Variations Among States

Understanding the AOD treatment field and its rapid growth and development in the last decade helps explain the wide array of organizational models seen in different States. Many States have umbrella social service organizations that include the AOD treatment system. Sometimes the umbrella organization is the social service, health, or mental health agency. In this model, health, mental health services, and AOD treatment services are in the same organizational branch, but never merged. Some States have created cabinet-level departments or commissions for AOD services.

While fragmentation has resulted from multiple changes in the AOD system, the same forces have forged flexibility and creative problem solving. Working in a rapidly changing environment takes its toll, but the treatment field on the whole is responsive to new approaches that can lead to high-quality care. As healthcare costs increase, the AOD treatment field is being recognized as a system that can effectively prevent and treat healthcare problems.

When criminal justice professionals approach AOD systems, it is advisable to inquire about the stated mission and goals of the larger agency and the working relationship between AOD services and other social and health services. This information may help provide an understanding of AOD treatment, because only a few States deliver AOD treatment services directly. In fact, most contract with certified private treatment providers or county governments.

The necessary involvement of the single State AOD agencies in treatment is generally helpful, but their involvement can also create problems by adding a layer of politics and bureaucracy to the delivery of treatment. For example, some State agencies operate their own AOD treatment programs and may want the criminal justice system to make referrals directly to them, not to community providers.

In many States, county systems play key roles in local needs assessments for prevention and treatment services. These county systems also disburse funds to service providers. Often, county-level working relationships between courts and the AOD system are more collaborative than those at the State level and can be enhanced. County government, unlike State government, often benefits from a sense of community. Cross-system efforts usually are easier and more "natural" with neighbors than they would be in the climate of strained relationships that can exist between State agencies. However, relationships on the local level can be badly strained by a history of not communicating or not working together.

Policy issues can divide AOD professional associations and, in some States, pit the associations against the State or county governments responsible for funding AOD programs. It is recommended that justice professionals ask the State AOD agency about the existence and activities of professional associations and be as inclusive as possible in initial forays with AOD providers.

Some States have a governor-level commissioner or "drug czar," usually with a discrete cabinet-level agency. The commissioner can be a high-level policy coordinator, with responsibility for bridging law enforcement, education, prevention, and treatment activities. Contacting the commissioner can be an effective starting point for justice professionals interested in linkages with treatment resources.

Prevention Policy

Prevention of AOD abuse should be a central priority at every level -- Federal, State, and local. Communities should systematically examine problems and risk factors related to AOD abuse at the local level to give policymakers and legislators the data they need to create effective laws and policies. For example, legislatures can ensure that money is spent jointly by the criminal justice and AOD treatment systems and that a certain percentage of criminal justice agencies' budgets is set aside for treatment. Legislative action can also change policy on forfeiture of illegally gained proceeds to direct some of these funds into prevention efforts.

One of the most effective ways to implement prevention efforts is to establish community-based multidisciplinary teams. These teams should include representatives of law enforcement, mental health, AOD treatment, public health, social service, and criminal justice agencies. These teams can function as strong mechanisms for gaining community support and involvement.

A model for such action at the community level is the Center for Substance Abuse Prevention (CSAP) Community Partnership program. The program makes grants to communities to develop coalitions of public agencies and private organizations. The aim is to develop comprehensive, self-sustaining, and replicable systems within a community, involving organizations and agencies in the areas of health, education, law enforcement, and social services; grassroots community organizations and religious groups are also involved. The emphasis is on preventing abuse of all drugs, including alcohol and nicotine. The importance of tailoring prevention models to specific cultures is also stressed. More than 250 Community Partnership Grants have been awarded in the past 3 years.

The Role of the Police in Prevention

The primary responsibility of police is law enforcement and public safety, not social services. However, because police officers work at the community level, they are in a remarkable position to identify and respond to problems, locate resources and alert people about them, make recommendations and facilitate obtaining resources, and provide informal followup. Thus, local police have a critical role to perform in AOD prevention efforts. Police also are recipients of a wealth of information that includes early warning signs and symptoms of impending AOD problems; these signs can be crucial in prevention efforts. Because the use of alcohol and other drugs is so closely linked with criminal activity, especially violent crime, AOD prevention in the community also serves justice system goals of reducing crime and violence and controlling the number of individuals who are incarcerated.

One of the most effective ways to implement prevention efforts is to establish community-based multidisciplinary teams. These teams should include representatives of law enforcement, mental health, AOD treatment, public health, social service, and criminal justice agencies. These teams can function as strong mechanisms for gaining community support and involvement in the prevention of AOD abuse.

However, the principal police intervention is arrest, and police are trained to look primarily for probable cause that can lead to arrest. In many cases, early warning signs and symptoms of AOD abuse precede probable cause for arrest, but police officers may be precluded from engaging in prevention efforts because of their orientation, time constraints, and lack of familiarity with AOD prevention techniques.

• Be cooperative
• Be collaborative
• Be sustained
• Be integrated
• Involve multiple strategies.

Police often meet their primary obligations by identifying current and potential problems, mediating disputes, deescalating crises, and recommending solutions. Many of these activities are remarkably similar to those used by social service providers. When the police are further informed about such topics as addiction, treatment, recovery, codependency, and dysfunctional families and become knowledgeable about local resources, their ability to provide prevention services is greatly enhanced.

In the early 1980s, a new direction in law enforcement began to emerge that has since become known as community policing. The community policing philosophy reaffirms that proactive crime prevention, not merely responding to calls for service, is the basic mission of the police. Community policing takes different forms, depending on the needs of the community in which it is applied. In general, police maintain a visible presence in neighborhoods; officers move from positions of anonymity in patrol cars to direct engagement with the community, giving police more immediate information about problems unique to the neighborhood and insight into their solutions. Police undertake activities to solve crime-producing problems, arrest law violators, maintain law and order, and resolve disputes. At the same time, community policing is anchored in the concept of shared responsibility for community safety and security. In community policing, the police and citizens are partners in establishing and maintaining safe and peaceful neighborhoods; this partnership approach improves relations between police and the public.

In some jurisdictions, community policing includes specific activities to prevent drug abuse and refer people to treatment. For example, in Portland, Oregon, the program features a landlord-training component aimed at reducing drug activity on rental property.

Approaching the AOD System

A careful analysis of the AOD system is needed to prepare for joint program strategies. Those with experience in the treatment-justice linkage are aware of problematic issues. Fortunately, a variety of mutually beneficial public policy agendas exist that can be used to facilitate collaboration between justice and treatment. The effort to control AOD abuse can bring the justice and AOD systems in closer proximity to each other. While many view the end of one system's responsibility as the beginning of the other's, professionals in both systems now have a better understanding of the repetitive, circular nature of the interactions among the justice system, the AOD treatment system, and the community.

Incarcerated AOD-Involved Offenders

AOD education and treatment differ depending on whether the targeted population is confined to a jail or a prison. While prison terms are generally measured in years, jail sentences are generally measured in days and months. Short stays, varying lengths of stay, and frequent disruptions such as court appearances, combined with overcrowding and understaffing, can make some jails less than ideal settings for effective AOD treatment. However, as discussed above, with adequate resources and careful linkage planning, effective treatment can be provided, or at least begun, in jails. In particular, given the characteristics of jails, flexible programming from community providers is critical. Some of the most innovative and creative AOD treatment approaches are taking place in jails. These range from educational and outpatient treatment services to entire jail facilities committed to treatment.

Regional collaborations among some jail jurisdictions have led to coordinated programming, including work-release programs, interventions related to driving while intoxicated (DWI), drug abuse education, and special treatment services. Jails also provide opportunities to identify lower risk populations that can be treated in separate, lower security facilities.

AOD treatment providers assisting incarcerated populations often must work in difficult situations with constraints on space, resources, and offender movement. If possible, inmates receiving AOD treatment should be segregated from the rest of the jail or prison population, although the lack of resources makes this arrangement impractical in many institutions. Segregation of inmates receiving treatment would permit the establishment of a supportive social milieu within the institution. The social milieu, in which individuals in treatment participate in a structured program and form supportive bonds with others in treatment and with treatment staff, has long been a critical aspect of recovery from AOD abuse and dependence.

The benefits derived from cooperation between the criminal justice system and AOD treatment system can flow both ways. AOD treatment for offenders helps the criminal justice system reduce recidivism and gives alternatives to incarceration, when appropriate. Treatment within prisons and jails may ameliorate inmate behavior problems. Neither AOD treatment nor criminal justice efforts alone are sufficient to deal effectively with AOD-involved offenders.

Referrals

Referral to appropriate AOD treatment, whether it is in the community or in a correctional facility, is a critical element of cohesive and continuing service for the AOD-involved offender. To make an effective referral, criminal justice and AOD treatment personnel must know what resources are available to address not only the offender's AOD treatment needs, but also needs in the areas of mental health, medical care, and vocational and social services. In addition to knowing available resources, staff also should have a general understanding of how different programs operate and how staff can access services. For example, staff should know specifically which types of programs will accept referrals and their hours of operation, costs, rules, and expectations. Staff also should be able to explain how a program works and what an offender can expect from it. Similarly, staff should be able to assess a program's ability to meet the offender's treatment needs and whether the offender can benefit appropriately from each treatment approach. The most effective referral procedures are developed when personal contact and relationships are involved. For this reason, criminal justice and AOD treatment staff should make active attempts to establish personal relationships and linkages.

• Knowing how the resources operate
• Understanding their rules, hours, costs, and expectations
• Knowing that each referral made is a good match
• Developing personal relationships with resource providers.

Referral Feedback

Rapid and open feedback helps make the AOD treatment and criminal justice systems function more effectively. Clear procedures are a foundation for timely feedback and rapid action and for establishing ongoing trust in the partnership of the systems.

As described in more detail in Chapter 8, Federal and State regulations protect the confidentiality of individuals who are receiving AOD assessment, referral, or treatment services. Special procedures must be established for sharing information about offenders in treatment. Some criminal justice personnel believe that confidentiality requirements impede feedback. However, routine use of consent forms can help overcome the perception of confidentiality as an obstacle. Unfortunately, feedback between the systems about referrals can be disjointed or nonexistent. Thus, in many jurisdictions, formal arrangements and coordination are necessary to channel appropriate information to relevant staff.

Pretreatment for Incarcerated Offenders

Pretreatment is the process of educating, preparing, and motivating individuals for treatment when appropriate programs are not immediately available. The pretreatment process is intended to prepare offenders for treatment by

• Providing education about recovery
• Increasing self-awareness regarding abuse and addiction and their effects on individuals and their families
• Providing understanding of the need for treatment
• Increasing awareness about solutions and resources
• Generating treatment motivation.

Although pretreatment is appropriate at every stage of the justice system for both nonincarcerated and incarcerated individuals, it is particularly useful in correctional facilities when there is a waiting list for community-based programs or limited capacity for institutional treatment. In institutions where no treatment is available, pretreatment helps individuals make the transition from being inmates to being participants in AOD treatment programs when they become available, and it helps to demystify the treatment and recovery process.

Pretreatment efforts can include education about the drugs of abuse and their effects, the effectiveness of treatment, and the benefits of living a drug- and alcohol-free life. In jails, where some offenders have very short stays, flexibility of pretreatment programming is essential. Based on needs assessment of their jail populations, personnel can decide which pretreatment components are critical to engaging individuals in treatment and divide pretreatment curricula into flexible units.

A treatment plan developed at this stage can address vocational, familial, and social issues that will help support treatment goals, minimize the risk of relapse, and decrease the risk of criminal behavior.

Transition From Institution to Community

It is important to recognize the need for offenders to make a smooth transition into the community, a process that involves identifying and addressing special needs before the offender's release from the institution. For those who have served a full term and for whom there are no conditions of release, incentives should be given to participate in treatment after incarceration. For example, increased contacts with and support from AOD counselors in the weeks prior to release may provide some offenders with the necessary incentive. Separate support groups for offenders who have received treatment while incarcerated and who are anticipating release can provide valuable peer support for remaining AOD free. These groups can invite treatment "alumni" who have successfully made the transition to the community. Meetings with offenders' families when appropriate prior to release can also enlist additional support. Such efforts can be effective for all offenders anticipating release, including those who will be paroled and for whom continuing treatment will be a condition of release.

• Biopsychosocial in nature
• Multidisciplinary in delivery
• Comprehensive in scope
• Driven by ongoing assessments
• Closely monitored.

At the end of the period of incarceration, recommendations about community-based treatment programs should be incorporated into parole plans. The case manager or AOD treatment coordinator should be involved in establishing the conditions of parole when appropriate. Sanctions regarding the offender's performance while in treatment also should be discussed in detail with the offender, appropriate community treatment program staff, and the parole officer.

The initial hours and days following an offender's release are critical with respect to relapse prevention and recidivism. There is a high rate of relapse shortly after release. Careful monitoring, especially over the first few days, is imperative. The first 24 hours after release can be especially critical, and there must be a system in place to ensure that an individual released from incarceration gets into treatment or a support group quickly. In many systems, 72 hours can elapse between the time offenders are released and the time they are required to see their parole officers. This time period should be shorter for those who have received AOD treatment services within the correctional system so that treatment goals are reinforced on a continued basis.

It is often preferable for the parole officer to accompany the offender to the treatment program after release. Because accompanying the offender raises issues of confidentiality, an effective parole officer will obtain a signed consent form from the offender before release, ensuring that he or she can provide this support in the initial period after release.

Ideally, a treatment slot should be identified and selected for use when an offender returns to the community. If a treatment slot is unavailable, temporary drug-free housing should be provided. Although self-help groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Rational Recovery are not treatment, when a treatment slot is not available, these programs can often provide the structure to support the offender in the community until a slot becomes available. Representatives of local treatment programs, as well as self-help representatives, can be invited to the institution so that offenders have some contact and familiarity with these programs prior to release.

In their role of protection of the community, parole officers often devote much of their attention to offenders with the lowest prospects of success. They should not overlook offenders who have made progress in treatment and who have high potential for success if the transition to the community has been carefully planned and implemented and if ongoing supervision and support are provided. For all parolees, no matter how responsive they have been to treatment, control and treatment effectiveness go hand in hand.

Offenders with previous AOD abuse histories should be closely monitored on a daily basis for the first 30 days after release. Monitoring should include random urine testing and breath analysis. During the parole period, monitoring should be intensive. As treatment progress is made, monitoring can be tapered. Electronic monitoring can be arranged for special groups of offenders so their activities are known to corrections officials. This strategy responds to the security concerns of the criminal justice system while allowing offenders to participate in treatment programs.

It is important that treatment programs provide the criminal justice system and the offender with specific plans that describe the frequency and duration of treatment contacts and the consequences of noncompliance. Immediate and decisive action should be taken when offenders fail to show up for treatment or follow their treatment plan. The treatment program should provide feedback to the correctional system in such cases, and appropriate sanctions should be applied.

The first 24 hours after release can be especially critical, and there must be a system in place to ensure that an individual released from incarceration gets into a treatment program.

Treatment agencies must be able to demonstrate that they are providing an appropriate level and intensity of treatment for each person they serve. The criteria used to determine placement, placement changes, and discharge, should be used system wide and should be based on the severity of AOD problems, not the offense. These criteria should be acceptable to criminal justice administrators.

Screening and Assessment

A detailed discussion of AOD screening and assessment, which are fundamental first steps in identifying persons with AOD problems, is beyond the scope of this TIP. A companion TIP in this series, TIP 7: Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System, specifically addresses these processes. It describes a variety of screening tools and assessment instruments commonly in use, specifically for offender populations. Many of these are reprinted in full in Appendix C of that TIP. Particularly useful assessment instruments that are included are the Offender Profile Index, which is used to determine the appropriate type of AOD abuse treatment for the offender (for example, long-term residential, intensive outpatient, or regular outpatient); the Addiction Severity Index (ASI), which is probably the most widely used standardized diagnostic instrument in the field; and the AIDS Initial Assessment Jail Supplement, which gathers information about HIV risk factors. The following discussion summarizes many of the points discussed more fully in that TIP. Screening and assessment are important procedures that are used to identify and describe an individual's AOD abuse problems. However, screening and assessment are distinct and are used differently. Screening is an initial process that identifies individuals who are likely to have AOD problems and indicates which individuals need AOD assessment. Screening generally includes the use of urine toxicology tests, which are laboratory methods of detecting the presence of drugs. Blood tests are often used to determine the level of alcohol and to provide an indicator of intoxication. Because laboratory tests indicate only recent ingestion of a substance, brief screening questionnaires are frequently used to supplement laboratory results. Questions about the amount and frequency of AOD use and patterns of use have been found to be very effective in identifying persons with AOD disorders. Problems related to AOD use, such as decreased ability to function at home or at work, are also indicative of AOD disorders.

An AOD screening should be completed for all offenders entering the criminal justice system. Screening in jails can be conducted during pretrial release interviews. When offenders score positively on an AOD screening, they should receive a biopsychosocial assessment by an addiction professional. The assessment should then be combined with a corrections assessment that addresses other issues such as the offender's security needs and risk to the community. Professionals in both systems should exchange information and assessment results to create a sound basis for case management and to develop a holistic approach to decisionmaking.

An AOD assessment is an interview that helps determine the extent of an individual's problem with alcohol and other drugs and the appropriate level of treatment. For example, the assessment may find that an individual is addicted to cocaine as well as alcohol. The assessment also identifies problems related to AOD abuse in an individual's life. Assessments should be biopsychosocial in nature and should address medical, psychiatric, psychological, emotional, social, familial, nutritional, legal, and vocational areas to determine the levels of treatment intervention and services that will be needed.

While an AOD screening is generally a one-time event, an AOD assessment should be approached as an ongoing process. Assessment is repeated throughout treatment and throughout the offender's involvement in the criminal justice system. Changes in the offender's severity of addiction and in problems related to addiction, as well as new life problems and crises, require modifications in the treatment plan.

Treatment Planning

Based on the results of the assessment, a treatment plan is developed that describes concrete goals and objectives to help the offender correct problems identified in the assessment. The treatment plan, revised periodically based on continuing assessment, should follow the offender through the criminal justice system for continuity of care and treatment planning.

In making decisions about appropriate treatment, patient-treatment matching is an important concept. In patient-treatment matching, every effort is made at each stage of treatment to identify a specific individual's needs, both for AOD treatment services and other services and to secure the appropriate services to match these needs. This approach has been found to increase retention in treatment and improve treatment outcomes. The evolution of this concept in the AOD treatment field reflects the growing understanding of the diversity of patient populations and needs. It also reflects the pressures on the treatment field, as on all areas of healthcare, to reduce costs by eliminating unnecessary and inappropriate treatment.

Another TIP in this series, TIP 20: Matching Treatment to Patient Needs in Opioid Substitution Therapy, includes discussions of key issues in patient-treatment matching, addressing, in particular, the importance of ongoing assessment.

Even if treatment or services for special needs cannot be provided or is provided only partially, treatment options and resources should be identified and contacted. For this reason, active liaisons with community treatment and social service agencies should be developed. Treatment should take into consideration a broad range of issues, including the crimes for which the offender was sentenced, medical concerns including possible HIV infection, mental health problems, and issues related to assault by other offenders. Staff from both systems can then select from an approved "menu" of various treatment components.

When offenders score positively on an AOD screening, they should receive a biopsychosocial assessment by an addiction professional. The assessment should then be combined with a corrections assessment that addresses other issues such as the offender's security needs and risk to the community. Professionals in both systems should exchange information and assessment results to create a sound basis for case management and to develop a holistic approach to decisionmaking.

The evolution of the concept of patient-treatment matching in the AOD treatment field reflects the growing understanding of the diversity of patient populations and needs. It also reflects the pressures on the treatment field, as on all areas of healthcare, to reduce costs by eliminating unnecessary and inappropriate treatment.

The biopsychosocial multidisciplinary approach proposed here, and described more fully in the TIP Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System, will provide data to make informed decisions in the best interests of the offender and the community. Planning for community reentry should begin when offenders first enter the criminal justice system, and conducting assessments early in the process can facilitate that planning.

Relapse Prevention

Relapse, or resumption of AOD use, should be understood as a characteristic of addiction that often cannot be avoided. Individuals who become addicted to alcohol and other drugs generally do so in an environment that encourages and supports AOD use. Many use AODs to cope with emotions, moods, and negative or traumatic life events and stressors. Many environmental factors, including persons, places, and times of day, are associated strongly with AOD use. All of these factors can trigger strong desires to resume AOD use.

Relapse prevention is a strategy to train AOD abusers to identify the stressors and triggers in their daily lives that may lead them back to AOD abuse and to train them to cope more effectively to overcome obstacles to recovery. In linkages between the treatment and criminal justice systems, educating court personnel, especially judges and other persons in the justice system about the dynamics of relapse is crucial.

CSAT has developed a Technical Assistance Publication Relapse Prevention and the Substance-Abusing Criminal Offender that provides an overview of the recovery process and describes approaches for preventing relapse, as well as specific relapse prevention programs in various States.

Relapse rates are high in offender populations. Relapse prevention is critical and should be part of each AOD-involved offender's treatment plan. Relapse prevention skills and activities should continue throughout the treatment process and be a particular focus for incarcerated offenders prior to release. Personal relapse plans should be developed for all parolees. The plans should include substantive input from offenders, with the understanding that after release they will be involved in making decisions about their own lives.

When relapse occurs, as it does for many in recovery, response to it is a critical element of treatment. Relapse should not be viewed as failed treatment or evidence of personal failure. Often, if properly handled, relapse can lead to increased motivation for recovery, strengthening an individual's knowledge of his or her limitations, the dangers inherent in stressors and triggers, and the individual's awareness of what he or she might lose by leaving the treatment process.

When an offender at any stage of the justice continuum and at any stage of treatment experiences a relapse, it is crucial to assess its seriousness and determine what interventions are indicated. One positive urine test or one drink after long abstinence should not be viewed as failure. Relapse should be seen as a signal noting the need for increased treatment and closer monitoring. However, because resumption of AOD abuse may lead to resumption of criminal activity, addressing relapse raises special issues. The key to renewed intervention is graduated sanctions, specified in an established treatment plan. It is essential that personnel from each system agree on the range of responses to relapse and the times that certain responses are appropriate. Many integrated systems have developed agreements in which the treatment program responds to issues of treatment noncompliance, such as relapse, and the criminal justice system responds to noncompliance with other conditions of probation or release.

Relapses must have consequences for the individual in the treatment, particularly repeated relapses. Decisions on consequences must be case management decisions based on the danger to the community and treatment progress of the offender. Sanction possibilities for relapse include

• House arrest
• Electronic monitoring
• Day treatment
• Brief jail stays.

When relapse occurs, as it does for many in recovery, response to it is a critical element of treatment. Relapse should not be viewed as failed treatment or evidence of personal failure. Often, if properly handled, relapse can lead to increased motivation for recovery, strengthening an individual's knowledge of his or her limitations, the dangers inherent in stressors and triggers, and the individual's awareness of what he or she might lose by leaving the treatment process.

Drug Testing and Monitoring

Drug testing generally refers to the testing of bodily fluids to determine if drugs are present. Urine is the most frequently tested bodily fluid, but blood can also be tested. Testing for the presence of alcohol is usually done on breath. In addition to providing information about the presence of illicit drugs and alcohol, testing can also provide information about medications prescribed for AOD abuse, such as disulfiram (Antabuse) for alcohol abuse and naltrexone (Revia) for heroin use (and now approved to treat craving for alcohol (O'Malley et al., 1992; Volpicelli et al., 1992), and medications prescribed for psychiatric problems. In addition to testing urine, breath, blood, and, in some cases, hair can be tested.

Drug testing is a vital part of AOD abuse treatment and provides a tool for determining an individual's progress in treatment and for making decisions about changes in the treatment plan. AOD abuse counselors encourage their clients to view drug testing from this perspective -- not as a punitive measure or as a way to control the individual, but as a tool that allows the counselor and client to better achieve treatment goals. In the criminal justice setting, drug testing is used for monitoring offenders' behaviors and ensuring that they comply with conditions set by the courts. Urine drug testing is an area where the differing goals of the two systems are highlighted.

Drug testing should be both a supervisory device and a therapeutic tool. For some offenders, urine testing is an important way to prove objectively to themselves and others that they are making progress. For others, urine testing can be an external source of motivation that helps them achieve abstinence. Drug testing should start at the beginning of the criminal justice process and continue from pretrial to arraignment and throughout the offender's involvement with the justice system, including parole and probation. It can be used in the context of progressive sanctions. Because drugs are available in jails and prisons, urine drug tests should also be used in those settings. Treatment programs that implement urine drug testing for incarcerated offenders will establish credibility with criminal justice officials. Testing should be done on a frequent and unscheduled basis. High-risk clients with previous recidivism and relapse experiences require strict monitoring programs to ensure treatment compliance. The sanctions that will be used in response to positive drug test results should be clearly specified.

Self-Help Groups

Self-help groups are frequently a crucial component of recovery for individuals in AOD treatment and can be especially important in providing support to recovering offenders. Self-help groups provide peer support and confrontation, and they serve as therapeutic bridges from incarceration to the community. They also help during crises and with personal growth. The best known self-help groups are AA and NA. However, there are other self-help groups that may be appropriate, depending on the offender's beliefs, needs, and interests. These include Survivors of Incest Anonymous (SIA), Rational Recovery, Secular Organizations for Sobriety (SOS), church groups, and feminist and veteran support groups. However, these groups are not a form of treatment, and attendance at meetings should not be used as a sanction.

• Support for AOD treatment and recovery
• Peer support
• Healthy peer confrontation
• Therapeutic bridges between the criminal justice system and the community
• Crisis prevention and management
• Personal growth.

Detoxification

Detoxification is the term used to describe withdrawal from alcohol, illicit drugs, or prescription medications that have been abused or misused. Detoxification, as the word implies, entails a clearing of "toxins" from the body. The most immediate purpose is to safely alleviate the short-term symptoms of withdrawal from chemical dependence, including physical discomfort.

Detoxification may occur in either an inpatient or an outpatient setting. It involves several procedures for therapeutically supervised withdrawal and abstinence over a short term (usually 5 to 7 days but sometimes up to 21 days), often using pharmacologic treatments to reduce patient discomfort and reduce medical complications such as seizures. It is a first step for many patients who will enter treatment, but it is not synonymous with comprehensive, ongoing treatment. The detoxification process entails more than the removal of alcohol and other drugs from the body; it includes a period of psychological readjustment that prepares the individual to enter ongoing treatment.

Detoxification is a first step for many patients who will enter treatment, but it is not synonymous with comprehensive, ongoing treatment. The detoxification process entails more than the removal of alcohol and other drugs from the body; it includes a period of psychological readjustment that prepares the individual to enter ongoing treatment.

Withdrawal from certain drugs such as sedative-hypnotics, alcohol, benzodiazepines, and barbiturates can include life-threatening seizures. Thus, it is recommended that medical detoxification be provided for these classes of drugs. Another TIP in this series, TIP 19: Detoxification From Alcohol and Other Drugs, describes clinical detoxification protocols for a variety of substances.

Within the criminal justice setting, there is a broad range of models, from intensive medical management in an inpatient setting to medication-free detoxification in a community-based outpatient setting. Acupuncture is increasingly used as a medication-free approach to relieving some of the discomfort of withdrawal. While many institutions do not provide pharmacologic assistance, others provide some medical management, such as dispensing medications that minimize some of the acute withdrawal symptoms.

Offenders should be educated about the withdrawal process and the type of detoxification they will receive. During withdrawal, people frequently become worried that the symptoms they are experiencing will last for prolonged periods. When educated about the expected course of their symptoms, offenders can deal more easily with withdrawal. Similarly, when offenders, AOD clinicians, and criminal justice staff all share an understanding of withdrawal, it is less likely that staff will misinterpret related behavior as purely manipulative.

Few jails have formal detoxification programs. When an offender is arrested and booked, he or she is screened for medical or other conditions that may need immediate attention. Intoxicated offenders are often held in medical services units under observation until the AOD effects diminish. If they need further intervention to treat withdrawal symptoms, they are transferred to the jail medical clinic or to a hospital, if necessary.

From an AOD treatment provider perspective, this situation raises several concerns. Many would characterize this as a "drunk tank" approach to detoxification. Jails are not certified to perform detoxification, and corrections personnel are not adequately trained. Further, detoxification is generally regarded as the first step into treatment, and how it is handled has a significant effect on treatment engagement and outcome. A more help-oriented model of detoxification is needed in a jail setting, a model that would pave the way for ongoing treatment while recognizing the importance of detaining violent or otherwise harmful individuals who threaten public safety.

Inpatient Treatment

The most intense levels of treatment are medically managed and medically monitored intensive inpatient hospitalization. At these levels of care, offenders are hospitalized. They can receive treatment for detoxification, medical problems associated with or unrelated to addiction, and psychiatric disorders, although not all individuals need these services. Participants also engage in psychosocial treatment for addiction that can include education, group therapy, and self-help.

Medically monitored intensive inpatient treatment usually provides 24-hour nursing care under the direction of a physician. In contrast, medically managed intensive inpatient treatment has 24-hour medical care in an acute medical-care setting. This approach is valuable for patients who have severe withdrawal or biomedical, emotional, or behavioral problems that require primary medical treatment.

Residential Treatment

Residential treatment incorporates several different models, approaches, and philosophies for the treatment of AOD disorders that involve cooperative living for people receiving treatment. Specific residential treatment approaches with various lengths of stay have been designed for offenders. Residential treatment programs vary with regard to intensity of treatment. Some programs provide treatment services 8 or more hours a day, 5 to 7 days a week, with clinical staff available both days and evenings. Other residential programs are recovery homes for employed residents, with evening and weekend AOD treatment and limited onsite staff supervision.

The physical environments of residential treatment programs vary greatly. The environments include hospitals, facilities on hospital grounds, institutional housing, multiroom houses, sections of apartment complexes, and dormitory-like structures. Residential treatment programs also vary in philosophical approach. Some therapeutic communities provide psychological treatment focusing on a global change in lifestyle and rehabilitation. Other residential programs are biopsychosocial but focus more on treatment and less on vocational counseling, work therapy, and social services. Other residential treatment programs have several self-help group meetings throughout the week, while others encourage or require attendance at community group meetings.

Residential treatment programs may be targeted to special populations. They may be designed for adult or younger offenders, males, females, pregnant women, people who are employed or unemployed, or individuals with psychiatric disorders. Most residential treatment models designed for offenders use a group approach to treatment, recovery, and rehabilitation. The purpose of group-centered residential treatment is to create an environment that duplicates certain aspects of a family. For example, residents in many of these programs must cooperate and collaborate on daily projects such as household chores, laundry, and meal preparation. This approach is therapeutic because it prompts problem solving, communication, goal setting, and combined efforts to accomplish single goals.

All residential treatment should be followed by continued care in an outpatient setting. It is important that residential treatment become part of continuing treatment, as outlined in the assessment and treatment plan. The Federal Corrections Institute in Lexington, Kentucky, has established a treatment program, Atwood Hall, that is an example of an intensive AOD residential treatment program. It includes 12 months of more than 10 hours of daily treatment and 6 months of supervised aftercare. In philosophy, it is a self-help-oriented program that uses group therapy, individual counseling, and large groups to deal with issues of denial, recovery, relapse prevention, and cognitive coping skills.

Outpatient Treatment

Like residential treatment programs, outpatient AOD treatment incorporates several approaches, models, settings, and philosophies. The most obvious difference among outpatient treatment programs is level of care. Outpatient treatment ranges from traditional outpatient services to intensive outpatient treatment (IOT) programs. Traditional outpatient treatment is used here to describe treatment provided by clinical addiction professionals in organized clinical settings. This treatment occurs in regularly scheduled sessions, with usually fewer than 9 contact hours per week. Examples include weekly or twice-weekly individual therapy, weekly group therapy, or a combination of the two in association with self-help activities. Because traditional outpatient treatment involves a limited number of sessions per week, it has been described as nonintensive treatment.

In contrast, intensive outpatient treatment consists of regularly scheduled and structured sessions with a minimum of 9 treatment hours per week. Examples or models include day or evening programs in which clients attend a full spectrum of treatment programming while living at home or in a special residence. Another TIP in this series, TIP 8: Intensive Outpatient Treatment for Alcohol and Other Drug Abuse, describes one approach to this level of care.

Variants of traditional outpatient treatment and intensive outpatient treatment can be adapted to meet the needs of incarcerated and nonincarcerated offenders within the justice system. Within the AOD treatment continuum, intensity decreases over time if an individual meets treatment goals. For example, offenders receiving AOD treatment may initially be placed in inpatient settings during withdrawal, followed by intensive outpatient treatment and continuing care. In contrast, outpatient treatment provided in correctional institutions is often less intense than that provided by AOD programs in community settings. Thus, offenders may receive more intense treatment after leaving a correctional setting, even though they continue to receive outpatient treatment.

Outpatient services can incorporate treatment topics and use group processes consistent with those used during an offender's institutional stay. Treatment or education begun within the institution also can provide a springboard for community outpatient care. Outpatient treatment can be provided to many more offenders for the same level of funding as residential treatment. Thus, outpatient treatment is a cost-effective option for some offenders.

"Boot Camp" Programs

In response to mandatory drug sentencing, there is a trend in many jurisdictions to develop "boot camp" or "shock incarceration" programs, mostly for young drug offenders. There are currently 47 such camps operating in 27 States and two in the Federal Bureau of Prisons. New York has the largest program, accounting for 30 percent of all inmates in boot camps. The approach incorporates a highly regimented, military-style schedule combined with confrontation, discipline, and behavior modification, in the belief that discipline and humiliation will shock young criminals into shape. The New York State Department of Correctional Services has estimated that the roughly 9,000 boot camp graduates to date have saved the State an estimated $305 million in custody and capital costs (Yen, 1994).

However, there is some question as to whether these programs reduce recidivism among young criminals. A recent eight-State study funded by the National Institute of Justice (MacKenzie and Souryal, 1994) concluded that recidivism rates of "shock graduates" are comparable to those of the general prison population. However, in New York the State Division of Parole has found a statistically significant reduction in recidivism within the first 2 years after release from the camps. After 4 years out, however, the recidivism rate of boot camp graduates was almost identical to the rate of regular parolees. The New York study found that high-quality AOD abuse treatment programming played a significant role in the improved recidivism rates in the first 2 years.

Opioid Substitution Therapy

Methadone and, more recently, LAAM (levo-alpha-acetyl-methadol) are used as opioid substitutes in the treatment of opiate users. These substitutes prevent withdrawal and block the effects of opiates, discouraging continued use of illicit drugs. With methadone, the individual is required to attend the methadone clinic once every day to ingest the methadone dose. LAAM is a longer acting (72 hours) opioid substitute, and clinic attendance is reduced accordingly when it is administered.

Three TIPs in this series, TIP 1: State Methadone Treatment Guidelines, TIP 20: Matching Treatment to Patient Needs in Opioid Substitution Therapy, and TIP 22: LAAM in the Treatment of Opiate Addiction , provide detailed descriptions of this treatment modality and related issues. A controversial issue that is raised in most discussions of methadone is the argument by some that methadone treatment "substitutes one drug for another"; many individuals remain on methadone indefinitely. Some people both inside and outside the treatment field believe treatment should result in a drug-free, or abstinent, state. In fact, in some areas, individuals receiving methadone are considered drug users and cannot enter drug-free treatment or support groups.

Most research, including several very large studies, has shown that participation in methadone treatment is associated with a reduction in illicit opioid use, a reduction in criminal activity, increased employment, and improvement in psychological status (California Department of Alcohol and Drug Programs, 1994; Hubbard et al., 1989; Senay, 1989). In addition, those involved in methadone maintenance treatment receive social, vocational, legal, and educational support services. Methadone maintenance also is an important approach used to reduce the incidence of needle sharing, and it helps reduce needle-spread diseases such as hepatitis and HIV. For many people, methadone maintenance is an opportunity to begin psychosocial stabilization and normalization, an introduction to self-help, and a pathway to abstinence and sobriety.

Offenders must be evaluated both medically and psychologically to determine if methadone maintenance is appropriate. These decisions must be individualized and based on medical history, psychological profile, HIV serostatus, and length of incarceration. Since the early 1970s, methadone maintenance has been recommended as a treatment for opiate-dependent pregnant women. For these women, methadone maintenance prevents erratic maternal opioid drug levels and protects the fetus from repeated episodes of withdrawal. Methadone treatment also can reduce the incidence of obstetrical and fetal complications, in utero growth retardation, and neonatal morbidity and mortality. Maternal nutrition usually is improved and exposure to HIV disease through ongoing needle use can be minimized.