Overview

Program planners should recognize that AOD-involved offenders are not a homogeneous group. There are differences among offenders, even among those of the same age and gender who have the same cultural, ethnic, social, and economic backgrounds. These differences include personality, patterns of AOD abuse, health status, socialization, education, family, job training, urban and rural influences, and mental functioning. Offenders also range from seriously antisocial individuals who prey on people in their communities, to those who are more prosocial and have family and community support systems. The latter offenders usually find themselves involved in the criminal justice system as a result of situational or drug-related offenses. Very often, their only shared characteristics include involvement with alcohol and other drugs and the criminal justice system.

While there always have been AOD-involved offenders in the criminal justice system, their number has increased dramatically over the last 12 to 15 years as a result of increased drug-related crime, Federal and State legislation, and mandatory sentencing. Today the majority of offenders, regardless of the type of charges against them, appear to be involved with alcohol and other drugs. Estimates vary, but State correctional administrators generally report that 70 to 80 percent of inmates are involved with AODs. Among State prison inmates, about one-third were under the influence of alcohol when they were apprehended by the criminal justice system, and data from the National Survey of State Prison Inmates indicate that 25 percent admitted injecting drugs for nonmedical purposes. Local jails also have high proportions of inmates involved with AODs. About 60 percent of offenders were using drugs when they came into contact with the justice system; one half had used cocaine, and one third had used cocaine or crack regularly. About one third of the crack users were in prison for violent offenses. About one fourth of offenders used heroin, and one in seven used heroin regularly.

Culture and Ethnicity

Offenders are most likely to be young males, primarily members of cultural and ethnic minority groups, and to have low educational attainment. Two thirds of offenders are under 35 years old, according to two 1991 Federal inmate surveys, one of people in State institutions and one of individuals in Federal facilities. These studies found that 22 percent of the inmates were under 25 and 46 percent were aged 25 to 30. The study also found that 95 percent of the offenders were men. (Although women constituted only 5 percent of the prison population, they also were the fastest growing segment of offenders.) The racial and ethnic data showed that 65 percent of the inmates were members of minority groups (46 percent African American, 17 percent Hispanic, and 2 percent "other") and 35 percent were Caucasian. Only one quarter graduated from high school, although about 60 percent received either a high school diploma or its equivalent.

AOD-involved offenders are not a homogeneous group. Differences are found, even among those people of the same age and gender who have the same cultural, ethnic, social, and economic backgrounds. Differences include personality, patterns of AOD abuse, health status, socialization, education, family, job training, urban and rural influences, and mental functioning. Very often, their only shared characteristics include involvement with alcohol and other drugs and the criminal justice system.

African American males now are involved in the criminal justice system at a higher rate than white and Hispanic males. While many of the reasons for this disparity in racial incarceration rates are due to factors outside the criminal justice system, evidence suggests that criminal justice practices and policies contribute to the differences. Meier (1992) reported that while rates of drug use among whites and African Americans vary only slightly (10.8 percent for whites versus 9.3 percent for African Americans), African Americans are arrested for drug crimes at far higher rates than whites (1,440 per 100,000 African Americans versus 302 per 100,000 whites), and the rate of drug-related arrests for African Americans increased at five times the rate for whites between 1972 and 1989. (The rate for whites increased 54 percent during that time versus 272 percent for African Americans.)

Meier (1992) also reported that 75 percent of regular drug users were white, 17 percent were Hispanic, and 8 percent were African American, but 43 percent of those imprisoned on drug charges were African American, 25 percent were Hispanic, and 25 percent were white. This pattern of differences was also found in a California study of plea bargaining practices that analyzed 700,000 criminal cases and concluded that "at virtually every stage of pretrial negotiations, whites are more successful than nonwhites in lessening the charges against them" (Schmitt, 1991). Of 71,000 adults with no prior records who were arrested on felony charges from 1989 to 1990, one-third of the whites had charges reduced to misdemeanors or infractions, while only one quarter of the African Americans and Hispanics were able to have their charges reduced. (An infraction involves breaking a rule -- such as a program rule or condition of probation -- not a law.)

Hispanic inmates were more likely than other inmates to have used drugs in the month prior to their offense (54 percent versus 49 percent). While Hispanic (34 percent) and white (32 percent) inmates were almost equally likely to have been under the influence of a substance at the time of their offense, African American inmates were less likely to be under the influence (29 percent). Twenty percent of Hispanic inmates reported getting money for drugs as a reason for committing their crimes, compared with 15 percent of white inmates and 17 percent of African American inmates.

A 1992 study by Meier reported that 75 percent of regular drug users were white, 17 percent were Hispanic, and 8 percent were African American; however, 43 percent of those imprisoned on drug charges were African American, 25 percent were Hispanic, and 25 percent were white.

The popularity of crack cocaine over the last decade has grown among all groups of drug users. However, African Americans are more than twice as likely as whites to use crack cocaine (14 percent versus 6 percent) (Bureau of Justice Statistics, 1993a).

Women

Women primarily enter the justice system when apprehended for nonviolent criminal activity arising from economic motives. These crimes include drug dealing, shoplifting, forgery, larceny, and prostitution. In 1993, 2.5 million women were arrested; about 500,000 of these arrests were related to alcohol and other drug charges (Bureau of Justice Statistics, 1994). The number of incarcerated women has tripled in the past decade, largely as a result of mandatory minimum sentencing for drug offenses. Currently, there are about 50,000 women in State and Federal prisons and 41,000 women in jails. Women are more likely than men to be serving sentences for drug offenses. About one third of female State prisoners and two thirds of female Federal prisoners are serving sentences for drug offenses (Bureau of Justice Statistics, 1994). Women are also more likely than men to have used heroin or cocaine both daily and in the month preceding their offense (Bureau of Justice Statistics, 1994). Mandated sentencing without the parallel development of services to address the needs of special populations has had a devastating impact on women in prisons.

Most women who are incarcerated are low-income, single heads of households with dependent children. Most are unemployed prior to incarceration. A large proportion come from families in which there is a pattern of incarceration over generations. More than 40 percent of incarcerated women report being physically or sexually abused before age 18. Approximately one in four women is either pregnant or postpartum when she enters prison; many women who enter prison have multiple medical problems, including problems related to pregnancy, HIV/AIDS and other sexually transmitted diseases, and TB (Smith, 1993).

Most women who are incarcerated are low-income, single heads of households with dependent children. Most are unemployed prior to incarceration. A large proportion come from families in which there is a pattern of incarceration over generations. More than 40 percent of incarcerated women report being physically or sexually abused before age 18. Approximately one in four women is either pregnant or postpartum when she enters prison; many women who enter prison have multiple medical problems, including problems related to pregnancy, HIV/AIDS and other sexually transmitted diseases, and TB.

Women in all stages of the criminal justice system create a variety of special challenges. Infants born to addicted mothers have much higher morbidity and mortality rates than those born to women who are not substance users. Women need prenatal care, particularly high-risk pregnancy care. Providers in both the criminal justice and AOD treatment systems who supply services for pregnant women need guidelines for addressing their needs. For example, detoxification from methadone or other drugs is risky during pregnancy.

In about one third of cases, incarceration of women with children requires child protective services and other social agencies to become involved in out-of-home child placement because there are no relatives to assume childcare responsibilities (Smith, 1993). Many female addicts choose not to enter treatment for fear of losing their children, and this choice in many cases leads to further involvement with the criminal justice system. Inpatient or residential treatment also may involve placing children for extended periods. Outpatient AOD treatment programs have long recognized the need for providing childcare services, as well as a variety of other services, including transportation, medical care, and case management, to improve treatment retention of women. In addition, many women in the justice system lack parenting skills because they never received adequate parenting, in some cases because of multigenerational incarceration and out-of-home placement. Special training in parenting skills should be a component of an effective AOD abuse treatment program in a correctional setting.

The Center for Substance Abuse Treatment (CSAT) and other Federal agencies have recognized the need for improving access to care for women and providing needed services. The Federal interim block grant requirements, which State AOD treatment programs must fulfill before obtaining Federal funds, include special provisions for granting pregnant women priority access to treatment and for ensuring that women's special needs are met by AOD treatment programs. Another Treatment Improvement Protocol (TIP) in this series,TIP 2:Treatment of Pregnant, Substance-Abusing Women, specifically addresses special issues related to pregnant women. Other TIPs, for example, TIP 1:State Methadone Treatment Guidelines, Matching Treatment to Patient Needs in Opioid Substitution Therapy, and, TIP 19: Detoxification for Alcohol and Other Drugs, include extensive discussions of the methods for providing effective services to women.

Treatment programs in the criminal justice system should address the special needs of women by providing comprehensive services. Linkages with social service agencies and effective case management are key elements in providing the needed array of services. Approaches must take into consideration the fact that female offenders are often the sole caretakers of their children. Medical services for women are critical, since rates of chronic disease are higher among women entering the system than among men. Many women are victims of domestic violence and other types of violence, intimidation, and abuse, which has a significant effect on their ability to engage in treatment and their likelihood of relapse. Programs must address these issues of victimization directly and provide women with access to shelters and legal services to enable them to gain safety. Housing and educational and vocational training are other needs that must be addressed.

However, most justice agencies lack adequate resources to deal with the influx of female offenders with this array of medical and social problems. Community collaboration is important in developing AOD treatment programs for female offenders, especially regarding issues such as housing, childcare, and child welfare and placement. Medical services are a critical treatment component. Psychiatric services are needed that address issues of guilt, remorse, and lack of self-esteem that are especially prominent among women entering AOD treatment. Women's partners should be involved in their treatment and case management whenever possible. Education in child rearing, including health and general homemaking, should be a component of treatment programs for female offenders.

Community collaboration is important in developing women's programs, especially regarding issues such as housing, childcare, and child welfare and placement.

Alternative sentencing for women, including work release programs, electronic monitoring, and day treatment centers, is important to avoid women's incarceration because it separates them from their newborns. When women are incarcerated, consideration also should be given to their need for contact with their children. (Such contact is also important for men.) Whenever possible, institutions should encourage children to visit their mothers during school vacations or holidays. For many female inmates, a prime incentive for entering AOD treatment is to regain custody of their children or to deliver their babies outside an institution. This goal may require not only arranging for early release, but also working with social service agencies and advocating for female clients. Because of these special needs, a strong argument can be made for selecting and training some case managers specifically to work with female offenders.

For nonincarcerated women in treatment, onsite childcare can be a strong motivator to complete treatment and can provide an opportunity to offer parenting training to improve mother-child relations. This approach benefits the children, who may receive better nutrition and healthcare than otherwise would be available.

HIV/AIDS

The incidence of HIV infection among incarcerated individuals is 10 times higher than the incidence in the general population. A 1992 survey of Federal and State prisons and large-city jails indicated that 195 of every 100,000 inmates were HIV positive (Hammet t et al., 1993). The incidence rate in the general population is 18 persons per 100,000. There are large regional differences in HIV prevalence rates, with higher rates in urban areas on both coasts.

This elevated rate is largely attributable to needle sharing among injection drug users. According to the National Survey of State Prison Inmates, 40 percent of inmates who used drugs in the month before their offense had used a needle to inject drugs, and half of these people self-reported sharing needles. In addition, 12 percent of prison inmates admitted sharing needles while incarcerated. Homosexual contact accounts for very few cases of AIDS among inmates; 2.2 percent of cases of HIV/AIDS among inmates are attributed to homosexual contact. Self-reported survey data from State and Federal prison inmates indicated that 2.2 percent were HIV positive (Bureau of Justice Statistics, 1993c). However, only 51 percent of those surveyed reported that they had been tested for HIV, 32 percent had never been tested, 9 percent did not know if they had been tested, 7.5 percent said they had been tested but had never learned the results, and only .1 percent refused to report their test results.

Of inmates who were tested for the presence of HIV and had their results reported, females (3.3 percent) were more likely than males (2.1 percent) to be HIV positive. Rates of HIV infection are higher among female prisoners than among women in the general population. The higher rates are related to prostitution, needle sharing, and unprotected sex. In addition, a review of data along ethnic and racial lines found that almost 3.7 percent of Hispanic inmates were HIV positive, compared with 2.6 percent of African American inmates and 1.1 percent of white inmates (Bureau of Justice Statistics, 1993c).

HIV must be addressed at every point of contact between the criminal justice and AOD treatment systems -- from arrest through incarceration and parole -- and across all age groups. As shown in the CSAT Criminal Justice Treatment Planning Chart(Appendix B), infectious diseases risk assessment should be addressed along with assessment for AOD problems. Prevention education is a key component, and every effort should be made to help offenders understand risk factors such as needle sharing and unprotected heterosexual and homosexual contact. The link between injection drug use and HIV transmission is well known; however, the link between use of noninjection drugs such as alcohol and crack and unsafe sexual practices should be strongly emphasized.

A critical factor in the prevention of further HIV transmission in this population is HIV and risk factor education and training of personnel in both the criminal justice and AOD abuse treatment systems. Such training is particularly important to ensure that HIV-infected offenders have equal access to treatment. Chapter 7 includes a discussion of training topics related to HIV/AIDS and other infectious diseases. A separate TIP in this series, TIP 15: Treatment for HIV-Infected Alcohol and Other Drug Abusers, provides treatment guidelines and discusses the needs and health problems of this treatment population.

Assistance to offenders should be comprehensive, including prevention education, medical and social service support, and grief counseling and other psychological services. Services should incorporate screening, support services, medical interventions such as primary care, and family counseling. In addition, continuing care should be provided and include followup and hospice care.

HIV must be addressed at every level of the criminal justice system. A critical factor in the success of preventing further HIV transmission in this population is education and training. Personnel in both the criminal justice and AOD abuse treatment systems should be taught about HIV/AIDS and its risk factors.

Tuberculosis

Tuberculosis in correctional facilities is not new. Historically, inmate populations contain disproportionate numbers of persons of low socioeconomic status, those with AOD problems, and people with generally high-risk and unhealthy life-styles and poor access to medical care. Prisons and jails are high-risk settings for the spread of TB infection: living conditions are generally crowded, and many buildings have antiquated systems with poor ventilation and air circulation.

Improvements in prevention and treatment of TB greatly reduced its incidence by midcentury and later. For example, from 1944 to 1948, the prevalence of TB in New York State correctional institutions was 1.2 percent for men and 0.7 percent for women; at the same time, the rate in the general population was significantly lower (0.3 percent) (Katz and Plunkett, 1950). Twenty years later, Hans Abeles, then head of Health Services for the New York City Department of Corrections, reported active tuberculosis among newly admitted inmates to Rikers Island to be 0.2 percent (Abeles et al., 1970).

However, in recent years the incidence of TB has risen dramatically, largely as a result of the appearance of a new, multidrug-resistant variety of TB. According to a recent estimate by the Centers for Disease Control and Prevention (CDC) as many as 133,000 persons with TB infection may be released each year from Federal and State correctional facilities (Centers for Disease Control and Prevention, 1993). In a widely publicized 1992 outbreak of multidrug-resistant TB, 36 New York State prison inmates and one correctional officer died. Ninety-eight percent of the inmates who died were also HIV infected. In response to the outbreak, New York instituted universal screening of inmates and developed a database to maintain all test results.

In late 1992, CDC and the National Institute of Justice conducted a survey of all 50 State correctional systems, the Federal Bureau of Prisons, and 37 large city and county jail systems. The survey found that, overall, 10 percent of male inmates and 12 percent of female inmates were TB infected; rates varied widely by geographic area. However, one third of the State and Federal systems and almost one half of the jail systems did not conduct routine skin tests for TB purified protein derivative (PPD) tests and therefore were not able to report prevalence rates. The CDC funds TB screening programs at selected correctional facilities where AIDS and TB cases are reported to be high. In these facilities, infection rates as high as 25 percent have been found (Hammett and Harold, 1994).

In 1989, the CDC issued guidelines for the prevention and control of TB in correctional facilities (Centers for Disease Control and Prevention, 1989). The guidelines address surveillance (screening, diagnosis, case reporting, and investigation of contacts), containment (isolation, treatment, and therapy to prevent TB-infected individuals from developing TB disease), and assessment (recordkeeping, case tracking, and ongoing evaluation of compliance with procedures). The guidelines also recommend centralized control and oversight of TB control efforts, both at individual institutions and systemwide.

As some policymakers have pointed out (Glaser and Greifinger, 1993), incarceration provides an opportunity for early detection and treatment of a variety of infectious diseases in an otherwise elusive group whose risk factors and prevalence rates far exceed those of the general population. It is more feasible to screen inmate populations and to ensure that they complete a course of preventive therapy or treatment than it is to carry out similar interventions in the community with high-risk populations.

Both inmates and staff should receive education about TB and how to prevent it. Although TB is transmitted through the air, fairly intensive exposure is required for transmission to occur. Inmates and staff should understand the importance of completing courses of medication. Chapter 7 describes specific training topics and resources for staff training.

Mental Disorders

Mental illness is diagnosed among a significant number of offenders who have AOD disorders. Researchers (Regier et al., 1990) examined data from the general United States population and reported that 30 percent of adults who had ever had a mental disorder also had a diagnosable substance use disorder during their lives. More than one half were addicted to drugs other than alcohol. Thirty-seven percent of those who were alcohol abusers had one or more mental disorders. A significant number of substance abusers experience severe emotional problems, including bipolar disorder, unipolar depression, and schizophrenia. Lifetime rates of depression of up to 75 percent have been detected among drug abusers (Mirin et al., 1988).

AOD abusers with mental illness have been involved in correctional settings for years. However, it has been only in the last 5 years that researchers, policymakers, and care providers have focused on the need to address coexisting AOD and psychiatric disorders (dual disorders) in correctional populations. Twenty-five percent or more of addicted offenders have lifetime histories of major depression, bipolar disorder, or atypical bipolar disorder, and 9 percent have histories of schizophrenia (Chiles et al., 1990; Cote and Hodgins, 1990). These are serious chronic mental illnesses that produce significant dysfunction if not treated.

In metropolitan jails, the prevalence rates of mental illnesses are much higher. Abram (1990) reported that 44 percent of jail inmates had lifetime prevalences of substance use disorders combined with either depression or antisocial personality disorders. Peters and fellow researchers (1992a) found that inmates with "high psychopathology" reported significantly more lifetime use of amphetamines, hallucinogens, and heroin, in addition to slightly more alcohol and cocaine use in the month prior to prison entry.

Substance abusers with mental illness who also are criminal offenders have special problems and need access to coordinated mental health services. Sometimes, mental health programs may not admit patients with dual disorders because of their substance abuse, and AOD treatment programs may not admit substance abusers because of their mental illnesses. Thus, arranging for treatment for these clients is particularly difficult and challenging.

AOD treatment and mental health programs should work together to focus attention on this segment of the offender population that often is not appropriately served. Mental health professionals should be involved in the case management of coordinated and continuous treatment. Another TIP in this series, TIP 9: Assessment and Treatment of Patients With Coexisting Mental Illness and AOD Abuse, focuses on these issues.

Sexual Abuse and Violence

Violence is an integral part of many AOD-involved offenders' lives. Many are perpetrators of violent behavior, and many more are victims. Issues related to victimization can interfere with AOD treatment. In particular, women offenders are often victims of physical, sexual, and emotional abuse -- both as adults and as children. Counseling provided in AOD treatment programs for offenders should focus on issues related to violence, such as domestic violence, anger and impulse control, and a history of physical and sexual abuse. Once treatment progress is made, feelings of guilt and remorse frequently surface, and individuals need support to address these issues. Anger management training can enhance the support. Sex offenders often are violent offenders and victims of violence, and they need special treatment in addition to AOD abuse treatment. They face issues that are similar to those faced by people with dual disorders, and these issues can greatly complicate substance abuse treatment efforts. Strategies are needed to determine when these clients should receive AOD treatment and how it can be integrated with sex offender treatment. Other considerations include the provision of specialized AOD treatment and support groups for sex offenders and assurance that confidentiality is protected.

Treatment Alternatives to Street Crime (TASC) has developed a model program that is designed to effect positive long-term attitude and behavior change in drug-involved adult and juvenile offenders. The Violence Interruption Process (VIP) helps individuals develop a broader understanding of the causes of violence and teaches them to apply that knowledge in their day-to-day environments. The program uses role-play, didactic presentations, group exercises, and discussion formats. The central assumption is that violence is not inherent to individuals or communities but is a learned behavior that can be unlearned. Respect for others, an understanding of societal interdependence, and a problem-solving approach are key elements of the program. Participants are encouraged to establish alliances in their communities to interrupt violence. VIP has been used effectively with a variety of groups.

It has been only in the last 5 years that researchers, policymakers, and care providers have focused on the need to address coexisting AOD and psychiatric disorders (dual disorders) in correctional populations. Twenty-five percent or more of addicted offenders have lifetime histories of major depression, bipolar disorder, or atypical bipolar disorder, and 9 percent have histories of schizophrenia. These are serious chronic mental illnesses that produce significant dysfunction if not treated.

Issues related to victimization can interfere with AOD treatment. In particular, women offenders are often victims of physical, sexual, and emotional abuse -- both as adults and as children. Counseling provided in AOD treatment programs for offenders should focus on issues related to violence, such as domestic violence, anger and impulse control, and a history of physical and sexual abuse.

Conclusions

There is no "representative or typical" offender. However, it is more likely that the offender is male, a member of a cultural or minority group, less than 35 years old, and has low educational attainment, low employability, and poor health. Major health problems for this population include substance abuse, consequences of injecting drugs, and HIV/AIDS, TB, and other infectious diseases. Many have psychiatric disorders in addition to substance abuse disorders. Additional problems are faced by female offenders, particularly those who are pregnant or have children, because the women need childcare assistance and have problems related to pregnancy, health, and victimization, often involving violence.

Endnote

Footnotes

1. This chapter was written for the Consensus Panel by Douglas S. Lipton, Ph.D.