US PRISONS are trapped in a cycle of drug-related crime. About half of the nation鈥檚 2.2 million jail inmates meet clinical criteria for drug or alcohol dependence, while the majority of state or federal inmates regularly used drugs prior to their incarceration.
Even worse, most drug-dependent criminals are released back into society with the same problems that got them locked up in the first place. Clearly, the punitive jail regime that sees few of these prisoners treated for their addiction is not working.
This week, however, may mark a turning point. On Monday, the National Institute on Drug Abuse (NIDA) released a guide detailing treatments that have been shown to help convicted criminals overcome their drug problems, and reduce crime. While no one expects change overnight, specialists in drug addiction see the existence of a treatment guide endorsed by a federal agency as an important step towards reform.
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鈥淚t is very difficult to change the culture of the criminal justice system,鈥� concedes NIDA鈥檚 director, Nora Volkow. 鈥淏ut the data is very cogent. It speaks for itself.鈥�
The US criminal justice system鈥檚 attitude to drug use is not among the developed world鈥檚 most progressive (see 鈥淐aptive audience鈥�). A 1997 survey found that fewer than 15 per cent of prisoners with drug problems received treatment in jail 鈥� and little has changed since. However, NIDA鈥檚 research into treating drug-dependent criminals is cutting-edge, and two studies in particular have shown that certain treatments can produce long-lasting benefits.
These studies, led by Michael Prendergast at the University of California, Los Angeles (UCLA), and James Inciardi of the University of Delaware, analysed an approach called 鈥渢herapeutic communities鈥�. The idea is to encourage abstinence by teaching drug avoidance strategies within a peer group. Those who relapse are viewed as letting down the entire group, and so are more motivated to stay clean. Counsellors are often former drug-using criminals themselves, and the process includes working through the problems that led individuals into addiction in the first place.
The approach seems to work well in jails 鈥� less than 1 per cent of inmates in such communities typically test positive for drugs, about a tenth the rate in the wider prison population. Although early studies suggested the benefits disappear relatively soon after release, sometimes within a year, the UCLA and Delaware teams have shown the positive effects can last much longer if treatment is lengthy enough and continues during and after inmates鈥� release.
Prendergast鈥檚 team studied released convicts in San Diego who had been treated in a prison therapeutic community for nine months to a year. On release they could volunteer to join a residential community for a further six to 12 months. Just under 42 per cent of these volunteers were jailed again within five years 鈥� less than half the rate of the other released prisoners who completed the prison component of the treatment but not the residential. 鈥淐ontinuity between prison and community treatment is important,鈥� Prendergast says.
The Delaware study similarly involved a year of prison treatment, followed by six months of therapeutic community treatment based around work-release from jail. Ex-convicts could then receive after-care involving regular counselling. Inciardi鈥檚 team found that the treatment reduced both drug use and arrests over the next five years (see 鈥淕etting clean鈥�). Again, completing the entire programme, including the work-release component, was important for achieving lasting reductions in criminal behaviour.
鈥淓very dollar spent treating a drug user can save another 10 over the following two years by reducing crime and its costs鈥�
Such treatment is not cheap: analyses of the UCLA study suggest that it costs around $80 for each day of subsequent imprisonment avoided 鈥� roughly the cost of keeping an inmate in jail. However, the total benefits are more widespread. A UK study led by Michael Gossop of the Institute of Psychiatry in London indicates that every dollar spent treating a drug user can save almost 10 over the following two years, mostly by reducing crime and its associated cost.
NIDA鈥檚 guidelines stress the importance of continuity and structure in treatment, and also note that it must often be tailored to individual convicts. For instance, prisoners with drug problems frequently have other behavioural or mental difficulties that may need to be tackled before addressing their drug use.
A team at Texas Christian University in Forth Worth, headed by psychologist Dwayne Simpson, is pioneering this approach. Simpson has developed manuals to assess the needs of drug users, and to direct and monitor their treatment. Such prisoners are usually poorly motivated, for instance, and locked into 鈥渃riminal thinking鈥� 鈥� failure to empathise or see that their behaviour is to their own long-term harm. Simpson鈥檚 manuals for prisoners concentrate on tackling these attitudes.
In some cases, drug use may be triggered by difficulties in a relationship with a partner, so Simpson has also drawn up manuals to assess and tackle such problems. It is pioneering work, says David Best, a psychiatrist at the University of Birmingham, UK, which helps to prevent treatment descending into 鈥渆ndless crisis management鈥�.
The new NIDA guidelines also stress the benefits of methadone and buprenorphine, substitute opiates that can help wean drug users off heroin and avoid contaminated illegal drugs. This is controversial in the US, where many specialists remain opposed to approaches that do not promote total abstinence, but Volkow argues that NIDA must follow the scientific evidence, which backs the targeted use of substitute opiates. 鈥淚t鈥檚 the only way we鈥檒l change policy,鈥� she says.
Achieving reform in prisons will be a difficult task. NIDA is distributing 175,000 copies of its guidelines to people involved in criminal justice, and is educating federal judges in the biology of drug addiction and its treatment. However, many drug-dependent criminals are dealt with at the state level, and not all states heed NIDA strategies. Nebraska is one that does. 鈥淚鈥檝e been able to implement some changes,鈥� says Rick McNeese, who has been responsible for substance abuse treatment within the state Department of Correctional Services for the past year. 鈥淲e鈥檙e doing some progressive things.鈥� But officials in many other states are less open to change. Simpson reckons some will only abandon their punitive approach if dragged 鈥渒icking and screaming鈥�.
NIDA鈥檚 guidelines will help, he says, but real reform will require extensive investment and training within state criminal justice systems. Despite strong evidence that treatment for drug use is cost-effective, Simpson says that programmes seen as helping criminals are often slashed by politicians when budgets become tight. 鈥淲e鈥檙e highly vulnerable,鈥� he says.
Yet drug use in the US is not receding, with the use of crack cocaine and methamphetamine of particular concern. For the benefit of both drug users and the wider community affected by the resulting crime, attitudes need to change, argues Alex Busansky, executive director of the Commission on Safety and Abuse in America鈥檚 Prisons, which in a report last month urged widespread US prison reform. 鈥淲e have to bring the public health system into the criminal justice system,鈥� he says.
Captive audience
The US 鈥渨ar on drugs鈥� has had mixed results, but one notable consequence has been the expansion of the nation鈥檚 prison population 鈥� it has more than quadrupled over the past three decades. Few countries are so willing to lock up offenders with drug problems.
UK jails too are filled with inmates serving drug-related sentences, but the past decade has seen a big expansion in treatment within UK prisons. 鈥淭his is a very good thing,鈥� says Michael Gossop of the Institute of Psychiatry in London, whose research showing the economic benefits of treatment helped prompt this shift.
Nevertheless, Gossop wishes the UK government would extend this effort into the wider community. One outstanding problem is that prisoners frequently receive no treatment after release, despite research showing how vital continued care is.
Gossop also believes that the approach taken in much of continental Europe, where addiction is treated as a public health problem and petty criminals with drug problems are much less likely to be jailed, may yield better results. However, it is difficult to make comparisons across national borders because of the varying social and economic factors, and different types of drugs involved.
One advantage in treating prisoners is that they are literally a captive audience, and so may be more likely to complete the programme. 鈥淒rug abuse treatment in the criminal justice system is effective,鈥� argues Nora Volkow, director of the US National Institute on Drug Abuse. 鈥淚t gives us a way in.鈥�
