Treatment of Substance Involved Offenders in Criminal Justice Settings – Challenges & Outcomes Igor Koutsenok, MD, MS Assistant Professor of Psychiatry, UCSD, Director, Center for Criminality & Addiction Research, Training & Application (CCARTA)

Let’s start with some bad news

California Statistics 172,785 in prison (1986: 39,373) Cost – $38 000 per inmate 117,136 on parole (1986: 19,780) Cost - $12 000 per parolee 77% of males and 83% of females incarcerated in California have drug and alcohol problems.

Nationwide cost Columbia University Report, March 2005 $ 30 billion states spent on adult corrections (incarceration, probation, parole) $24.1 billion of it was on substance involved offenders

On Women… During the 1980s and 1990s, the number of incarcerated women tripled, while the number of men doubled. 80% of these women have substance abuse problems. More likely to adjudicate women today than 20 years ago. “What Works,” Dr. Rudy J. Cypser, CURE-NY, 2000

Under 15 % receive systematic treatment Some Other Sad Facts Over 2 million inmates inhabited U.S. jails & prisons They are parents of 3.4 million children 2 in 3 convicts have been tested positive for drugs at time of arrest. 2 in 3 inmates have verified drug histories, BUT… Under 15 % receive systematic treatment Deitch, Koutsenok & Ruiz, 2004

Recidivism Within 12 months after release from custody 70- 75% of substance involved offenders are back to institutions It is clear that criminal-justice sanctions by themselves do not reduce recidivism in this population Prisons do manage behaviors, but do not shape behaviors

Policies for Drug Offenders Diversion Drug Courts Incarceration Probation w/o verdict (Prop 36) Intermediate sanctions

Policies for Drug Offenders Public Safety Risks Diversion Drug Courts Incarceration Probation w/o verdict (Prop 36) Intermediate sanctions

Policies for Drug Offenders $$$$$$ Costs $$$$$$$$$ Public Safety Risks Diversion Drug Courts Incarceration Probation w/o verdict (Prop 36) Intermediate sanctions

Policies for Drug Offenders Over-reliance Diversion Drug Courts Incarceration Probation w/o verdict (Prop 36) Intermediate sanctions

Prison Criminal Recidivism in 3 Years 68% re-arrested 47% convicted 50% re-incarcerated Relapse to Drug Use in 3 Years 95% relapse Marlow D., Treatment Research Institute, 2006

Policies for Drug Offenders Diversion Drug Courts Incarceration Probation w/o verdict (Prop 36) Intermediate sanctions

Policies for Drug Offenders Over-reliance Diversion Drug Courts Incarceration Probation w/o verdict (Prop 36) Intermediate sanctions

Referral to Treatment Attrition 50% - 67% don’t show for intake 40% - 80% drop out in 3 months 90% drop out in 12 months 70% of probationers and parolees drop out within 2 - 6 months D. Marlow D. & T.McLellan, TRI, 2004

Time for some better news What will happen if we combine incarceration and treatment?

From the work of Douglas B. Marlowe, J.D., Ph.D. Types of Substance Involved Offenders From the work of Douglas B. Marlowe, J.D., Ph.D.

Criminogenic Risks Age during rehabilitation < 25 years Criminal onset < 16 years Prior rehabilitation failures History of violence Antisocial Personality Disorder Psychopathy Familial history of crime Criminal associations

Criminogenic Needs Drug Dependence or Addiction

Criminogenic Needs Drug Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms

Abstinence is a distal goal Criminogenic Needs Drug Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms Abstinence is a distal goal }

Abstinence is a distal goal Criminogenic Needs Drug Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms Drug Abuse or Misuse Abstinence is a distal goal }

Abstinence is a distal goal Abstinence is a proximal goal Criminogenic Needs Drug Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms Drug Abuse or Misuse Abstinence is a distal goal Abstinence is a proximal goal } }

Abstinence is a distal goal Abstinence is a proximal goal Criminogenic Needs Drug Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms Drug Abuse or Misuse Collateral needs E.g., dual diagnosis, HIV+ Abstinence is a distal goal Abstinence is a proximal goal } }

Abstinence is a distal goal Abstinence is a proximal goal Criminogenic Needs Drug Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms Drug Abuse or Misuse Collateral needs E.g., dual diagnosis, HIV+ Abstinence is a distal goal Abstinence is a proximal goal } }

Risk & Needs Matrix High Risk Low Risk High Needs Low Needs

Risk & Needs Matrix High Risk Low Risk High Needs Low Needs & Accountability & Treatment High Needs Low Needs

Risk & Needs Matrix High Risk Low Risk High Needs Low Needs Treatment Accountability & Treatment High Needs Low Needs

Risk & Needs Matrix High Risk Low Risk High Needs Low Needs Treatment Accountability & Treatment High Needs Accountability Low Needs

Risk & Needs Matrix High Risk Low Risk High Needs Low Needs Treatment Accountability & Treatment High Needs Accountability Prevention Low Needs

Practice Implications High Risk Low Risk Frequent meetings with PA Intensive treatment Compliance is proximal Positive reinforcement Intensive treatment Treatment is proximal Positive reinforcement High Needs Secondary prevention Abstinence is proximal Abstinence is proximal Restrictive sanctions Low Needs

Why Therapeutic Community Model? The profile of a successful high risk/high need client in community based therapeutic community is very similar to the one of a substance abusing offender in custody

Delaware/Crest Program: 3-Year Re-Arrest & Drug Use Rates Martin, Butzin, Saum, & Inciardi, 2001 (The Prison Journal)

Texas In-prison TC Program: Return to custody rates (24 months follow-up), 2001 Aftercare Completers K. Knight, D. Simpson. The Prison Journal, 2002

California/Amity Program: 3-Year Return-to-Custody Rates (%) Wexler, Melnick, Lowe, & Peters, 2002 (The Prison Journal)

Coercion in the Criminal Justice System A 2000 report from the Institute of Medicine summarized that “contrary to earlier fears among clinicians, criminal justice pressure does not threaten treatment effectiveness, and it improves outcomes” Cost Effectiveness of Drug Treatment Drug addiction treatment is cost-effective in reducing drug use and its associated health and social costs. Treatment is less expensive than alternatives, such as not treating addicts or simply incarcerating addicts. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $18,400 per person. According to several conservative estimates, every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft alone. When savings related to health care are included, total savings can exceed costs by a ration of 12 to 1. Major savings to the individual and society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents.

Research Findings Multiple studies The length of time spent in treatment is a reliable predictor of post treatment outcomes and recidivism Coerced patients tend to stay longer and do as well as volunteers overall Most substance involved offenders would never seek treatment without pressure from the criminal-justice system Cost Effectiveness of Drug Treatment Drug addiction treatment is cost-effective in reducing drug use and its associated health and social costs. Treatment is less expensive than alternatives, such as not treating addicts or simply incarcerating addicts. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $18,400 per person. According to several conservative estimates, every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft alone. When savings related to health care are included, total savings can exceed costs by a ration of 12 to 1. Major savings to the individual and society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents.

General Findings & Recommendations 1. Duration, Setting, Training: fundamental for In-prison TC (ITC) programs ITC = 9-12 months in a residential (segregated) treatment unit Staff training is a must On-going monitoring & evaluation 2. Engagement in transitional aftercare is crucial for effectiveness 3. ITC is most cost effective for high-risk offenders 4. Boot camps & periodic drug-focused counseling have poor outcomes 5. Risk assessments should guide selections for treatment

Thank you