With the incarcerated population approaching 2 million offenders, the majority of them with drug and alcohol abuse problems, an unprecedented gathering of professionals from public health and public safety considered how to move beyond traditional barriers and address comprehensively the related problems of substance abuse and crime.
Recent studies have demonstrated the sheer scope of the problem. General Barry McCaffrey, Director of the Office of National Drug Control Policy, noted that between 50 and 85 percent of prisoners are incarcerated because of problems related to drug and alcohol abuse. In 1998 alone, about two-thirds of adult and one-half of juvenile arrestees tested positive for at least one illicit drug. And nearly one in five state inmates said they had committed the offense that landed them in jail to obtain money to buy drugs.
Crime, substance abuse and mental illness are inextricably linked. Indeed, it is becoming unusual for an offender not to have a substance abuse and/or mental health problem. "The criminal justice system has replaced our state mental hospitals," Nelba Chavez, Ph.D., Administrator of the Substance Abuse and Mental Health Services Administration in the U.S. Department of Health and Human Services, told conference participants. For more than 8 million children, one or both parents are dependent on alcohol and illicit drugs, and many have a mental illness or are involved in criminal activity as well.
By coming together, the conference participants reflected a new model for dealing with substance-abusing offenders—one that overcomes traditional barriers and blends the public health and public safety approaches, methodologies, and cultures, as well as funding streams when appropriate. Throughout the conference, participants explored ways to create a multidisciplinary system that can redefine what it means to hold offenders accountable for their behavior and for the damage they do to society.
The public discourse on these issues, partly shaped by traditional divisions between public safety and public health professionals, often is polarized. One either is "tough on crime" and thinks a punitive prison experience is sufficient for any offender, substance-abusing or not; or one is "compassionate" and favors treatment, believing that substance abuse should be blamed almost entirely for the offender's criminal behavior. Prison and treatment are presented as an either/or proposition.
But officials and participants argued that requiring treatment for offenders, especially those already in prison, is the truly tough approach to crime. Through treatment, offenders come to terms with their pasts and generate the capacity to lead productive lives. Whether they are treated or not, more than 96 percent of prisoners eventually return to society, at a rate of about 500,000 each year from state prisons alone, McCaffrey noted. They can return drug-free and able to contribute to society, or they can return likely to abuse substances and commit crimes. Thus, the argument for treatment rests largely on a need to protect the public.
Ultimately, officials noted, effective policy must be based on science, not politics or ideology. In the last few years, research has established that treatment works—even mandatory treatment—and what kind of treatment works for whom. (Some of that research is summarized in Principles of Drug Addiction Treatment: A Research-Based Guide, published by the National Institute on Drug Abuse.) There is no longer any doubt that addiction is a brain disease in which repeated drug use impairs the capacity of the brain to function even after drug use ceases, and that appropriate, comprehensive, and sustained treatment yields enormous benefits for the addict, his or her family, and society.
A recent federal study found that 18 months after release, an inmate who receives treatment is 73 percent less likely to be rearrested and 44 percent less likely to return to drug use than one who receives no treatment. Other federal and state studies have found similar results. Repeatedly, studies find substantial declines—of 40, 60, even 80 percent—in drug selling, prostitution, homelessness, and welfare receipt and substantial increases in employment among those receiving treatment.
Treatment produces obvious financial savings. While a year of outpatient treatment costs less than $5,000 per participant, and comprehensive residential treatment programs range between $5,000 and $15,000, a 6-year prison term can cost as much as $150,000. The National Center on Addiction and Substance Abuse at Columbia University estimates that 80 percent of the cost of incarcerating offenders is linked to substance abuse. By investing in treatment, especially while offenders are in prison and are mandated to comply, society can save billions of dollars when offenders return to society less likely to abuse drugs and alcohol and to commit crimes. And society reaps the benefit, of course, when former offenders return to society able to work, pay taxes, and otherwise contribute to their communities.
The scope of treatment is important. Experts at the conference repeatedly noted that offenders with substance abuse problems often have a variety of other problems that make it difficult for them to sustain compliance with treatment programs or otherwise maintain productive behavior. Mental illness, the effects of physical or emotional abuse, poverty, homelessness, educational and work skill deficits, difficulties in parenting or, for juveniles, abusive parents—most offenders face a combination of these serious problems in addition to substance abuse.
Women, juveniles, and some other populations have special needs, several panelists stressed. Large proportions of female offenders have histories of sexual trauma and/or domestic violence or are mothers of young children. Practices that are commonplace in dealing with male offenders—such as strip searches, confrontational styles of discipline, or placement in a prison far from families—can be especially inappropriate for women.
Juveniles are not miniature adults. They do not have fully developed rational/cognitive abilities and usually do not respond well to the same treatment parameters as adults. Juvenile substance abuse usually is just one problem among several. Many of these issues reflect an effort to identify with a peer group: Gang membership, gun possession, violence, and general delinquency usually accompany the substance abuse behavior. Juveniles often are following the path of their parents into substance abuse. Treatment of the whole family may be indicated, and intensive aftercare is always necessary.
Drug prevention programs, while important with all populations, can be especially important for juveniles. Young people who use drugs are several times more likely to commit various crimes, such as assault and property destruction, as those who do not use drugs.
In every session of the Assembly, presenters urged cross-disciplinary and multidisciplinary approaches to assemble the specific services each offender requires and deliver them through clear, easy-to-access case management systems. Moreover, coordinated treatment must remain consistent and must be sustained throughout the prisoner's incarceration and reentry into society.
Unless an offender's multiple needs are addressed, treatment is more likely to fail as one or another set of problems ultimately undermines the effort. Addressing drug addiction without also addressing, for example, mental illness or an abusive family situation reduces the likelihood of success. Failure to provide aftercare and follow-up services also negatively affects outcome.
There simply is not enough funding to deliver services in the traditional "stove-pipe" way, with each agency operating independently, nor is there enough expertise or funding in any one discipline to meet the multiple needs of substance-abusing offenders at each stage of the process.
The consensus for a multidisciplinary approach is now widespread. However, significant difficulties arise, even when determined people of good will try to make such an approach operational, when agencies come together to pool funding or share data or generate a common plan for treating particular offenders. Senior officials from several federal agencies spoke of how difficult and time-consuming it has been to sort through the morass of conflicting laws and regulations to coordinate programs and offer financial incentives at the federal level. Programs have separate constituencies, political sponsors and funding streams, and even legal prohibitions on combining funds. Furthermore, program professionals often have different priorities, methodologies, philosophies, and professional cultures.
Three Cabinet officials set an example in a "Call to Action." In a rare joint public appearance, Attorney General Janet Reno, Secretary of Health and Human Services Donna Shalala, and Barry McCaffrey promised the kind of coordinated approach at the senior level that they urged conference participants to adopt in states and localities. To provide technical assistance toward that effort, a "one-stop shopping" office has been established at the U.S. Department of Justice to coordinate available assistance from several federal agencies.
In the end, the hard work of organizing and building comprehensive, coordinated programs must be done at the state and local levels. Panelists in the individual sessions offered insights into and recommendations for developing strong coalitions of service providers, convincing state and local policymakers to fund comprehensive, multidisciplinary programs, and providing a full range of services. Among the themes that emerged from the panelists' discussions were:
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Early Collaboration/Early Intervention. Public safety, public health, and other social service agencies should meet early and regularly to establish and refine system needs, agency roles, and agency accountability. The highest priority is defining responsibility for conduct of a thorough assessment. The completed assessment will guide development of a treatment plan, case management procedures, and identification of lead agencies in each case. Moreover, a thorough and early assessment will help identify appropriate candidates for diversion and community corrections. It will also help to determine the appropriate extent of family involvement. Judicial leadership and oversight can initiate and maintain this process.
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Written Agreements. Because of the potential involvement of numerous agencies in certain cases, roles and responsibilities must be clear, understood, and accepted. Memoranda of Understanding are useful tools for specifying authority and fostering accountability.
Shared Resources. Funding is not sufficient to meet treatment and supervision needs if each agency acts independently. However, by combining expertise and funding, where possible, existing resources can be deployed with greater impact. Furthermore, a team approach fosters decisionmaking regarding use of existing resources.
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Coerced Treatment. The authority of the justice system can create an opportunity for intervention by treatment and other social services and reinforce their efforts. Research indicates that coerced treatment, especially if guided by a thorough assessment, is as effective as voluntary treatment. This is a public safety matter of some importance, in that juvenile and criminal justice populations are often treatment resistant.
Carefully Planned and Consistently Delivered Treatment. A treatment plan must be established in accordance with assessment results and must be understood by justice officials, service providers, case managers, and treatment participants. Testing, combined with sanctions and rewards, should be in place to foster compliance. Discharge planning should begin early in the treatment process, involving agencies that will participate in transitional and follow-up supervision and support, and should include employment and housing considerations. Intensive relapse prevention training should be provided to prepare the participant for success and for quick recovery from relapses. In short, a continuum of recovery and accountability should be established and maintained.
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Adherence to and Advocacy for Established Science. Appropriate treatment has demonstrated a significant, positive impact on crime, criminal justice and health costs, and family and community well-being. State and local policymakers should be made aware of the cost-effectiveness of treatment and persuaded to provide adequate resources. To maintain credibility, programs must evaluated by experts with no ties to the programs. To foster a spirit of trust with policymakers, programs should highlight collaborative efforts between public safety and public health.
Last Updated: March 4, 2002
