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Nov. 10, 1998
WASHINGTON, D.C. --- A major new series of research studies on drug courts and drug treatment programs for prisoners, parolees, and teenage drug users
finds that the best new programs reduce drug use, crime, and re-arrest rates.
In analyzing this new level of success, a core component cited in the studies is the need for close collaboration among components of the criminal
justice system, community public health agencies, cognitive and behavioral counselors, drug treatment specialists, health care providers and employment specialists.
"These drug court and prison and teen treatment studies show a critically important alternative to strictly punitive approaches. Drug arrests,
which have increased about 150% between 1980 and 1995, have overloaded our prisons and done little to cut substance abuse," said David Lewis, M.D., Project Director for Physician Leadership on National Drug
Policy (PLNDP) and Director of the Center for Alcohol and Addiction Studies at Brown University.
"A major concern is that drug abusers, with little access to treatment, simply repeat the pattern of drug use, arrest and incarceration. "
"The good news is that when drug treatment is available in the Criminal Justice System, it works," Dr. Lewis added. "The bad news is
that it's usually not available."
PLNDP, which is a non-partisan group of 37 physicians organized to do a policy review of the nation's anti-drug efforts, commissioned the studies.
Funds for the project come primarily from the John D. and Catherine T. MacArthur Foundation and the Robert Wood Johnson Foundation.
An important finding is that aggressive policing and incarceration have had little effect on drug usage, while greatly increasing the state and federal
prison populations. Meanwhile, enforcement costs continue to rise, along with the negative impact on society from drug related crimes and the serious health problems, with related treatment costs, common to many
drug abusers.
"There is a growing awareness that effective rehabilitation programs must be developed to reduce the high recidivism rates which are a primary
cause of prison overcrowding," according to the study by Douglas S. Lipton, Ph.D. and Frank S. Pearson, Ph.D. of the National Development and Research Institutes, Inc. in New York City.
"These studies show us how to save the nation major enforcement costs, greatly reduce crime rates and illegal drug use, and return more people to
positive, healthy lifestyles. That means optimizing drug treatment through the drug courts, through in-prison treatment and parolee treatment, and by treating teenagers," said June Osborn, M.D., who is Chair of
PLNDP and President of the Josiah Macy, Jr. Foundation in New York City.
"Still," said Lonnie Bristow, M.D., the Vice Chair of PLNDP and a past President of the American Medical Association, "This field is in
an evolving stage. We need more serious research, and ongoing evaluations of existing programs, to determine which programs work best, for who, and how to sustain them."
Dr. Lewis added that the "working relationships between the Criminal Justice system and the mainstream of the health system are still few and far
between. But where they have been established the results are very promising."
As said in "The Effectiveness of Correctional Treatment Revisited" study by Drs. Lipton and Pearson of the National Development and Research
Institutes, Inc., more research is needed "to provide correctional administrators, policy makers, legislators, service providers and social scientists with answers to the questions 'what works? with whom? and
under what circumstances?'"
However, a baseline conclusion comes from researchers at the Drug Abuse Research Center at the University of California, Los Angeles. The study by M.
Douglas Anglin, Ph.D., David Farabee, Ph.D., and Michael Prendergast, Ph.D., said, "The drug abuse research literature provides overall support for the coercion of offenders into treatment for their drug
problems." Their study "provides empirically based recommendations for enhancing the use of coercion to increase the effectiveness of offender drug treatment."
DRUG COURTS
According to the drug court study prepared by Steven Belenko, Ph.D., of the National Center on Addiction and Substance Abuse at Columbia University,
"All evaluations that have compared post-program recidivism for drug court graduates and comparison groups find much lower recidivism rates...
"A few evaluations have gathered employment data, and these generally found that drug court participants are more likely to gain employment while
participating and upon graduation," the study said.
Relative to the importance of collaboration between drug courts and their communities, Dr. Belenko's study also said, "Drug courts have been quite
successful in bridging the gap between the court and the treatment/public health systems and spurring greater cooperation among the various agencies and personnel with the criminal justice system, as well as between
the criminal justice system and the community."
As to the cost savings, the Belenko study said, "Research by the RAND Corporation on the relative cost-effectiveness of treatment, domestic
enforcement, interdiction and source country control found that for heavy users of cocaine, treatment interventions would cost one-seventh as much as enforcement to achieve the same reduction in cocaine use."
A comprehensive study of 440 drug court clients in Multnomah County, Cal. found a two-year savings to the state of $10.2 million. This includes savings
in the criminal justice system, victimization, theft reduction, public assistance and medical claims.
The studies indicate that the most important components of the most successful drug courts, which now exist in more than 275 jurisdictions, include
close, efficient, team-based collaboration between the drug court and the community's drug abuse treatment systems. This includes the coercive power of the court to promote abstinence and prosocial behavior. But as
important, this also means personalized problem-solving efforts to include skilled drug counseling, job referral counseling, personal psychological problems, and meeting the drug abuser's sometimes significant
health care needs. Substantive involvement of a drug abusers family can also be critical in the success of treatment, according to an independent study by Carol Shapiro, MSS, who is Project Director of La Bodega de
la Familia in New York City. While some drug abusers do not have the family structure or relationships for such efforts, many do.
"If parole and probation officers could turn to families as natural case managers, there would be an additional resource from which to draw to
help an offender stay the course," Ms. Shapiro's study says. "When supported, families can offer instrumental and emotional support; can serve as supervisors, mentors, and confidants; and can operate as a
check on negative health behaviors."
Research shows that a substantial portion of drug or alcohol-abusing offenders enter prison with various infections, nutritional deficiencies, liver
problems, sexually transmitted diseases, HIV/AIDS, violence related injuries, dental problems, and other physical and mental trauma.
A national review of drug courts by researchers at American University found that the best organized ones, with judges who reach out and effectively
engage their community's best resources, have produced major reductions in drug use, recidivism and crime.
A key marker of success is the drug abuser remaining in the program. "Retention rates for drug courts are much greater than the retention rates
typically observed for criminal justice offenders specifically, and treatment clients in general," the Belenko report says.
The best long-term residential treatment (LTR) is similar to the services offered by the drug courts, and the outcomes in the LTR circumstances are
very similar. For instance the study on "Correctional Treatment in Community Settings," by D. Dwayne Simpson, Ph.D. and Kevin Knight, Ph.D. of Texas Christian University, said, "Drug use rates
following LTR treatment declined by 67% from pretreatment levels for weekly cocaine use, 65% for weekly heroin use, and 53% for heavy drinking."
In short, the best drug courts provide more comprehensive and closer supervision of the offender than other forms of community supervision. And
successful drug courts can work as well with the more common first-time offenders as they do with those with a chronic history of drug use and arrests.
PRISON DRUG TREATMENT
An important factor in prison-based treatment success is a prisoner's self-selection for the program. "The Effectiveness of Correctional Treatment
Revisited" study by Douglas S. Lipton, Ph.D. and Frank S. Pearson, Ph.D., of the National Development and Research Institutes, said, "Among those persons who opt for treatment, self selection contributes
to retention in and compliance with the treatment regimen, and thereby to treatment efficacy."
"Prior research suggests an ideal treatment of three to nine months and several episodes of primary treatment, aftercare, and relapse should be
expected," according to the Drug Abuse Research Center study by Drs. Anglin, Farabee and Prendergast. One reason is that drug dependency tends to be a relapsing condition. Still, according to their study,
"approximately 50 percent reported that they would be willing to participate in an in-prison drug or alcohol program even if it meant extending their stay in prison for three months."
A serious problem is that for many prisons there is a greater demand for treatment than there are qualified professionals to provide it.
Drs. Lipton and Pearson point out in their study that two modalities stand out as successful treatments for prison inmates who have very serious
predatory behavior or are hard-core users of cocaine and other drugs. Therapeutic communities and cognitive behavioral treatments appear to produce consistent, positive outcomes in terms of reduced recidivism.
They also note the importance of the continuity of treatment after prison release.
An analysis by The National Center on Addiction and Substance Abuse at (CASA) Columbia University "estimated that each inmate who successfully
completes a one-year prison-based treatment program and remains drug-free and employed after release, generates $68,800 in economic benefits, compared to a treatment and aftercare cost of $6,500."
PAROLEES AND COMMUNITY AFTERCARE
While two-thirds of probationers have had serious drug and alcohol problems, only 17% of these probationers have access to substance abuse treatment
once they leave prison and return to their communities.
However, according to the "Correctional Treatment in Community Settings" study by Drs. Simpson and Knight at Texas Christian University, long
term residential (LTR) treatment for these former prisoners can make major improvements. According to their study of the best LTR programs, weekly cocaine use dropped by 67%, weekly heroin use by 65% and heavy
drinking by 53%.
Particularly dramatic were their findings that 27% of "aftercare completers" returned to custody, compared to 75-84% returning to custody
from comparison groups.
Their study also reflected the findings of other studies, that those who stayed in treatment for 3 months or more had significantly better outcomes.
And like the positive outcomes in drug courts, parolees who had legal pressure to stay in the program had much better outcomes. Again, like the drug courts, this is accomplished by positive organizational
connections between the community treatment system and the criminal justice system, where there is genuine concern for the enrollee.
"Better therapeutic engagement and retention rates are needed," Drs. Simpson and Knight said, if we hope to sustain these important
improvements in patient outcomes. While passage of the 1994 Crime Act produced an increase in emphasis and resources for adjudication and treatment for drug cases, much more remains to be done.
This includes more work "to establish standards and procedures for effective treatment protocols" for those who leave prison, their study
said.
JUVENILE SUBSTANCE ABUSE TREATMENT
The growing body of research on juvenile drug treatment indicates that the best programs can cut recidivism by 30% or more.
In the "Substance Abuse and Juvenile Centers" study by Ken C. Winters, Ph.D., he said, "This is a rather substantial drop and rather
impressive given that the juveniles involved exhibited delinquency at the upper end of the severity continuum."
Dr. Winters points out that conduct and delinquency problems "have shown a deep, pervasive and long-standing association with youth drug
involvement." While there is a complex relationship between substance abuse and delinquency, most studies indicate that the conduct problems usually precede the development of substance abuse problems. Thus
delinquency is a key risk factor for adolescent substance use and abuse, rather than drugs triggering delinquency.
His study points out that there are "preliminary indications that desistance of delinquency behaviors during adolescence and young adulthood is
associated with a discontinuation of substance abuse over time." In contrast, onset of substance abuse early in adolescence is a predictor or ongoing drug abuse and later criminality.
The Winters study offers a list of program components for which there is "clear and credible evidence" that they will reduce substance abuse,
violence and disruptive behaviors among youth in grades K-12.
These include: targeting high risk youth; increased involvement/supervision with an adult; increased accountability to an adult role model; sustained
length of program across early years and through high-risk period of puberty; skill enhancement of youth and parents and/or guardians; not a punishment model; not solely peer-lead; multiple components, preferably
with the flexibility to address individual- specific needs.
Dr. Winters' study said that "the increasingly complex nature of both delinquency among juveniles and drug abuse has contributed to more serious
and violent criminal activity and escalating degrees of substance abuse." The factors that bring a youth into the courts include family issues, community factors, peer issues, and other individual and
environmental variables.
Problematic youth drug abuse can trigger serious consequences including psychiatric co-morbidity and suicide, mortality from drug-related traffic
crashes, risky sexual practices, and substantial health care costs.
Since conventional approaches, such as high levels of arrest, are having little effect on juvenile substance abuse, a growing number of jurisdictions
are considering adaptation of adult drug court practices to juveniles.
One of the many challenges to this approach is the fact that most adolescent substance abusers have rarely "hit bottom" like many long-term
adult substance abusers have, which gives teenagers much less motivation to engage in a recovery process.
In the new adolescent model, which has some parallels with adult drug courts, "treatment personnel and representatives of health and social
service agencies in the community participate from the beginning and function as partners with juvenile justice system in designing the program." These partners collaborate to agree on a strategy to
"maximize the safety needs of the community and to address the treatment needs of the drug-abusing offender."
In closing, the Winters report said, "Judges report impressive sustained turnaround by juveniles who were otherwise at high risk for continued,
escalating criminal involvement and drug abuse. It has also been observed that the juvenile drug court and diversion programs exercise closer supervision over the juvenile offender than would be provided in the
traditional court process."
In conclusion, these various studies should help develop the effectiveness of drug treatment in drug courts, in prison, for parolees, and for
adolescents. Without such progress the national trend is likely to continue for more apprehension of low-level street dealers, stronger penalties for drug sales and possession, and a proliferation of mandatory
sentencing laws for drug related crimes.
The outcome will be increasing overcrowding of jails and prisons, increasing law enforcement costs, and little impact on drug usage, related crime,
health and social problems.
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