and theory-based practices in substance abuse treatment contributes significantly to rates of relapse and recidivism among offenders receiving treatment through drug courts. Overall, it appears that the longer an offender is in treatment, the greater their chances are of succeeding in a drug court program—a finding consistent with research on all substance abuse treatment programs.
Treatment Accountability for Safer Communities
Treatment Accountability for Safer Communities was developed in 1972 as a strategy to provide case management to bridge the gap between the criminal justice system and community substance abuse treatment. Treatment Accountability for Safer Communities models operate under the assumptions that drug addiction is prevalent among offenders; that there is a cycle of crime, incarceration, release, and relapse among drug-dependent individuals; and that this cycle provides frequent opportunities for treatment interventions. Most Treatment Accountability for Safer Communities programs provide screening for program eligibility, assessment of treatment needs, referrals for treatment outside of Treatment Accountability for Safer Communities, and client-centered case management. Many programs emphasize a continuum of care and provide regular drug screens and correspondence with the criminal justice system regarding the client’s progress. Treatment Accountability for Safer Communities currently operates in almost 40 states, and about 100 organizations use the Treatment Accountability for Safer Communities model.
Anglin and colleagues assessed Treatment Accountability for Safer Communities programs at five sites in the United States across three domains: service delivery, drug use, and recidivism. Compared with individuals receiving the standard strategy of referral to community treatment services, offenders participating in Treatment Accountability for Safer Communities had access to significantly more services at four of the five sites (drug counseling, urinalysis, and/or AIDS/HIV education). At three of the five sites, drug use decreased for Treatment Accountability for Safer Communities participants. However, there were no significant differences in recidivism (as assessed by re-arrest rates) among control and Treatment Accountability for Safer Communities groups. In fact, at two of the sites there were indications that Treatment Accountability for Safer Communities participants were more likely to be re-arrested than control group participants. More positive findings occurred at sites where the Treatment Accountability for Safer Communities services included group counseling and offenders did not have to go to another agency to acquire the needed clinical services treatment. Similar findings for intensive supervision programs (i.e., the probation officer monitors the offender through more frequent contact) suggest that increased monitoring leads to easier detection of criminal behavior among participants. Thus the increase in arrests among Treatment Accountability for Safer Communities participants can be seen as a success from a viewpoint of community safety, even though it increases technical violations and reincarcerations. Other researchers have postulated that the case management approach taken by Treatment Accountability for Safer Communities programs does not decrease recidivism because it does not lead to increased participation in substance abuse treatment, treatment is usually of a short duration, and there are often no provisions in place for noncompliance (e.g., positive drug tests or missed treatment sessions).
A more recent study revealed that jurisdictions with Treatment Accountability for Safer Communities had increased use of motivational interviewing, continuum of care policies, and services for offenders with cooccurring disorders. In addition, the survey found that Treatment Accountability for Safer Communities administrators were stronger supporters of training initiatives likely to enhance cooperation among criminal justice organizations. A general survey of treatment services offered in correctional settings found that innovations tended to be clustered. Treatment Accountability for Safer Communities organizations are more likely than program and parole agencies to offer this clustering of innovative practices. This finding allows a better understanding of implementation issues based on how organizations such as Treatment Accountability for Safer Communities, jails, and community correctional agencies affect the treatment delivery system. Overall, the survey findings suggest that communities that have organizations like Treatment Accountability for Safer Communities or Treatment Accountability for Safer Communities have made greater gains in improving service delivery for offenders in measurable ways, but that there is also considerable room for improvement in access to services and treatment and supervision outcomes.