An Informed Approach to Substance Abuse
Fighting Crime by Treating Substance Abuse
Tackling the core problem of addiction could curb criminal behavior and ease the burden on government budgets.
During the past 15 years, concerns about crime and violence have prompted increased law enforcement, prosecution, and punishment. But although the "get tough" approach may have contributed to recent reductions in crime, there are limits to its ability to enhance the public's safety and general well-being in the long run. The reason is that it does little to address drug and alcohol abuse and addiction. Although these problems have had a fundamental impact on the criminal behavior of 80 percent of inmates, only one in six of those who need substance abuse treatment receives it while in prison, and far fewer receive comprehensive intensive treatment with aftercare. As a result, our prison doors open to release tens of thousands of untreated or inadequately treated offenders back into the community every year. Most will return to a life of drug and alcohol use and crime, typically committing as many as 100 offenses annually.
The financial and social costs of current policies are staggering. In fact, the current well-intended but uninformed crackdown on crime has already put an excessive burden on state, federal, and local budgets. Between 1980 and 1996, the price of constructing, maintaining, and operating U.S. prisons and jails rose from $7 billion to $38 billion. Just as troubling is a recent U.S. Department of Justice study, which found that at current incarceration rates, one out of every 20 Americans born in 1997 will spend time in prison, including one in 11 men and one in four black men. Even now, one in three young black males is under the supervision of the criminal justice system in cities such as Baltimore and Washington, D.C., largely for drug-related crimes.
Fortunately, we see a viable alternative to today's policies: treatment-based substitutes for incarceration, combined with intensive prison-based treatment, support services, and aftercare. A growing body of research indicates that correctional treatment reduces criminal recidivism and relapse to drug use. When community-based treatment and other services are provided after parole, rearrest rates drop still further. And investing in prison treatment pays off quickly. Our own research shows that each inmate who successfully completes prison treatment and receives educational, vocational, and aftercare services, at a cost of $6,500, and remains drug-free, crime-free, and employed after release yields an annual economic benefit of $68,800. Furthermore, these findings are based on a particularly difficult population: the 1 million in state prisons, which house three-fifths of all inmates and the most serious offenders.
The link to crime
Drugs and alcohol are implicated in all types of crimes. From 1980 to 1995, the proportion of the state prison population who were incarcerated for drug law violations nearly quadrupled, from 6 percent to 23 percent. In addition, about half of state inmates were under the influence of drugs or alcohol or both when they committed their crime, no matter what it was.
Crimes of violence, for which 47 percent of state inmates have been incarcerated, are particularly associated with alcohol abuse. Twenty-one percent of state inmates serving time for a violent crime admitted being under the influence of alcohol and no other drug at the time of their offense. (Comparatively, only three percent were under the influence of cocaine or crack alone and no other drugs, and one percent was under the influence of heroin alone.) Although the connection between alcohol and violence is complex and experts disagree about exactly how it operates, a number of plausible psychological and biological mechanisms have been suggested. First, being drunk may provide an alibi for normally proscribed behaviors. Alcohol may also lower inhibitions, sharpen aggressive feelings, and lead attackers and victims to misread one another's signals in violent situations. Another problem is that alcohol interferes with the functioning of the brain's frontal lobe, which can affect the ability to handle unexpected or threatening situations. Moreover, neurochemical systems that mediate aggressive behavior tend to be disrupted when people are under the influence of alcohol.
Other research suggests that drugs, especially cocaine and crack, are tied to violence as well. As conceptualized by Paul Goldstein of the University of Illinois at Chicago, drug-related violence takes three types: the systemic violence of drug-dealing organizations; the economic-compulsive violence that results from securing money to purchase drugs; and psychopharmacological violence, which is caused by the excitability, irritability, aggression, or paranoia associated with the physiological action of drugs. Systemic violence has been most closely linked to the crack trade of the late 1980s and early 1990s, and some studies have noted a connection between psychopharmacological violence and cocaine, methamphetamine, and PCP as well as crack. In all, 73 percent of violent offenders in state prisons committed their crime to get money for drugs, were under the influence of drugs or alcohol at the time, and/or have a history of alcoholism, alcohol abuse, or regular drug use.
As for property crimes, the financial requirements needed to support addiction make many of them almost inevitable. Most drug abusers who enter the criminal justice system have limited resources. Unlike middle- or upper-class users, whose salaries allow them to purchase drugs, these inmates come mostly from the lower socioeconomic strata of society. They typically are unemployed or underemployed and have no savings or investments. And all the common ways for indigent drug abusers to get drugs put them at high risk of arrest. They can sell drugs and then keep some for their own use or use their earnings to buy other drugs. They can trade sex for drugs or earn money through prostitution.
They can also commit property crimes to get the money to buy drugs. Of the 23 percent of state inmates who are incarcerated for property crimes, 80 percent committed their offense to get money for drugs, were under the influence of drugs at the time, and/or have a history of alcoholism, alcohol abuse, or regular drug use. Property offenders are more likely than other types of offenders to have committed their crime for drug money. Some 27 percent of them did so, compared with only 11 percent of violent offenders.
Finally, data on recidivism make an especially compelling case for the connection between substance abuse and crime. The more prior convictions an individual has, the more likely it is that that individual is a drug abuser. In state prisons, 41 percent of first offenders are regular drug users, compared with 63 percent of inmates who have two prior convictions and 81 percent of those who have five or more convictions. Some 39 percent of regular drug users in state prisons have two or more prior incarcerations, compared with only 21 percent of state inmates who are not regular drug users. The pattern is the same whether the offenses for which the inmates have been incarcerated are property crimes or violent crimes.
The impact of treatment
During the past 10 years, studies have found that well-designed residential programs of sufficient length that are linked to aftercare services in the community reduce post-release relapse and recidivism. In these programs, the inmates are generally housed in a separate unit in the prison facility. The programs usually last from 9 to 12 months, after which the inmate may be phased into an independent living environment while continuing to have contact with treatment staff and other professionals.
One common model of residential treatment in prisons is the therapeutic community (TC). TCs provide a very structured environment focusing on resocialization, intensive therapy, behavior modification, and gradually increasing responsibilities. Aftercare can include post-prison transition, treatment, or case management, as well as drug-free housing, educational and vocational training, and psychological or medical treatment. Although such services have often been viewed as separate from the core issue of substance abuse, they are crucial. Substance-abusing offenders have been found to be most vulnerable to relapse in the first several months after their release, as they face social and psychological pressures.
A particular problem is that drug- and alcohol-abusing inmates frequently have limited educational backgrounds and sporadic work histories. Among regular drug users, 61 percent in state prison have had fewer than four years of high school. And unfortunately, substance abuse, poor education, and low vocational skills operate in a circular pattern, reinforcing and exacerbating each other. Indeed, 36 percent of regular drug users were unemployed in the month before they were incarcerated. We need to break this cycle. Studies have shown that inmates who receive educational and vocational training are less likely to return to prison after release. Regular employment enhances self-esteem, provides a reliable and legal source of income, helps reintegrate individuals into the community, and removes them from a substance-using subculture.
Psychological counseling is also important, because substance abuse and mental disorders often go hand in hand. It has been estimated that 13 percent of the prison population have both a substance abuse and a mental health problem, often as the result of childhood physical or sexual abuse. Among state inmates who regularly use drugs, a startling 45 percent of women and 13 percent of men had been victims of physical and/or sexual abuse, primarily when they were children. Offenders who have problems with alcohol have similar rates of prior abuse. To effectively treat such inmates, their mental health problems must be addressed.
Recent evaluations of prison-based TCs show just how effective good programs for substance abuse treatment and aftercare can be. One example is the Amity Righturn program at the R.J. Donovan medium security prison in San Diego, California. Operating since 1989, it features three phases: three months of assessment and orientation; five to six months of individual and group counseling; and three months of community reentry, in a component called Vista. Using an experimental design, Harry Wexler of the National Development and Research Institutes in New York City and his colleagues found that among inmates in Amity who completed both treatment and aftercare, only 8 percent were reincarcerated within a year, compared with 39 percent of those who completed treatment but not aftercare, 45 percent of those who failed to complete treatment, and 50 percent in a control group who received no treatment at all.
The Key-Crest program in Delaware, another successful endeavor, also has three phases: in-prison treatment (Key), transitional treatment through a residential work release center, and aftercare for parolees (Crest). James Inciardi of the University of Delaware and his colleagues compared participants in all three phases of the program with inmates who received no intervention other than education in HIV prevention and discovered that after 18 months, only 28 percent of the Key-Crest graduates had been rearrested, compared with 64 percent of the comparison group. And only 25 percent of the Key-Crest graduates were using drugs, compared with 83 percent of the comparison group.
Other evaluations of prison treatment programs, such as New York's Stayin' Out, Oregon's Cornerstone, and the Kyle program in Texas, have found similar positive results. Interestingly, studies of treatment under other forms of criminal justice supervision have revealed that legally coerced clients do as well as or better than voluntary clients. Mandated treatment results in longer stays in the program, which in turn is associated with more successful treatment outcomes. "Numerous large-scale studies that examined the outcomes of treatment provided in a variety of settings have found drug treatment to be effective," the U.S. General Accounting Office (GAO) has concluded. "Clients receiving treatment report reductions in drug use and criminal activity, with better outcomes associated with longer treatment duration." The GAO went on to note that we now need to learn more about which types of treatment interventions work best for which types of drug abusers.
The treatment gap
Despite the encouraging findings on prison-based substance abuse treatment-and despite the ever-increasing number of inmates in need of such treatment-programs are woefully underdeveloped. In a 1996 survey by the National Center on Addiction and Substance Abuse at Columbia University (CASA), corrections officials estimated that an average of 74 percent of state inmates need alcohol and drug treatment. Yet the percentage of them in treatment has actually declined slightly in recent years. In 1993, 22 percent of inmates needing treatment were receiving it; by 1996, the figure had dropped to 17 percent.
And most of this treatment is nonintensive, short-term drug education, or 12-step groups such as Alcoholics Anonymous or Narcotics Anonymous, rather than the intensive long-term psychotherapeutic or residential treatment so many inmates require. A 1994 survey of 37 state and federal prison systems by the National Institute of Justice and the Centers for Disease Control and Prevention found that only 5 percent of all inmates received either residential treatment or ambulatory counseling for substance abuse.
Similarly, programs and resources to address inmates' educational and vocational deficits have not kept pace with the need. More than half of the 44 state prison systems responding to a 1993 survey by the Correctional Education Association had reduced such programs since 1989, with 12 states cutting adult basic education classes, 10 states cutting General Education Development (GED) programs, and 16 states cutting vocational programs. On average, educational/vocational program budgets were only 2 percent of state correctional budgets in 1994. Moreover, in the limited programs that do exist, the participation of substance-abusing inmates is modest. Only 47 percent of state inmates who regularly use drugs receive some education in prison, and only 29 percent receive education at the high school level. No more than a third of these inmates receive vocational training. The psychological problems of substance-abusing inmates have likewise been neglected. A recent national survey of state corrections departments by the Criminal Justice Institute found that only 3 percent of state and federal inmates were receiving treatment for such difficulties in 1996. Why is there relatively little substance abuse treatment in prisons? The correctional departments in the CASA prison survey cited some common barriers: budgetary limits (70 percent), lack of treatment space (51 percent), too few counselors (39 percent), lack of inmate interest (18 percent), and inmate movement in and out of prison facilities (12 percent).
Why treatment makes economic sense
One key to correcting this unfortunate situation might be a greater understanding of the fact that comprehensive correctional treatment makes economic sense. Such a claim is not difficult to support. A RAND Corporation study has found that for heavy users of cocaine, treatment interventions would cost one-seventh as much as law enforcement to achieve the same reduction in cocaine consumption. A comprehensive study of the economic benefits and costs of drug treatment in California found that the benefits were seven times greater than the costs.
Finally, our own estimate that a comprehensive treatment and training program would cost $6,500 per inmate (in addition to basic incarceration costs)and yield an annual benefit of $68,800 for each successful graduate is based on the most recent available data, using conservative assumptions. We arrive at the $6,500 figure by adding $3,500, the cost for a year of residential treatment in prison, and $3,000, the cost of providing vocational training and aftercare for each participant, as well as GED programs for the 61 percent of inmates who are not high school graduates.
The estimated $68,800 return on this investment results from a long list of anticipated gains: $5,000 in reduced crime savings, conservatively assuming that drug-using ex-inmates would have committed 100 crimes per year with $50 in property and victimization costs per crime; $7,300 in reduced arrest and prosecution costs, assuming two arrests per inmate per year; $19,600 in reduced incarceration costs, assuming that one of those rearrests would have resulted in a one-year prison sentence; $4,800 in health care and substance abuse treatment cost savings, which is the difference in annual health care costs between substance users and nonusers; and $32,100 in economic benefits, calculated by multiplying $21,400-the average income of an employed high school graduate-by 1.5, which is the standard factor used for estimating the local economic effects of a wage.
The success rate needed to break even is fairly modest: If just 10 percent of the inmates who are given one year of residential treatment stay sober and work during the first year after release, the investment is more than returned in economic benefits. But we feel that a 15 percent success rate should be achievable. And actual treatment costs would probably be lower than anticipated, because some inmates would need less intensive, nonresidential treatment. It is worth noting, moreover, that the benefits we are counting do not even include reductions in foster care or state or federal entitlements such as welfare. In addition, economic benefits will accrue from the many ex-inmates who will remain sober and employed beyond the first year after release.
An agenda for change
We can no longer afford the economic and social costs of current incarceration policies toward substance-abusing offenders. Not only are these policies wreaking economic havoc on state budgets, they will inevitably result in increased crime rates as thousands of untreated inmates are released back to society.
Clearly, first of all, corrections departments must make treatment and training more available to inmates. A range of treatment modalities, particularly intensive residential treatment, should be in place to meet the needs of inmates with problems of different types and levels of severity. Also, treatment design should take into account the length of the inmate's sentence, as well as the individual characteristics of various groups of drug and alcohol abusers and addicts, such as women. And prisons need to provide inmates with a variety of other support services in addition to treatment, including educational and vocational training, medical and mental health care, and HIV education, testing, and counseling. All this will require an outlay of funds from corrections departments or state legislatures, or a reallocation of block grant monies for federal substance abuse treatment, but it will pay off substantially for taxpayers.
The effect of such reform will be greatly enhanced if state legislators and corrections officials can encourage inmates to seek treatment and stay in it. Incentives should be available to keep inmates in educational and vocational training as well. A good first step would be to modify mandatory sentencing laws. In particular, sentences that provide no chance of early release or parole need to be reconsidered, because they eliminate the possibility of participating in treatment as a way to reduce a prison sentence. They also do away with the threat of reincarceration and supervision that parole officers can use to encourage released offenders to seek treatment and aftercare. In addition, laws should allow prosecutors and judges to divert nonviolent substance abusers into treatment and alternative sentences instead of prison. Such diversion can save taxpayer dollars while reducing crime and addiction.
State legislators, treatment providers, criminal justice policymakers, and judicial and correctional officials should foster the development, implementation, and evaluation of these treatment alternatives to prison. The federal government has played an important role in the past and should continue to do so. Promising innovations are already in place, among them drug courts, which use graduated sanctions, mandatory drug testing, and treatment and aftercare programs to more efficiently and effectively address the drug and alcohol problems of offenders before they are incarcerated. Drug court judges and personnel work as a team with prosecutors, defense attorneys, and counselors to help offenders not only overcome their drug problem but resolve related issues having to do with work, finances, and family. There were some 275 drug courts operating in the United States as of April 1998, and recent studies suggest that they help keep offenders in treatment and reduce recidivism.
Within a few months before release from prison, correctional and parole staff need to help substance-abusing inmates plan for continued treatment, identify other needs, and locate appropriate community-based services to address those needs. Released inmates might, for example, require drug-free housing, literacy training, HIV/AIDS education, job placement, long-term relapse management, and social services. Parole departments need to provide comprehensive case management and supervision, ensuring both that parolees are referred to appropriate services and that incentives are provided where necessary to maintain parolees in treatment.
Another goal we must pursue is to improve procedures for assessing the level and character of substance abuse problems among arrestees and inmates. Such assessment, which law enforcement agencies, judicial officials, and corrections departments should routinely perform when offenders are arrested and again when they enter prison, must include not only drug testing but also a thorough evaluation of substance abuse history by a trained counselor. The results can form the basis for decisions about pretrial supervision, sentencing, and treatment.
An important adjunct to all these endeavors is more research, with more sophisticated data collection and analysis. Criminal justice organizations should collect data on a timely basis so that they can identify the substances involved in violent, property, and drug crimes and learn more about how to increase inmate participation in treatment, education, and job training programs. Also, diversion programs, drug courts, boot camps, coerced abstinence, and other efforts should be continually evaluated to determine which modalities work best for which offenders. More research on the key elements of treatment that reduce relapse and recidivism should be encouraged as well.
Finally, dissemination of the knowledge we do have is key. Corrections departments must make certain that their staff is trained in substance abuse and addiction issues so that they can help prevent alcohol and drug use in prison and assist inmates in the recovery process. Parole and probation departments should also provide their staff with such training, since they must help parolees and probationers find services and stay in treatment. And state substance abuse, health, and education policymakers should expand training for substance abuse counselors and make more of these counselors available for corrections-based treatment. Moreover, the curricula for substance abuse counseling should cover treatment and recovery issues raised by inmates' particular problems, such as childhood sexual abuse.
In addition, police departments, court administrations, state bar associations, state legal education departments, state or county health departments, and state or county substance abuse agencies should provide police, prosecutors, and judges with the training and assistance they need to manage their caseloads of offenders with substance abuse problems. It is essential that these professionals make informed decisions about probation, diversion, and sentencing and have access to experts in public health, mental health, and substance abuse for advice.
Most of these changes in policy need to be developed and implemented at the state and local level, but the federal government can also play an important role. Specifically, federal leadership can support national research on correctional treatment and the effects of alternatives to incarceration. It can guide the development of program demonstrations and provide economic backing for them, and fund expanded treatment for prison inmates as well as offenders in other parts of the criminal justice system. The federal government can also disseminate research findings and information about best practices to policymakers and help provide training and technical assistance to practitioners in the criminal justice and treatment communities. It should continue developing and disseminating educational materials, such as the series of treatment improvement protocols published by the Center for Substance Abuse Treatment of the U.S. Department of Health and Human Services.
Implementing the proposals outlined here requires a major shift in priorities and in the way we conceive of crime and punishment. A substantial financial investment is called for as well. However, the rewards in reduced crime, incarceration, recidivism, and addiction are enormous. We could help tens of thousands of individuals whose core problem is alcohol and drug abuse and addiction become productive, law-abiding citizens. Without these policy changes and funding priorities, the revolving door of substance abuse, crime, and incarceration will continue to spin.
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Steven Belenko is a senior research associate and Jordon Peugh is a research associate at the National Center on Addiction and Substance Abuse at Columbia University. They headed a team that produced the center's recent report Behind Bars: Substance Abuse and America's Prison.