DRUG USE IN CORRECTIONAL POPULATIONS
Eighty percent (1.4 million) of the 1.7 million adult Americans in state or federal prisons or local jails are involved with alcohol or drugs.1 Sixty-four percent of state inmates, 43% of federal inmates, and 59% of local jail inmates reported having used drugs regularly (ie, at least weekly for a period of at least 1 month). Forty-eight percent, 23%, and 55% of state, federal, and local jail inmates, respectively, were under the influence of alcohol, drugs, or both at the time they committed the crime for which they were currently serving time. Nineteen percent, 55%, and 21% of state, federal, and local jail inmates, respectively, had been convicted of a drug law violation. Twenty-nine percent, 14%, and 15% of state, federal, and local jail inmates, respectively, had been in treatment for alcohol dependence at some point.
Pre-arrest drug use was reported by 755 (43%) of 1,751 imprisoned men.2 A retrospective survey of these inmates found that 34% reported use of marijuana, 9% opiates, 9% amphetamines, and 5% cocaine. These inmates represented a crosssection of ages, security levels, types of offense, and sentence lengths.
Among inmates who had ever used drugs regularly, 76% of those in state prisons, 69% in federal prisons, and 70% in local jails had used drugs in the month prior to their arrest. In comparison, only 6% of the general adult population surveyed in 1996 had used illicit drugs in the month prior to being surveyed. Lifetime drug use is much higher among inmates than in the general population: 79%, 60%, and 78% of state, federal, and local jail inmates, respectively, had used illicit drugs, compared with 48% of the non-incarcerated adult population.1
THE ROLE OF ALCOHOL AND DRUG USE IN VIOLENT CRIMES
Alcohol and drug use plays an enormous role in violent crimes. More than 50% of murders are committed when the murderer is intoxicated.3 Seventy-three percent of violent offenders in state prisons and 65% of violent offenders in both federal prisons and jails fulfilled one or more of the following criteria: used drugs regularly or had a history of alcohol disorders, committed their crimes to get money to buy drugs, or were under the influence of alcohol or drugs at the time they committed their crimes.1
Prison inmates who have alcohol disorders are more likely than either the general inmate population or regular drug users to be imprisoned for a violent offense.1 In state prisons, 59% of offenders involved with alcohol are imprisoned for a violent offense, compared with 47% of the overall state prison population and 43% of regular drug users. In federal prisons, 64% of inmates involved with alcohol are imprisoned for a violent crime, compared with 23% of all federal inmates and 29% of regular drug users.
Alcohol is connected with murder, rape, assault, and child and spousal abuse more than any illegal drug. Alcohol disorders are contributing factors in incest, child molestation, and domestic violence. Reasons for this connection are many: alcohol can provide justification for assaultive behaviors, lower inhibitions and accentuate aggression, decrease the user's ability to handle unexpected or threatening behaviors, and disrupt neurochemical pathways that mediate aggressive behavior.1
A study of 18 wife abusers sentenced to prison found that 17 of the men had been drunk at the time of the offense.4 Fifty percent of these men regarded themselves as currently addicted to either alcohol or drugs. However, when selfreports were supplemented with court records, the proportion of addicts rose from 50% to 89%. Drug or alcohol disorders, along with depression, are the most common psychiatric disorders in men who abuse their wives.4 Despite the high percentage of alcohol and drug disorders in these men, addiction treatment is generally not included as part of the rehabilitation.
Alcohol and drug use also increase the likelihood of male batterers being killed by their partners. A study comparing abused women who had killed their partners with abused women who had not found that men who were killed had used drugs more frequently and had become intoxicated more often.5 Women who use alcohol or drugs are more likely than women without substance disorders to commit murder.6 A study of 23 men and 11 women charged with killing a spouse found that both the men and the women had been drinking on the day of the murder, and that the men were more likely than the women to have a history of alcohol disorders.7
A study of 1,565 inmates in a jail in the Pacific Northwest found that 332 (21%) were identified as having a mental disorder.8 Of these 332, 74.3% had substance disorders, and only 10% of those with substance disorders were in treatment when they were arrested.
TREATMENT OUTCOME IN ADDICTED PATIENTS
The prison population tripled between 1980 and 1996, primarily due to aiminal activity related to substance abuse.9 Incarceration without treatment leads to increased recidivism followed by reincarceration, leading to increased costs to society in terms of factors such as law enforcement, adjudication, and corrections. The rate of alcoholism is positively associated with the number of previous imprisonments, which in turn is a predictor of future violent behavior.3 Early recognition and intervention is essential to break this cycle. The total annual cost to society for substance disorders is estimated at $245.7 billion.10
Offenders who complete treatment for drug and alcohol disorders are less likely to return to criminal behaviors and, subsequently, to the correctional system. One study found that 63% of those on parole who completed a treatment program for use of alcohol and other drugs were rearrested within 3 years, compared with 79% of those who did not complete treatment.11 Another study found that 43% of offenders who completed treatment in Wisconsin's Treatment Alternative Program were rearrested within 18 months, compared with 74% of offenders who did not complete the program.12
Drug and alcohol treatment is generally effective in reducing offender relapse, rearrest, convictions, and reincarceration.9 Therapeutic communities are particularly effective, with participants in these programs having the lowest recidivism rates. Inmates in therapeutic communities are housed apart from the general population and receive a 4-stage treatment intervention consisting of orientation, intensive treatment, transition, and aftercare. Intensive treatment includes cognitive and behavioral therapy and 12-step meetings. Only 26% of the program graduates in a therapeutic community in Oregon returned to prison, compared with 85% of the nongraduates.9
Characteristics of successful programs include appropriately matching offenders to treatments, addressing co-occurring mental health disorders, using cognitive-behavioral techniques, and using a psychoeducational approach.9 Although inmates must be appropriately motivated to succeed in treatment, this motivation can be either external, with sanctions imposed for failure to make progress, or internal.
A program implemented in the Manhattan House of Detention for Men treated heroin addicts with a rigid schedule of methadone detoxification.13 Inmates received 40 mg of methadone hydrochloride the first day, 30 mg the second day, 20 mg on the third and fourth days, and 10 mg for the next 3 days. This schedule was implemented universally because the vast numbers of inmates who needed treatment (17,000 per year) precluded the possibility of individualLzed treatment. Although many inmates received less than the ideal amount of methadone to treat their symptoms, inmate violence and suicide attempts were reduced markedly after implementation of mis program.
One hundred four male inmates with addictions were compared with 499 males with addictions who had never been convicted of a criminal offense (nonoffenders with addictions) and with 553 males with addictions who were not currently imprisoned but had been convicted of at least one criminal offense (offenders with addictions).14 The inmates with addictions were less likely to be employed and more likely to have deficits in social skills than were the offenders with addictions. More offenders with addictions had been in treatment previously than had either nonoffenders with addictions or inmates with addictions. Inmates with addictions displayed more antisocial behaviors but had fewer symptoms of mental health problems than did either offenders with addictions or nonoffenders with addictions.
A study of unconvicted prisoners in England and Wales found that 19% of the men and 29% of the women reported dependence on street drugs.15 Twelve percent of the men and 6% of the women reported being solely dependent on alcohol. Twenty-four percent of the 995 prisoners (23% of the men and 26% of the women) who participated in the study requested treatment for their drug misuse in the form of residential rehabilitation, counseling, alcohol education classes, a drug-free living situation, or Alcoholics Anonymous or Narcotics Anonymous. Such a high percentage of inmates requesting assistance exceeds the current capabilities of most prisons. However, this is a window of opportunity for intervening for inmates with drug and alcohol disorders and may help break the cycle of crime and prison for addicts.
A multistage therapeutic community treatment system in the Delaware correctional system has shown promise for reducing drug relapse and criminal recidivism.16 This program instituted a three-stage model that corresponded with incarceration, work release, and parole. Individuals who received treatment during prison and work release, or during prison, work release and parole were significantly less likely to experience relapse and recidivism than were those who were treated only while in prison.
A survey of prisons in the United Kingdom found that 91% provide services for prisoners with alcohol problems.17 However, the development of these services tends to be haphazard. Results of the survey argue for the appointment of a facilitator who is responsible for staff training, the establishment of a communications network, the encouragement of new interventions to address the needs of inmates, the establishment of links with community workers, and the evaluation of the success of programs.
MENTAL ILLNESS AND ADDICTION
Individuals with co-occurring mental illness and drug or alcohol disorders progress more rapidly from initial use to dependence on drugs, are less likely to comply with psychotherapeutic medications and to complete treatment, are more likely to be hospitalized or attempt suicide, and experience a more rapid recurrence of symptoms after being released from treatment.18 Estimates of the percentage of inmates who have co-occurring Axis I mental health disorders and drug or alcohol disorders range from 3%19 to 50%.20
A study comparing random selections of inmates in 1973 and 1986 defined "psychiatric" inmates as those who had received inpatient or outpatient psychiatric treatment or who had attempted suicide.21 Twenty-nine percent and 27% of inmates in 1973 and 1986, respectively, had received either inpatient or outpatient psychiatric treatment. Psychiatric inmates were found to be more seriously addicted to drugs than were control inmates during both years (P < .05 in 1973 and P < .01 in 1986). Psychiatric inmates consumed more alcohol than did control inmates (P < .05). The study concluded that there is a substantial incidence of both substance disorders and psychiatric disorders in imprisoned offenders. Offenders released from prison may be caught in a cycle of drug and alcohol disorders, which both precipitate and are precipitated by the recurrence of psychiatric symptoms.
In 1990, 109 inmates at the Washington State Corrections Reception Center were evaluated for lifetime prevalence of depression, dysthymia, alcohol disorders, drug disorders or dependence, schizophrenia, schizophreniform disorder, mania, and antisocial personality disorder.20 Ninety-six offenders (88%) received at least one psychiatric diagnosis, and 54 inmates (50%) received a dual diagnosis of drug or alcohol abuse or dependence and another psychiatric disorder.
A study of 1,565 inmates in a jail in the Pacific Northwest found that 332 (21%) were identified as having a mental disorder.8 Of these 332, 74.3% had substance disorders, 36.7% were mentally ill, and 14.5% were mentally ill with substance disorders. (The remaining 3.9% were developmentally disabled.) Inmates with co-occurring substance disorders and mental illness constituted 4.4% of the total sample.
A study of 309 men on probation and parole found a prevalence of antisocial personality disorder of 72% in whites and 67% in blacks.22 In both racial groups, antisocial offenders were younger, less educated, and more likely to use illicit drugs than were non-antisocial offenders. White antisocial offenders had twice the prevalence of alcoholism as did black offenders (34% vs 17%; P < .05). White antisocial offenders had a significantly higher rate of alcoholism than did their non-antisocial counterparts. Use of illicit drugs was also positively associated with antisocial personality in white subjects. There was no difference in rate of alcoholism between black antisocial offenders and black non-antisocial offenders.
The problem of co-occurring disorders in criminal offenders is not limited to the United States and Great Britain. A study in Italy found that a dual diagnosis of alcohol disorders and personality disorders occurs in 14.2% of inmates.3
TREATMENT OF PATIENTS WITH A DUAL DIAGNOSIS
Treatment approaches must be modified for use with inmates with a dual diagnosis.18 Counselors working with these inmates must have smaller case loads to provide more individualized counseling or case management. Meetings should be shorter and educational programs should be simplified to accommodate the more limited cognitive abilities of inmates with co-occurring disorders. In addition, psychoeducational information should be repeated to facilitate comprehension and retention. Inmates with co-occurring disorders must be educated about the importance of proper use of medications. These inmates may incorrectly believe that use of any drug will be counterproductive and must understand the difference between useful and harmful drugs. Confrontation, although often used as a primary intervention with those who have drug and alcohol disorders, should be avoided for inmates with a dual diagnosis due to their lowered ability to tolerate the stress and emotional arousal caused by confrontational methods. Programs for these inmates should instead provide a more supportive and educational approach in group therapy sessions.
PAROLE AND SUPERVISION OF ADDICTED PATIENTS
Achievement and maintenance of sobriety during parole is particularly important for the reduction of recidivism. Adult male property offenders on felony probation have a recidivism rate of 31.2%. Those offenders with a history of drug disorders are particularly likely to reoffend.23
A 1996 study compared the treatment outcomes of 296 patients on probation or parole with those of 314 patients who received voluntary methadone maintenance treatment.24 Prior to treatment, the groups differed only on the following variables: age at first daily intravenous drug use (22.0 years for those on probation or parole compared with 23.6 years for volunteers); months incarcerated in the 5 years prior to .treatment admission (16.0 months for those on probation or parole compared with 3.2 months for volunteers); and days of productive activity in the 30 days prior to admission (8.1 days for those on probation or parole compared with 11.1 days for volunteers).
Following treatment, the groups differed on 6 outcome variables: retention in treatment for 1 year (39% of those on probation or parole compared with 56% of volunteers); months of productive activity in the year following treatment (5.2 months for those on probation or parole compared with 6.6 months for volunteers); months of incarceration (2.1 months for those on probation or parole compared with 0.7 months for volunteers); days worked for pay in the 12th month after admission (5.5 days for those on probation or parole compared with 8.1 days for volunteers); days of productive activity in the 12th month after admission (10.7 days for those on probation or parole compared with 16.0 days for volunteers); and days incarcerated in the 12th month after admission (8.2 days for those on probation or parole compared with 3.1 for volunteers).
Patients on probation or parole differed in their reasons for leaving treatment. Forty-four percent of those on probation or parole left treatment because of incarceration, compared with 18% of the voluntary treatment group. However, only 5% of those on probation or parole were discharged for noncompliance with treatment, compared with 22% of the volunteers. The results indicate that many patients on probation or parole remain in treatment and benefit from it.
The Treatment Alternative Program (TAP) began in Wisconsin in 1989.12 Based on the Treatment Alternatives to Street Crimes program, TAP offers treatment for alcohol and drug disorders in addition to case management. TAP includes identification, assessment, monitoring (including urinalysis), and coordination and provision of treatment services. TAP can divert offenders from the criminal justice system, but offenders who violate conditions of their TAP agreement are returned to the correctional system. TAP is successful at reducing recidivism. Fortythree percent of offenders who completed TAP were rearrested within 18 months, compared with 74% of those who did not complete TAP. TAP was also more cost-effective than incarceration.
Forty percent of those on probation or parole in the Northern District oí California had previous or current problems with drugs or alcohol.25 A proactive drug aftercare (DAC) program was developed in which intervention was begun immediately for clients identified as a DAC case. Those identified for the program either were already addicted or had the potential for addiction. The premise was that recreational users would be discouraged due to the risks involved, and that serious users would have to accept either responsibility to confront their addiction or the consequences. Clients participated in a threephase treatment system involving random drug tests, treatment évaluation, counseling, and Narcotics Anonymous meetings. They were subject to graduated sanctions for failure to adhere to the program. Evaluations of this DAC program found that it contributed to the reduction of drug use by clients in addition to preventing renewed criminal behavior.
THE ROLE OF PRODATION AND PAROLE OFFICERS
Probation and parole officers hold different standards regarding alcohol and drug use by offenders.26 Officers in general advise offenders not to drink, but at the same time send the message that if an offender has to drink, he or she should try to control his or her drinking. Alternatively, any use of illicit drugs is considered grounds for having supervision revoked. Up to one-third of offenders are addicted to both alcohol and another drug, and 87% of offenders who use cocaine also use other mind-altering substances.26 If allowed to consume alcohol, those with addictions to a drug other than alcohol may substitute alcohol for the illicit drug. Alternatively, use of alcohol may reactivate a compulsion to use the original drug or lower resistance to using that drug. Offenders with substance disorders must remain abstinent if they are to overcome their addiction.
Supervision of individuals on probation and parole who have drug problems can be complicated if they are able to obtain prescriptions for controlled substances.27 For example, an offender who uses heroin may seek (and obtain) a prescription for codeine. A positive result on drug testing for opiates can then be attributed to the prescription, which may mask the use of illegal drugs. In such a case, officers must be aware of indications of subterfuge, such as evidence of injections and signs of opiate intoxication. If officers are concerned about possible misuse of prescription medication, they may require the offender to return to the prescribing physician and request a substitute non-opioid medication. Officers may also request to see medical records that indicate the reason for the prescription. In some cases, prescription medication is used for legitimate medical reasons. However, officers do their clients on probation and parole, and society at large, a disservice if they fail to further investigate potential substance misuse, even when it occurs under the guise of medical treatment.
MANDATED OR COERCED ADDICTION TREATMENT
Treatment is considered to be coerced if an alcoholic or a drug addict has the choice of either participating in addiction treatment or receiving the consequences prescribed by the enforcement of the law, policy, or agency. Typically, the client must comply beyond the initial treatment period or face consequences that are defined as part of the agreement for the recovery from the addiction. In rare cases, the client is forced to accept addiction treatment as part of sentencing.28
Concerns surrounding the use of coerced treatment include its potential for success and costeffectiveness. In particular, some researchers argue that coerced treatment is unlikely to effect any lasting changes because participants lack the desire to change - a factor believed by many to be necessary for lasting changes.29
A recent review of the literature indicates that favorable treatment outcomes can be obtained through the use of coerced addiction treatment.29 Outcome studies to date strongly suggest that coercion is fundamental to favorable outcomes from therapeutic interventions. Often individuals with alcohol problems must be given the opportunity to feel, face, or experience the consequences of their drinking before the denial of their problems can be penetrated and motivation for changes in attitudes and behaviors related to alcohol use can be developed. Continued use of alcohol is an unhealthy and dangerous state for those who are affected and for their friends, relatives, and employers. Effective therapeutic interventions are more likely to succeed if alternative consequences are contingent on continued compliance with interventions aimed at specific targeted populations.
Studies show that favorable treatment outcomes can be obtained despite less than optimal compliance with coerced treatment. A nationally representative sample of 330 outpatient addiction treatment organizations was surveyed in 1990. Sixty-four of the organizations had 75% or more court-mandated clients, and 122 had 25% or fewer court-mandated clients. Although the former organizations (75% court ordered) had less compliance with the treatment plan than did the latter, there were no differences in clients meeting their goals of treatment.30
Employment assistance programs have traditionally worked on behalf of employers and employees to identify and refer for addiction treatment to the benefit of both. Employers and employees have long recognized the benefits of addiction treatment in terms of reduced psychiatric, medical, and legal consequences and increased productivity in the workplace. Many studies have shown the improved benefits in psychosocial functioning of the individual.31
A study of treatment of substance disorders detected through urine samples at a workplace found coerced treatment to be effective in improving employees' problems.32 The study compared employees who were coerced into treatment after failing a urine toxicology screen with employees from the same job sites who selfreferred for treatment of substance disorders. On intake, die coerced group was found to have significant substance use and other problems, but these were less severe or less chronic than those of the self-referred group. Coerced participants were significantly more likely to remain in treatment, regardless of whether the treatment was inpatient or outpatient, than were their selfreferred counterparts. Posttreatment follow-up found comparable improvements in alcohol and drug use and in employment, medical, family, and psychiatric problems among coerced and self-referred patients.
TREATMENT FOR DRUNKEN DRIVING OFFENDERS
In Massachusetts, individuals who were convicted of a second drunken driving offense were mandated to incarceration for 7 days or more or to enter a 14-day residential alcoholism treatment program.33 A 2-year follow-up study of arrest rates assessed the impact of the two sentencing options on subsequent arrests for driving under the influence of alcohol. Offenders admitted to the 14-day program were significantly less likely to be rearrested for drunken driving (10% vs 20%). The odds were 1.9 times greater for rearrest among the incarcerated offenders. The twofold reduction in rearrest for drunken driving suggested that mandated short-term residential treatment was an effective intervention.
A study in Franklin County, Ohio, in 1987 examined mandated sentencing to either jail or a certified driver intervention program (DIP) after an initial drunken driving conviction.34 Potentially important covariates were controlled for, such as gender, age, race, blood alcohol concentration, additional charges filed at the time of arrest, and driving history. DIP attendees had significantly lower rates of subsequent impaired driving. Drivers were significantly more likely to display additional impaired driving when jailed as opposed to enrolled in a DIP. DIPs appeared most effective when used for individuals who had not had previous alcohol-related crashes or driving offenses.
Improving intervention for alcohol problems is an important priority. In this vein, the Institute of Medicine of the National Academy of Sciences conducted a comprehensive study of the alcohol treatment process and system.35 The conclusions emphasized that alcohol treatment was effective, but that there was a need to improve the current alcohol treatment system in a cost-effective manner. The Institute of Medicine report identified several areas of treatment that needed improvement, including (1) standardization in the diagnosis and assessment of alcoholism; (2) more community-based assessment and interventions; (3) treatment referrals and level of treatment based on the assessments; (4) linkages among primary care, community-based treatment, and specialized treatment services; (5) a treatment system that provides better continuity of care; (6) financing for a spectrum of treatment modalities and sites to match the diversity of the population; and (7) the elimination of organizational, personal, and regulatory barriers to the diagnosis and treatment of alcohol problems.
The use of drugs and alcohol is strongly associated with criminal activity varying from property crimes to violence. Eighty percent of inmates in federal and state prisons and local jails are involved with alcohol or drugs. Crimes related to alcohol and drugs impose enormous costs on society both directly due to the loss of property and human potential and indirectly in terms of court costs, incarceration, and supervision. Failure to treat these disorders results in a cycle of criminal activity and imprisonment, with untreated offenders significantly more likely to return to criminal behavior after release.
Fortunately, this cycle can be broken for many offenders through treatment of drug and alcohol disorders during incarceration and continuing after release into the community. Approximately one-fourth of offenders request treatment for their addictions, indicating internal motivation to break the cycle of drug abuse, criminal behavior, and incarceration. However, recent research indicates that treatment of substance disorders can be effective even for those offenders who are coerced into participating. Given the success and costeffectiveness of drug and alcohol treatment, we do these inmates and society at large a disservice by failing to acknowledge and treat these disorders.
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