Inmates and Substance Abuse

Prison is a tough place to be. For inmates, deserved or not, who are serving their time as mandated by the criminal justice system, it can be a festering stew, an unending cauldron of violence, or a time for reshaping their lives, coming clean, and learning how to live a life free of substance abuse or addiction. According to a report from the National Center on Addiction and Substance Abuse (CASA) at Columbia University, 85 percent of the prison population in 2010 needs treatment for substance abuse. That’s a huge number of individuals either dependent upon or addicted to drugs and/or alcohol.

Scope of the Problem

Of the 2.3 million inmates in prisons and jails in the U.S. in 2006, 1.5 million met the diagnostic criteria for substance abuse or addiction, as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM IV). Another 458,000, while not meeting the strict DSM IV criteria, had histories of drug abuse; were under the influence of alcohol or drugs at the time of their crime; committed their offense in order to get money to buy drugs; were incarcerated for a drug or alcohol-related violation; or some combination of these. The two groups comprise 85 percent of the U.S. prison population.

According to the 144-page CASA report, in 2006, alcohol and drugs were significant factors in all crime, involved in:

• 78 percent of violent crimes
• 83 percent of property crimes
• 77 percent of public order, immigration, or weapon offenses, and probation/parole violations
Interestingly, and contrary to public opinion, only 2 percent of all inmates were incarcerated for marijuana possession as their only or controlling offense.

In 2005, federal, state and local governments spent $74 billion on incarceration, court proceedings, probation and parole for substance-involved adult and juvenile offenders. Yet less than 1 percent of that amount, or $632 million, went toward prevention and treatment.

Drug Abuse Treatment Programs in the Bureau of Prisons

More than two decades ago, the Bureau of Prisons (BOP) implemented its current drug abuse treatment strategy. In the intervening years, the strategy has changed and grown, reflecting advances in treatment and prevention. Some would say it’s still not enough, but there are the realities of budgets and other factors that come into play. Still, what’s available today to inmates with substance abuse who want to get clean is incrementally better than what was available before – or available to them when they were on the street. Not everyone who wants and needs substance abuse treatment during their incarceration will be able to receive treatment. That’s another reality. Programs fill up, budgets are limited, and a prisoner’s window to get into a treatment program may pass because of date conflicts or other factors.

• Drug Abuse Education – While not a substance abuse treatment program, drug abuse education is available to help encourage offenders with a history of substance abuse to review their past choices and how those have negatively affected them psychologically, socially, and physically. During drug abuse education, the inmate learns about the cycle of drug use and crime, and is shown compelling evidence of how continued drug use will lead to a perpetuation of criminality and related negative consequences. The purpose of drug abuse education is to motivate appropriate offender into wanting to participate in nonresidential or residential drug abuse treatment programs, as needed, while they are incarcerated.

o Criteria for participation – Upon entry into the BOP, prisoners are assessed to see if they’re suitable for drug abuse education. Criteria for participation include evidence that the offender has a prolonged history of drug or alcohol use, evidence that drug or alcohol use contributed to the offense for which they are incarcerated, a judicial recommendation for treatment, or a violation of community supervision as a result of alcohol or drug use.

o Referrals – Upon completion of the drug abuse education program, appropriate inmates are referred for nonresidential drug abuse treatment or residential drug abuse treatment.

o Inmate participation – In Fiscal Year (FY) 2008, 23,230 inmates participated in the drug abuse education program, according to the BOP Annual Report for 2008 (http://www.bop.gov/inmate_programs/docs/annual_report_fy_2008.pdf). For FY 2010, per a Department of Justice BOP report (http://www.whitehousedrugpolicy.gov/publications/policy/10budget/justice.pdf), an estimated 23,400 are expected to participate in the program.

• Nonresidential Drug Abuse Treatment – A flexible program designed to meet the treatment needs of all inmates, the nonresidential drug abuse treatment program is available at every BOP facility. It is offered through the Psychology Services Department and is staffed with at least one drug abuse program psychologist and one treatment specialist.

o Admission criteria – There are specific populations targeted for nonresidential drug abuse treatment. These include those inmates who have a low-level or relatively minor substance abuse impairment; those with a drug use disorder who don’t have sufficient time to complete an intensive residential drug abuse treatment program; inmates with longer sentences who need treatment and are awaiting placement in the residential program; those inmates with a drug abuse history who did not participate in the residential treatment program and are preparing for community transition; and inmates who completed the unit-based component of the residential program and are required to continue with “aftercare” treatment upon their return to the general prison population.

o Program specifics – The nonresidential drug abuse treatment program uses the cognitive behavioral therapy (CBT) treatment model. Length of treatment is a minimum of 12 weeks for a minimum of 4 hours per week (although, depending on the needs of the inmate and the ability of the facility to provide the services, these minimums may be increased). Aftercare treatment consists of a minimum of 1-1/2 hours per week for 12 months or until the inmate is transferred to a residential reentry center. A drug abuse treatment specialist, under the supervision of a psychologist, develops an individualized treatment plan based on an inmate’s psychosocial assessment. Self-help 12-step groups, such as Narcotics Anonymous and Alcoholics Anonymous, are available to inmates to support the nonresidential treatment program regimen.

o Inmate participation – In FY 2008, 14,208 inmates participated in the nonresidential drug abuse treatment program. For FY 2010, an estimated 14,500 inmates are expected to participate.

• Residential Drug Abuse Treatment Program (RDAP) – The residential drug abuse treatment program (RDAP), is intensive drug abuse treatment provided to inmates diagnosed with a drug use disorder (based on DSM IV criteria). A drug program coordinator (doctoral-level psychologist) supervises the treatment staff. The ratio of treatment staff to inmates is 1 to 24. RDAP inmate participants are housed together in a treatment unit separate from the general prison population.

o Program specifics – Treatment is provided for a minimum of 500 hours over the course of 9 to 12 months. The CBT treatment model used targets major criminal/drug-using risk factors (including pro-criminal and anti-social behaviors, attitudes, values, and beliefs). It does so by reducing anti-social peer associations, increasing inmates’ self-control, self-management, and problem-solving skills, and by promoting positive relationships; ending drug use; replacing unhealthy behaviors, such as lying and aggression, with pro-social alternatives. Treatment also includes the development of a transition plan specific to the inmate.

o Inmate participation – In FY 2008, 17,523 inmates participated in RDAP. In FY 2010, an estimated 17,500 are projected to participate.

• Community Transition Drug Abuse Treatment – Inmates who participate in RDAP are required to participate in the Community Transition Drug Abuse Treatment program. This ensures a continuum of treatment/supervision until the inmate is transferred to a residential reentry center. Research has shown the benefit of continuing treatment and supervision in decreasing the chances of relapse or other behavioral problems and in reducing the likelihood of return to custody.

o Program specifics – Using residential reentry centers, the BOP places inmates in community-based settings prior to their release from custody in order to prepare them for life in the community and to help them find employment. Such centers provide supervised, structured environment, and support in job placement, counseling, and other services. During this time, the inmate must continue to participate in the drug abuse treatment regimen through community transition drug abuse treatment. Failure to do so results in a return to custody and loss of residential program incentives (early release).

o Co-occurring disorders – Since FY 2008, the BOP has been providing treatment for offenders with co-occurring disorders (such as drug use and mental illness) during this transition period. Sex offenders with substance use disorders receive community transition treatment combining supervision with continued drug abuse treatment while residing in the residential reentry center.
o Inmate participation – In FY 2008, 15,406 inmates participated in the community transition drug abuse treatment program. In FY 2010, an estimated 15,400 inmates are expected to participate.

• Early Release – Federal law allows the BOP to grant up to 1 year off a non-violent offender’s prison term for successful completion of the RDAP. In FY 2008, 4,800 prisoners received a reduction in their term of imprisonment based on this law. From the implementation of the provision in June 1995 through 2008, a total of 32,618 inmates received such a reduction.

Principles of Drug Abuse Treatment for Criminal Justice Populations

The National Institute on Drug Abuse (NIDA), in Principles of Drug Abuse Treatment for Criminal Justice Populations (http://www.drugabuse.gov/drugpages/cj.html), lists 13 principles that are essential to a successful drug abuse treatment program for incarcerated individuals.

1. Drug addiction is a brain disease that affects behavior.
2. Recovery from drug addiction requires effective treatment, followed by management of the problem over time.
3. Treatment must last long enough to produce stable behavioral changes.
4. Assessment is the first step in treatment.
5. Tailoring the services to meet the needs of the individual is an effective part of drug abuse treatment programs for criminal justice populations. (Note: Incarcerated women have high rates of substance abuse, mental disorders, and other health problems.)
6. Drug use during treatment should be carefully monitored.
7. Treatment should target factors that are associated with criminal behavior.
8. Criminal justice supervision should incorporate treatment planning for drug-abusing offenders, and treatment providers should be aware of correctional supervision requirements.
9. Continuity of care is essential for drug abusers re-entering the community.
10. A balance of rewards and sanctions encourages prosocial behavior and treatment participation.
11. Offenders with co-occurring drug abuse and mental health problems often require an integrated treatment approach.
12. Medications are an important part of treatment for many drug abusing offenders. (Note: FDA-approved medications such as methadone and buprenorphine (Suboxone, Naltrexone) may be useful for inmates with heroin/opiate abuse. Disulfiram (Antabuse), Acamprosate, or Naltrexone may be prescribed for the treatment of alcohol abuse. New medications, when approved by the FDA, will likely be added for the treatment of various types of substance abuse.)
13. Treatment planning for many drug abusing offenders who are living in or re-entering the community should include strategies to prevent and treat serious, chronic medical conditions such as HIV/AIDS, hepatitis B and C, and tuberculosis. (Note: The prevalence of AIDS is 5 times higher among incarcerated offenders than the general population.)

NIDA/BOP Goal: Decrease Relapse and Reduce Recidivism

NIDA and BOP, working together in the development and implementation of effective substance abuse treatment programs for incarcerated individuals, have as a common goal to decrease rates of relapse and to reduce the likelihood of return to custody for substance-related offenses.

This includes refining and adapting substance abuse treatment programs in America’s prisons to help inmates with substance abuse and co-occurring disorders to become educated about addiction, learn new coping mechanisms, wean off cravings through appropriate use of medication, prepare for re-entry into the community, learning prosocial behavior and better communication skills – in essence, incorporating NIDA’s 13 principles for drug abuse treatment for criminal justice populations.
Providing such treatment still holds inmates accountable for their crimes, while laying the foundation for their successful return to society. The benefits to society are enormous as well, including significant reductions in crime and its associated societal costs.

Joseph A. Califano, Jr., CASA’s chairman and president and former U.S. Secretary of Health, Education and Welfare (http://www.alcoholdrughelp.org/2010/02/27/alcohol-and-drugs-prisons-new-report/), said that “The United States has less than five percent of the world’s population and we consume two-thirds of the world’s illegal drugs and incarcerate almost a quarter of the world’s prisoners, more than eight of ten of whom have some substance involvement.”

Since research proves that effective substance abuse treatment reduces relapse and recidivism, there’s no argument that continuing and improving substance abuse treatment programs in America’s prisons will reap a positive benefit.
In 2002, NIDA funded the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) (http://www.ibr.tcu.edu/projects/crimjust/cjdats.html) cooperative agreement, selecting nine National Research Centers to study current drug treatment practices and outcomes in correctional settings and to examine strategies for improving treatment services for drug-involved offenders.

The nine National Research Centers include:

• Brown University
• University of California at Los Angeles
• University of Connecticut
• University of Delaware
• University of Kentucky
• University of Miami
• National Development and Research Institutes
• Virginia Commonwealth University
• University of Maryland

A key objective of this landmark project is the establishment of science-based evidence and interventions (including TCU mapping and enhanced counseling) for the role of corrections-based treatment in reducing drug use and crime-related costs to society. Phase I of the CJ-DATS project period was September 2002 to August 2008. Phase II of CJ-DATS is from September 2008 to August 2013.

The good news is that there is progress. The bad news is that it will take time for any such programs (currently in place or improvements contemplated and/or implemented) to begin to show the kind of dramatic results research indicates is possible.