Frequently Asked Questions (FAQs)

8.	How long should drug abuse treatment last for individuals involved in the criminal justice system?

While individuals progress through drug abuse treatment at different rates, one of the most reliable findings in treatment research is that lasting reductions in criminal activity and drug abuse are related to length of treatment. Generally, better outcomes are associated with treatment that lasts longer than 90 days, with the greatest reductions in drug abuse and criminal behavior accruing to those who complete treatment. Again, legal pressure can improve retention rates.

A longer continuum of treatment may be indicated for individuals with severe or multiple problems. Research has shown that participation in a prison-based therapeutic community followed by community-based treatment after release can reduce the risk of recidivism to criminal behavior as well as relapse to drug use.

Early phases of treatment help the participant stop using drugs and begin a therapeutic process of change. Later stages address other problems related to drug abuse and, importantly, help the individual learn how to self-manage the drug problem.

Because addiction is a chronic disease, drug relapse and return to treatment are common features of an individual’s path to recovery, so treatment may need to extend over a long period of time and across multiple episodes of care. It is also the case that those with the most severe problems can participate in treatment and achieve positive outcomes.

9.	How can rewards and sanctions be used effectively with drug-involved offenders in treatment?

The systematic application of behavioral management principles underlying reward and punishment can help individuals reduce their drug use and criminal behavior. Rewards and sanctions are most likely to change behavior when they are certain to follow the targeted behavior, when they follow swiftly, and when they are perceived as fair.

It is important to recognize and reinforce progress toward responsible, abstinent behavior. Rewarding positive behavior is more effective in producing long-term positive change than punishing negative behavior. Nonmonetary rewards such as social recognition can be as effective as monetary rewards. A graduated range of rewards given for meeting predetermined goals can be an effective strategy when used in conjunction with behavioral management approaches such as contingency management. In community-based treatment, contingency management strategies may use voucher-based incentives or rewards, such as bus tokens, to reinforce abstinence (measured by negative drug tests) or to shape progress toward other treatment goals, such as program session attendance or compliance with medication regimens. Contingency management is most effective when the contingent reward closely follows the behavior being monitored.

Graduated sanctions, which invoke less punitive responses for early and less serious noncompliance and increasingly severe sanctions for more serious or continuing problems, can be an effective tool in conjunction with drug testing. The effective use of graduated sanctions involves consistent, predictable, and clear responses to noncompliant behavior.

Drug testing can determine when an individual is having difficulties with recovery. The first response to drug use detected through urinalysis should be clinical—for example, an increase in treatment intensity or a change to an alternative treatment. This often requires coordination between the criminal justice staff and the treatment provider. (Note that more intensive treatment should not be considered a sanction, but rather a routine progression in healthcare practice when a treatment appears less effective than expected.)

Behavioral contracting can employ both rewards and sanctions. A behavioral contract is an explicit agreement between the participant and the treatment provider or criminal justice monitor (or all three) that specifies proscribed behaviors and associated sanctions, as well as positive goals and rewards for success. Behavioral contracting can instill a sense of procedural justice because both the necessary steps toward progress and the sanctions for violating the contract are specified and understood in advance.

10.	What is the role of medications in treating substance abusing offenders?

Medications can be an important component of effective drug abuse treatment for offenders. By allowing the body to function normally, they enable the addict to leave behind a life of crime and drug abuse. Opiate agonist medications, which work by replacing neurotransmitters in brain cells that have become altered or desensitized as a result of drug abuse, tend to be well tolerated and can help an individual remain in treatment. Antagonist medications, which work by blocking the effects of a drug, are effective but often are not taken as prescribed. Despite evidence of their effectiveness, addiction medications are underutilized in the treatment of drug abusers within the criminal justice system. Still, some jurisdictions have found ways to successfully implement medication therapy for drug abusing offenders.

Effective medications have been developed for opiates/heroin and alcohol:

• Opiates/Heroin. Long-term opiate abuse results in a desensitization of the brain’s opiate receptors to endorphins, the body’s natural opioids. Methadone replaces these natural endorphins, stabilizing the craving that otherwise results in compulsive use of heroin or other illicit opiates. Methadone is effective in reducing opiate use, drug-related criminal behavior, and HIV risk behavior. Buprenorphine is a partial agonist and acts on the same receptors as morphine (a full agonist), but without producing the same high, level of dependence, or withdrawal symptoms. Suboxone is a unique formulation of buprenorphine that contains naloxone, an opioid antagonist, which limits diversion by causing severe withdrawal symptoms in those who inject it to get “high,” but has no adverse effects when taken orally. Naltrexone, an opiate antagonist, blocks the effects of opiates.

• Alcohol. Disulfiram (also known as Antabuse) is an aversion therapy that induces nausea if alcohol is consumed. Acamprosate works by restoring normal balance to the brain’s glutamate neurotransmitter system, helping to reduce alcohol craving. Naltrexone, which blocks some of alcohol’s pleasurable effects, is also FDA-approved for treatment of alcohol abuse.

11.	How can the criminal justice and drug abuse treatment systems reduce the spread of HIV/AIDS, hepatitis, and other infectious diseases among drug abusing offenders?

It is critical for the criminal justice and drug abuse treatment systems to be involved in efforts to reduce the spread of HIV/AIDS and other infectious diseases, which occur at higher rates among drug abusers in the criminal justice system than among the general population. The prevalence of AIDS has been estimated to be approximately five times higher among incarcerated offenders than the general population, and rates of HIV are also higher than in the general population. In addition, individuals in the criminal justice system represent a significant portion of hepatitis B, hepatitis C, and tuberculosis cases in the United States. Although most infectious diseases are contracted in the community and not in correctional settings, they must be treated in the correctional setting once diagnosed.

Infectious diseases among offenders who are re-entering or living within the community present a serious public health challenge. While incarcerated, offenders often have access to adequate healthcare, which offers opportunities for integrating strategies to address medical, mental health, and drug abuse problems. Offenders with infectious diseases who are returning to their communities should be linked with community-based medical care prior to release. Community health, drug treatment, and criminal justice agencies should work together to offer education, screening, counseling, prevention, and treatment programs for HIV/AIDS, hepatitis, and other infectious diseases to offenders in or returning to the community. Drug abuse treatment can decrease the spread of infectious disease by reducing high-risk behaviors such as needle sharing and unprotected sex.

The need to negotiate access to health services and adhere to complex treatment protocols places a large burden on the addicted offender, and many offenders fall through the cracks. Untreated or deteriorating medical or mental health problems increase the risk of relapse to drug abuse and to possible re-arrest and re-incarceration.

12.	What works for offenders with co-occurring substance abuse and mental disorders?

It is important to adequately assess mental disorders and to address them as part of effective drug abuse treatment. Many types of co-occurring mental health problems can be successfully addressed in standard drug abuse treatment programs. However, individuals with serious mental disorders may require an integrated treatment approach designed for treating patients with co-occurring mental health problems and substance use disorders. Although not readily available, specialized therapeutic community “MICA” (for “mentally ill chemical abuser”) programs are promising for patients with co-occurring mental and addictive problems.

Much progress has been made in developing effective medications for treating mental disorders, including a number of antidepressants, mood stabilizers, and antipsychotics. These medications may be critical for treatment success with offenders who have co-occurring mental disorders such as depression, anxiety disorder, bipolar disorder, or psychosis. Cognitive-behavioral therapy can be effective for treating mental health problems, particularly when combined with medications. Contingency management can improve adherence to prescribed medications, and intensive case management may be useful for linking severely mentally ill individuals with drug abuse treatment, mental health care, and community services.

13.	Is providing drug abuse treatment to offenders worth the financial investment?

In 2002, it was estimated that the cost to society of drug abuse was $180.9 billion (Office of National Drug Control Policy, 2004), a substantial portion of which—$107.8 billion—is associated with drug-related crime, including criminal justice system costs and costs borne by victims of crime. The cost of treating drug abuse (including research, training, and prevention efforts) was estimated to be $15.8 billion, a fraction of these overall societal costs.

Drug abuse treatment is cost effective in reducing drug use and bringing about associated healthcare, crime, and incarceration cost savings. Positive net economic benefits are consistently found for drug abuse treatment across various settings and populations. The largest economic benefit of treatment is seen in avoided costs of crime (incarceration and victimization costs), with greater economic benefits resulting from treating offenders with co-occurring mental health problems and substance use disorders. Residential prison treatment is more cost effective if offenders attend treatment postrelease, according to research. Drug courts also convey positive economic benefits, including participant-earned wages and avoided incarceration and future crime costs.

14.	What are unique treatment needs for women in the criminal justice system?

Although women are incarcerated at far lower rates than men, the number and percentage of incarcerated women have grown substantially in recent years. Between 1985 and 1995, the number of men in prisons and jails doubled, while the number of incarcerated women tripled. Women in prison are likely to have a different set of problems and needs than men. Surveys indicate that female offenders used more drugs more frequently prior to incarceration than males, and a higher percentage of females (54 percent compared to 50 percent) had used drugs in the month before committing their offense. In addition to being more likely to have a substance abuse problem, approximately 50 percent of female offenders are likely to have histories of physical or sexual abuse. Women are also more likely than men to be victims of domestic violence. Past or current victimization can contribute to drug or alcohol abuse, depression, post-traumatic stress disorder, and criminal activity. Female offenders are also more likely to have mental illnesses, employment problems, and childrearing responsibilities.

Substance abuse, mental health, and health problems and treatment in a sample of incarcerated women (N=50)

Note: Graph shows lifetime percentages except for multiple drugs, alcohol, and cocaine, which are the percent reporting use in the 30 days prior to incarceration.

Treatment programs serving both men and women can provide effective treatment for their female clients. However, gender-specific programs may be more effective for female offenders, particularly those with histories of trauma and abuse. Female offenders are more likely to need medical and mental health services, childcare services, and assistance in finding housing and employment. Following a comprehensive assessment, women with mental health disorders should receive appropriate treatment and case management, including victim services as needed. For female offenders with children, parental responsibilities can conflict with their ability to participate in drug treatment. Regaining or retaining custody of their children can also motivate mothers to participate in treatment. Treatment programs may improve retention by offering childcare services and parenting classes.

15.	What are the unique treatment needs of juveniles in the criminal justice system?

In recent years, there has been a dramatic increase in the number of juveniles with substance abuse problems involved in the criminal and juvenile justice systems. From 1986 to 1996, drug-related juvenile incarcerations increased nearly threefold. In 2002, about 60 percent of detained boys and nearly half of the girls tested positive for drug use. The number of juvenile court cases involving drug offenses more than doubled between 1993 and 1998, and 116,781 adolescents under the age of 18 were arrested for drug violations in 2002. One study found that about one-half of both male and female juvenile detainees met criteria for a substance use disorder (Teplin et al., 2002).

Juveniles entering the criminal justice system can bring a number of serious issues with them—substance abuse, academic failure, emotional disturbances, physical health issues, family problems, and a history of physical or sexual abuse. Girls comprise nearly one-third of juvenile arrests, a high percentage reporting some form of emotional, physical, or sexual abuse. Effectively addressing these issues requires their gaining access to comprehensive assessment, treatment, case management, and support services appropriate for the age and developmental stage. Assessment is particularly important, because not all adolescents who have used drugs need treatment. For those who do, there are several points in the juvenile justice continuum where treatment has been integrated, including juvenile drug courts, community-based supervision, juvenile detention, and community re-entry.

Families play an important role in the recovery of substance-abusing juveniles, but this influence can be either positive or negative. Parental substance abuse or criminal involvement, physical or sexual abuse by family members, and lack of parental involvement or supervision are all risk factors for adolescent substance abuse and delinquent behavior. Thus, the effective treatment of juvenile substance abusers often requires a family-based treatment model that targets family functioning and the increased involvement of family members. Effective adolescent treatment approaches include Multisystemic Therapy, Multidimensional Family Therapy, and Functional Family Therapy. These interventions show promise in strengthening families and decreasing juvenile substance abuse and delinquent behavior.

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