Chapter 2—The Effectiveness of AOD Treatment in the Criminal Justice System

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In 1991, it was estimated that of the 680,000 inmates in State prisons nationwide more than 500,000 had substance abuse problems. However, States had the resources to provide treatment to less than 20 percent of prisoners (General Accounting Office, 1991). In the same year, only 364 inmates of Federal prisons were receiving treatment in intensive residential programs, and aftercare services were not in place (General Accounting Office, 1991).

This chapter provides an overview of several studies that focus on AOD treatment within the criminal justice system and reviews the evidence related to treatment effectiveness.

Coerced Treatment

A major issue in serving offenders is the effectiveness of treatment for drug abusers who are coerced into treatment. Several authors (Hartjen et al., 1982; Platt et al., 1988; Rosenthal, 1988) have argued that there is little benefit when a client is forced into treatment by the criminal justice system. Some researchers are opposed to coerced treatment on philosophical or constitutional grounds, while others argue against coerced treatment on clinical grounds, maintaining that treatment can be effective only if the person wants to change. Other authors (Anglin and Maugh, 1992; Orsagh and Marsden, 1985; Salmon and Salmon, 1983) have argued that few chronic addicts will enter treatment without some type of external motivation and that legal coercion is as justified as any other treatment motivation.

Advocates of coerced treatment also cite empirical evidence that coercion does not impair treatment effectiveness. For example, Sells and Simpson (1976) and Simpson and Friend (1988) examined the effect of contact with the criminal justice system at treatment admission on the length of stay in treatment and on the performance of clients during and after treatment. They found that those entering treatment with some legal involvement functioned as well as those who entered voluntarily. A number of other studies also report that legal pressure increases admission rates into treatment programs and promotes treatment retention.

Anglin and associates (1989) compared three groups of heroin addicts who entered methadone maintenance treatment under high, moderate, or low coercion. They found no significant differences among the groups at followup on measures of drug use and criminal behavior, indicating that those coerced into treatment benefited as much as those entering voluntarily. De Leon (1988) reported that clients who were legally referred to therapeutic communities stayed in treatment longer than those admitted voluntarily, and that posttreatment outcomes were similar. These studies support the argument that users can benefit from treatment even if their motivation for entering treatment is external.

More recently, Goldkamp and Weiland(1993) evaluated the effectiveness of the Dade County felony drug court, known as the "Miami model." Since 1989, when Dade County implemented the drug court model, defendants have been referred primarily to the Diversion and Treatment Program (DATP), an outpatient program with centers in four locations across the county. DATP was designed to require 1 year's participation, during which the offender would proceed through three phases of treatment: detoxification, counseling, and educational/vocational assessment and training.

Among other aspects of the program, Goldkamp and Weiland examined treatment outcomes, which they classified as "favorable" or "unfavorable." Of 245 DATP participants, 40 percent had unfavorable outcomes (dropped out, disappeared, or were terminated for noncompliance) and 60 percent had favorable outcomes (graduated from DATP or successfully completed diversion according to court records). Offenders with favorable outcomes spent an average of 364 days in the treatment program, while those with unfavorable outcomes averaged 225 days. The investigators compared the 245 DATP participants with other groups of offenders who were not eligible or not assigned to DATP. DATP participants showed much lower rates of rearrest than offenders in the comparison groups; those who were rearrested averaged two to three times longer to first rearrest. Thus, the Dade County drug court program had an important effect on reducing the criminal caseload of the circuit court.

Several studies indicate that clients who enter AOD treatment because they are forced to do so by the criminal justice system make as much progress as those who enter treatment voluntarily. However, some researchers are opposed to coerced treatment on philosophical or constitutional grounds, and there are clinicians who believe there is little benefit to forced treatment.

Community-Based Drug and Crime Reduction Initiatives

Several States have developed community-based treatment programs that refer AOD-involved offenders to treatment in lieu of prosecution. Offenders who are on probation and who face revocation of probation (that is, return to jail for violation of the terms of probation) can also be referred to treatment. The most well-known example of this approach is the Treatment Alternatives to Street Crime (TASC) program, which was initiated in 1972 and currently is used in 130 programs in 25 States (Cook and Weinman, 1988; Inciardi and McBride, 1991). TASC identifies, assesses, and refers drug-involved offenders to community treatment services as an alternative or supplement to existing criminal justice sanctions.

After referring the client to community-based treatment, TASC monitors progress and compliance, including drug abstinence, employment, and personal and social functioning. Dropping out of treatment or other noncompliance is handled by the courts as a violation of the conditions of release (that is, terms that must be met while on community supervision), and the individual is returned to criminal justice processing.

The National Institute on Drug Abuse has been involved in a 3-year evaluation of TASC. Most TASC programs have carried out their treatment-outreach function successfully. Sells (1983), for example, reported that 50 percent of offenders referred to treatment by TASC were entering treatment for the first time, an important finding that demonstrated that TASC's outreach efforts were effective in targeting untreated offenders. Other independent evaluations also concluded that local TASC programs effectively intervened with clients to reduce drug use and criminal activity (Inciardi and McBride, 1991).

The most extensive although limited evaluations of the impact of TASC have been based on analyses of data from the Treatment Outcome Prospective Study (TOPS). TOPS is a longitudinal survey of 11,000 drug abusers in 10 cities; the study examined treatment outcomes, including renewed criminal activity of offenders after treatment. These studies compared clients involved in the criminal justice system -- in TASC and under other forms of criminal justice supervision -- with clients who voluntarily entered drug treatment; clients were compared on a variety of characteristics and behaviors. TASC clients improved to the same degree as voluntary clients with respect to drug use, employment, and criminal behavior during the first 6 months of treatment. TASC clients also remained in residential and outpatient drug-free treatment programs 6 to 7 weeks longer than voluntary clients or those with other types of criminal justice referral. Thus, TASC clients tend to participate longer in treatment, a factor that has been associated with better treatment outcomes.

Another community-based effort to reduce drug use and crime is intensive supervised probation or parole, known as "ISP" (Petersilia, 1987; Petersilia and Turner, 1990; Petersilia et al., 1992). ISP programs are not all designed specifically to treat drug users. However, these programs have features that might be expected to reduce drug use and recidivism; for example, probation or parole officers in ISP programs generally have low caseloads, allowing for close supervision of offenders; random drug testing is required. Early evaluations of ISP programs found the rearrest rates to be 10 percent or lower (Petersilia, 1987). However, a more recent study of ISP programs in seven cities found that ISPs for drug offenders were no more successful than routine supervision in reducing recidivism (Petersilia et al., 1992).

However, the study reported wide variations across sites in recidivism rates, suggesting that the design, implementation, and management of individual programs may have a large impact on outcomes. Data from three ISP programs in California indicate that clients who participated in rehabilitation programs, including drug counseling, had lower levels of recidivism (Petersilia and Turner, 1990). Given that many ISP clients in the study had difficulties obtaining drug treatment, it was not surprising that as many as 30 percent of new ISP arrests were for drug-related offenses.

Another evaluation of five ISP programs in various parts of the country found that, although ISP offenders were tested for drugs more frequently than offenders under routine supervision, test results were similar for the ISP offenders and the routinely supervised groups: more than 50 percent tested positive for drugs during the 1-year followup period (Turner et al., 1992). Although ISP programs do not appear to differ significantly from routine supervision in reducing recidivism and drug use, it should be noted that most of the recidivism among ISP offenders was due to technical violations of parole or probation conditions -- resulting from increased supervision -- rather than arrests for new crimes.

Civil Commitment

One early approach to treatment within the criminal justice system is civil commitment. Developed in the 1960s, civil commitment was a legal procedure that permitted people addicted to drugs to be committed to compulsory drug treatment programs that typically involved a period of residential care and community-based aftercare. This approach provided the benefits of rehabilitation, while reducing the demand for drugs during both treatment and aftercare phases.

The California Civil Addict Program (CAP), an early program of this type, also was the most successful and the most studied. One study (McGlothlin et al., 1978) compared the outcomes for 1) addicted persons admitted to CAP and subsequently released to community supervision, with the outcomes for 2) addicted persons who were discharged from the program after a short period because of legal errors in the commitment procedures. During the 7 years after commitment, CAP clients reduced their daily narcotics use by 21.8 percent, while comparison clients reduced their daily use by only 6.8 percent. Furthermore, criminal activities among the civilly committed group were reduced by 18.6 percent, while the discharged group reported a reduction of only 6.7 percent. Thus, civil commitment as implemented in the California CAP reduced daily narcotic use and associated crime by program participants to one-third the levels among other addicted people not in the program.

Drug Courts

As discussed in Chapter 1, recent efforts to deal with the increase in drug-related cases in the Nation's courts have resulted in the creation of drug courts -- special courtrooms dedicated to providing substance abuse treatment to individuals under close supervision of a judge. Proponents of these programs regard drug use, possession, and sale not only as a law enforcement problem but also as a public health problem that has deep roots in society. Proponents of the model argue that solutions to the drug crisis are more likely to lie in using AOD treatment to effect a long-term amelioration of the problem than in using strictly punitive approaches.

  • Treatment Alternatives to Street Crime (TASC)
  • Intensive supervised probation (ISP)
  • Civil commitment
  • Drug courts.

In drug court programs the court plays a role that goes well beyond the traditional one; as much emphasis is placed on effective AOD treatment as on adjudication of cases. The conviction that treatment works -- not in every case, but often enough to make this a better approach for some types of cases -- is a key premise of the programs.

Treatment for Incarcerated Offenders

Prisons

A major study of drug treatment provided in prison -- an evaluation of the Stay'n Out therapeutic community for offenders at two New York prisons (Falkin et al., 1991; Wexler et al., 1990) -- had three major findings:

The Stay'n Out group had lower arrest rates than a comparable no-treatment group during the followup period.

  • The Stay'n Out group had lower arrest rates than comparable groups exposed to other prison treatment approaches, such as milieu therapy or counseling.
  • For the Stay'n Out clients, success after release was directly related to the length of time they remained in the program, although positive effects dropped off for those in treatment more than 12 months.

For example, after release on parole, only 27 percent of the male subjects who had been in Stay'n Out were rearrested, compared with 41percent of those who had received no treatment while in prison. Stay'n Out clients who stayed in treatment for less than 9 months were almost three times more likely to be reincarcerated within 3 years after release than those who remained in treatment for 9 to 12 months. For offenders receiving other types of prison treatment, reincarceration was not related to time spent in treatment. There were fewer differences between outcomes measures for women in the various programs than for men. Overall, the evaluation of Stay'n Out established that prison-based treatment based on a therapeutic community model can result in significant reductions in recidivism rates.

Two evaluation studies of the Cornerstone program, a modified therapeutic community for offenders at the Oregon State Hospital, examined the effectiveness of the program and reviewed various treatment outcomes, including recidivism. The first study (Field, 1985; Gerstein and Harwood, 1990) compared outcomes of Cornerstone graduates with three other groups: program dropouts, Oregon parolees with histories of drug abuse, and a similar group of Michigan parolees.

After 3 years, Cornerstone graduates had greater success rates than the other groups on two main outcomes measures -- not returning to prison and not being convicted of any crime. Seventy-one percent of Cornerstone graduates did not return to prison during the 3-year followup period, and 54 percent were not convicted of any crime. The percentages for Oregon parolees, who had the next-best outcomes, were 63 percent and 36 percent, respectively. These differences are greater than they appear since Cornerstone graduates had more severe criminal and substance abuse histories than the parolee group.

In the second evaluation of Cornerstone (Field, 1989), outcomes for program graduates were compared with those of three program dropout groups defined by length of time in program (at least 6 months, 2 to 5 months, and less than 2 months). The results were similar to those of the earlier evaluation. For example, 3 years after program completion, 37 percent of Cornerstone graduates had no arrests, 51 percent had no convictions, and 74 percent had no time in prison. The 6-month dropout group had worse outcomes: only 21 percent had no arrests, 28 percent had no convictions, and 37 percent had no time in prison. The other two dropout groups had the worst outcomes.

Jails

A number of jails have recently developed substance abuse intervention programs for inmates, often with funding from the Bureau of Justice Assistance (BJA) or the Center for Substance Abuse Treatment (CSAT). The substance abuse treatment program operated by the Hillsborough County Sheriff's Office in Tampa, Florida, is one jail intervention program that has been evaluated (Peters et al., 1992b). During the course of treatment, program participants demonstrated significant improvement in their perceived ability to handle community high-risk situations and in their knowledge of issues related to relapse prevention and coping skills. More important, in the year after treatment, inmates who had been involved in the substance abuse treatment program remained in the community an average of 221 days before arrest, compared with an average of 180 days for the untreated offenders. During the 1-year followup period, treated inmates also had fewer arrests than the comparison inmates (an average of 1.1 arrests versus 1.5) and spent fewer days in jail (an average of 32 days versus 45 days). In addition, the arrest rates of the treated group decreased relative to their preincarceration arrest rates, while the rates for the untreated group increased.

Summary

In summary, this overview of research studies of outcomes for substance-abusing offenders indicates that AOD treatment interventions can be effective in a variety of settings in reducing relapse and recidivism and in producing desired changes in psychosocial behavior. As discussed in Chapter 1, the results of the California Drug and Alcohol Treatment Assessment (CALDATA), a long-term study of treatment outcomes published in 1994, have provided strong confirmation of earlier findings on the effectiveness of treatment in reducing crime and recidivism. The CALDATA study found that in the year after AOD treatment, crime was reduced by two thirds. The greater the length of time spent in treatment, the greater the percent reduction in crime. In effect, there was a daily trade-off: each day of treatment paid for itself (the benefits to taxpaying citizens equaled the costs) on the day it was received, primarily through avoidance of crime.

Costs and Funding

Any strategy discussion eventually leads to the question: How will additional services be funded? Funding AOD abuse treatment for clients in the criminal justice system requires dedicated financial outlays. New funding sources may become apparent when developing joint approaches. Funds can be reallocated to establish or support programs where they are needed without new financing. In determining costs of treatment, services can be considered not only for what they cost to deliver, but also as a cost offset. That is, what future costs will be avoided if these services are successful?

The Scope of the Problem

A survey conducted by the Department of Justice in June 1994 revealed that the number of men and women in Federal and State prisons had topped 1,000,000 for the first time. The prison population grew by 40,000 in the first 6 months of 1994 alone -- equivalent to 1,500 new prisoners per week. This figure does not include the number of persons in jails -- estimated to be about 500,000 (Holmes, 1994b).

According to Bureau of Justice Statistics (1993b) the State and Federal prison population in the United States has been growing at an annual rate of 7 percent for 3 years, growth that is largely attributable to mandatory sentencing, especially for drug offenses. In 1980, for every 1,000 people arrested for AOD-related offenses, 19 were sent to prison. By 1992, this figure had risen fivefold, to 104 per 1,000 (Holmes, 1994a). If the present prison population continues to grow at 7 percent, four new 500-bed prison facilities will be needed each week to house all of the prisoners in the United States. In 1992, the United States spent an estimated $6.8 billion on the construction of new prisons; more than 120,000 new prison beds were added in 1993 (Edna McConnell Clark Foundation, 1993). The national crime bill, passed in late 1994, provided $8.7 billion for State prison construction.

California estimates that it will have to add 20 new prisons to the State's 58 to handle the increased number of inmates under California's new "three-strikes" law. Florida, which has doubled prison construction spending in the past 4 years, plans eight new prisons. Texas will open a new corrections installation each week for the next 18 months. Since 1982, the number of Federal prisons has risen from 43 to 77; yet these facilities house 30 percent more inmates than they were designed to accommodate. Forty-one States have put either the entire prison system or one or more major institutions under court order to alleviate overcrowding or poor delivery of services to inmates (Holmes, 1994a).

The cost of construction for new prisons averages $54,209 per bed for State facilities and $78,000 for Federal facilities. (New York State reported that the cost of a single communicable-disease cell for an offender infected with tuberculosis cost $450,000. In 1991, the Federal Government ordered New York State to build 84 of these cells.) Financing and debt servicing costs boost the price tag on prisons. A 1990 study by the New York State comptroller found that the cost of building a maximum security bed was $94,000, but with financing charges, the cost rose to $246,783 -- a threefold increase (Edna McConnell Clark Foundation, 1993).

Operating costs for prisons are approximately $4.5 billion per year; costs vary among States and types of facilities, averaging between $9,500 and $32,000 per inmate per year. In New York City, where labor costs are high, $58,000 per year is required to keep an inmate in jail. According to the National Council on Crime and Delinquency, over a 30-year period -- about the length of a life sentence -- the cost of building and operating the average prison bed is $1.3 million.

  • Operating costs for prisons are approximately $4.5 billion a year.
  • The average cost to a State for an inmate every year varies from $9,500 to $32,000.
  • Education and mental health services can add $12 million a year to the total cost paid for by State agencies other than the corrections department.
  • Over a 30-year period, the average cost of building and operating one prison bed is $1.3 million.

In some States, operating costs are beyond the reach of State budgets. A January 1992 survey by the National Institute of Corrections found that, nationwide, 12,814 beds were completed but not open because of lack of funds.

Many prison expenses are paid by State agencies other than the corrections department -- expenses such as education and mental health services -- and taken together, they raise the real operating costs. A 1989 study in Alabama examined such costs and found they added $12 million per year to the total cost of operating the system.

The costs of building and operating these needed correctional facilities can be contrasted with the costs of establishing AOD abuse treatment programs in correctional facilities. The Federal Bureau of Prisons has recently reported that it has costs of about $2,100 per inmate per year to provide AOD abuse treatment to offenders (this figure does not include the costs to operate the facilities and largely reflects the costs of salaries). In Illinois, a 250-bed therapeutic community housed within a medium security prison costs approximately $790,000 annually, or about $3,200 per inmate per year (personal communication, Illinois Department of Alcohol and Substance Abuse, December 1994). These costs include a process-and- outcome evaluation and postrelease case management. (No capital costs associated with program startup, incarceration, or security are included.)

The costs of building new correctional facilities can also be contrasted with the lower costs of providing community-based treatment to nonincarcerated, nonviolent offenders who are being supervised in the community. Such arguments can be very convincing in appeals to legislatures for annual appropriations, and the criminal justice and AOD treatment fields can join forces for this purpose.

  • AOD abuse treatment for one offender costs about $2,100 a year.
  • One therapeutic community housed within a medium security prison costs approximately $3,200 a year for each inmate. (No capital costs associated with program startup, incarceration, or security are included.)

Reallocation

The basic premise of reallocation is that front-end investment in programs such as early AOD intervention will produce savings and decrease future treatment costs. Perhaps even more significantly, effective AOD treatment and prevention can keep AOD-abusing offenders from engaging in future criminal activity.

Cooperation between the criminal justice and AOD treatment systems regarding the allocation of treatment funds can have clear advantages for both systems. A portion of funds earmarked for quality control in a correctional institution might be allocated to support quality control of the institution's AOD treatment program. Also, reallocating funds for expanded AOD community treatment could decrease the need for additional prison beds. However, political forces often create barriers to major reallocations of funds.

Cost Offsets

The recently published CALDATA study described earlier in this chapter showed that every dollar invested in treatment saved $7.14 in future costs, largely because of reductions in criminal activity during treatment and in the 2 years following treatment (California Department of Alcohol and Drug Programs, 1994). The investigators in the CALDATA study found that treatment affected criminal activity in two ways -- directly and indirectly. They pointed out that a person in treatment generally was introduced into new "reference groups" that provide new moral and ethical standards to substitute for reference groups and standards that had helped to engender past criminal activity. Treatment can indirectly affect criminal activity by reducing the economic motivations for crime; crimes are often committed to obtain money to buy alcohol and other drugs.

The CALDATA study also found significant cost offsets in healthcare utilization. AOD treatment improved health on several indicators and reduced future hospitalizations and outpatient medical visits. Healthcare benefits in the first year after AOD treatment offset about 55 percent of the cost of an AOD treatment episode. Persons treated in less expensive outpatient programs realized the same health benefits as those treated in more intensive residential settings.

Although these data on cost offsets are impressive, cost offsets are not guaranteed for every AOD treatment program in every correctional facility or outpatient setting. To effectively incorporate AOD treatment into all stages of the criminal justice system, many upfront costs are involved. For example, there are start-up costs associated with introducing treatment staff into a criminal justice setting. In addition, residential treatment programs, which provide intensive services, are expensive to operate. In the CALDATA study, almost half of the total funds invested in treatment in the State in 1992 were spent on treating only 15 percent of the total treatment population -- in residential programs. However, the study also found that the greatest long-term benefits were derived from the most expensive programs (i.e., residential treatment). Ongoing evaluation research will play a significant role in determining which treatments are most effective with which subgroups of offenders. Carefully designed research is needed in order to provide planners and policymakers with reliable data for making decisions about funding. Chapter 9 of this TIP describes approaches to measuring treatment outcomes.

New Funding Sources

When representatives from the criminal justice and AOD abuse treatment systems approach funding sources jointly, potential funding sources may be broadened. Some innovative strategies have been used to increase funds available for treatment:

  • Many jurisdictions offset supervision costs by charging offenders for their treatment. Such an approach may not be realistic in all instances, since a large proportion of offenders are indigent.
  • Resources recovered from confiscation and forfeiture of offender assets should be considered as treatment-funding possibilities.
  • Minimum security work-release treatment centers can be set up to pay for themselves by using offender payments.
  • Many jails and prisons have Inmate Welfare Funds, which must be used in programs that benefit inmates. Funds are usually generated through inmate phone commissions and commissaries.
  • Federal, State, and private philanthropic funding might be available for creatively designed demonstration programs, especially funding sources that encourage systems coordination.

For example, CSAT has funded a variety of demonstration projects in several States to expand and enhance treatment for substance abusers under criminal justice supervision. All projects incorporate the CSAT comprehensive care model (as described in Chapter 5) and a continuum of treatment, health, and mental health services for incarcerated and nonincarcerated offenders. The projects support interagency criminal justice and human services linkages.