1. Treatment of Substance Involved Offenders in Criminal Justice Settings –
Challenges & Outcomes
Igor Koutsenok, MD, MS Assistant Professor of Psychiatry, UCSD, Director, Center for Criminality & Addiction Research, Training & Application (CCARTA)

2. Let’s start with some bad news

3. California Statistics
172,785 in prison (1986: 39,373)
Cost – $ per inmate
117,136 on parole (1986: 19,780)
Cost - $ per parolee
77% of males and 83% of females incarcerated in California have drug and alcohol problems.

4. Nationwide cost Columbia University Report, March 2005
$ 30 billion states spent on adult corrections (incarceration, probation, parole)
$24.1 billion of it was on substance involved offenders

5. On Women…
During the 1980s and 1990s, the number of incarcerated women tripled, while the number of men doubled.
80% of these women have substance
abuse problems.
More likely to adjudicate women today than 20 years ago.
“What Works,” Dr. Rudy J. Cypser, CURE-NY, 2000

6. Under 15 % receive systematic treatment
Some Other Sad Facts
Over 2 million inmates inhabited U.S. jails & prisons
They are parents of 3.4 million children
2 in 3 convicts have been tested positive for drugs at time of arrest.
2 in 3 inmates have verified drug histories,
BUT…
Under 15 % receive systematic treatment
Deitch, Koutsenok & Ruiz, 2004

7. Recidivism
Within 12 months after release from custody % of substance involved offenders are back to institutions
It is clear that criminal-justice sanctions by themselves do not reduce recidivism in this population
Prisons do manage behaviors, but do not shape behaviors

8. Policies for Drug Offenders
Diversion
Drug Courts
Incarceration
Probation w/o verdict
(Prop 36)
Intermediate
sanctions

9. Policies for Drug Offenders
Public Safety Risks
Diversion
Drug Courts
Incarceration
Probation w/o verdict
(Prop 36)
Intermediate
sanctions

10. Policies for Drug Offenders
$$$$$$ Costs $$$$$$$$$
Public Safety Risks
Diversion
Drug Courts
Incarceration
Probation w/o verdict
(Prop 36)
Intermediate
sanctions

11. Policies for Drug Offenders
Over-reliance
Diversion
Drug Courts
Incarceration
Probation w/o verdict
(Prop 36)
Intermediate
sanctions

12. Prison Criminal Recidivism in 3 Years 68% re-arrested 47% convicted
50% re-incarcerated
Relapse to Drug Use in 3 Years
95% relapse
Marlow D., Treatment Research Institute, 2006

13. Policies for Drug Offenders
Diversion
Drug Courts
Incarceration
Probation w/o verdict
(Prop 36)
Intermediate
sanctions

14. Policies for Drug Offenders
Over-reliance
Diversion
Drug Courts
Incarceration
Probation w/o verdict
(Prop 36)
Intermediate
sanctions

15. Referral to Treatment Attrition 50% - 67% don’t show for intake
40% - 80% drop out in 3 months
90% drop out in 12 months
70% of probationers and parolees drop out within months
D. Marlow D. & T.McLellan, TRI, 2004

16. Time for some better news
What will happen if we combine incarceration and treatment?

17. From the work of Douglas B. Marlowe, J.D., Ph.D.
Types of Substance Involved Offenders
From the work of
Douglas B. Marlowe, J.D., Ph.D.

18. Criminogenic Risks Age during rehabilitation < 25 years
Criminal onset < 16 years
Prior rehabilitation failures
History of violence
Antisocial Personality Disorder
Psychopathy
Familial history of crime
Criminal associations

19. Criminogenic Needs
Drug Dependence or Addiction

20. Criminogenic Needs Drug Dependence or Addiction Binge pattern
Cravings or compulsions
Withdrawal symptoms

21. Abstinence is a distal goal
Criminogenic Needs
Drug Dependence or Addiction
Binge pattern
Cravings or compulsions
Withdrawal symptoms
Abstinence is a distal goal }

22. Abstinence is a distal goal
Criminogenic Needs
Drug Dependence or Addiction
Binge pattern
Cravings or compulsions
Withdrawal symptoms
Drug Abuse or Misuse
Abstinence is a distal goal }

23. Abstinence is a distal goal Abstinence is a proximal goal
Criminogenic Needs
Drug Dependence or Addiction
Binge pattern
Cravings or compulsions
Withdrawal symptoms
Drug Abuse or Misuse
Abstinence is a distal goal
Abstinence is a proximal goal } }

24. Abstinence is a distal goal Abstinence is a proximal goal
Criminogenic Needs
Drug Dependence or Addiction
Binge pattern
Cravings or compulsions
Withdrawal symptoms
Drug Abuse or Misuse
Collateral needs
E.g., dual diagnosis, HIV+
Abstinence is a distal goal
Abstinence is a proximal goal } }

25. Abstinence is a distal goal Abstinence is a proximal goal
Criminogenic Needs
Drug Dependence or Addiction
Binge pattern
Cravings or compulsions
Withdrawal symptoms
Drug Abuse or Misuse
Collateral needs
E.g., dual diagnosis, HIV+
Abstinence is a distal goal
Abstinence is a proximal goal } }

26. Risk & Needs Matrix
High Risk
Low Risk
High
Needs
Low
Needs

27. Risk & Needs Matrix High Risk Low Risk High Needs Low Needs &
Accountability
&
Treatment
High
Needs
Low
Needs

28. Risk & Needs Matrix High Risk Low Risk High Needs Low Needs Treatment
Accountability
&
Treatment
High
Needs
Low
Needs

29. Risk & Needs Matrix High Risk Low Risk High Needs Low Needs Treatment
Accountability
&
Treatment
High
Needs
Accountability
Low
Needs

30. Risk & Needs Matrix High Risk Low Risk High Needs Low Needs Treatment
Accountability
&
Treatment
High
Needs
Accountability
Prevention
Low
Needs

31. Practice Implications
High Risk
Low Risk
Frequent meetings
with PA
Intensive treatment
Compliance is proximal
Positive reinforcement
Intensive treatment
Treatment is proximal
Positive reinforcement
High
Needs
Secondary prevention
Abstinence is proximal
Abstinence is proximal
Restrictive sanctions
Low
Needs

32. Why Therapeutic Community Model?
The profile of a successful high risk/high need client in community based therapeutic community is very similar to the one of a substance abusing offender in custody

33. Delaware/Crest Program: 3-Year Re-Arrest & Drug Use Rates
Martin, Butzin, Saum, & Inciardi, 2001 (The Prison Journal)

34. Texas In-prison TC Program: Return to custody rates (24 months follow-up), 2001
Aftercare
Completers
K. Knight, D. Simpson. The Prison Journal, 2002

35. California/Amity Program: 3-Year Return-to-Custody Rates (%)
Wexler, Melnick, Lowe, & Peters, 2002 (The Prison Journal)

36. Coercion in the Criminal Justice System
A 2000 report from the Institute of Medicine summarized that “contrary to earlier fears among clinicians, criminal justice pressure does not threaten treatment effectiveness, and it improves outcomes”
Cost Effectiveness of Drug Treatment
Drug addiction treatment is cost-effective in reducing drug use and its associated health and social costs. Treatment is less expensive than alternatives, such as not treating addicts or simply incarcerating addicts. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $18,400 per person.
According to several conservative estimates, every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft alone. When savings related to health care are included, total savings can exceed costs by a ration of 12 to 1. Major savings to the individual and society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents.

37. Research Findings Multiple studies
The length of time spent in treatment is a reliable predictor of post treatment outcomes and recidivism
Coerced patients tend to stay longer and do as well as volunteers overall
Most substance involved offenders would never seek treatment without pressure from the criminal-justice system
Cost Effectiveness of Drug Treatment
Drug addiction treatment is cost-effective in reducing drug use and its associated health and social costs. Treatment is less expensive than alternatives, such as not treating addicts or simply incarcerating addicts. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $18,400 per person.
According to several conservative estimates, every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft alone. When savings related to health care are included, total savings can exceed costs by a ration of 12 to 1. Major savings to the individual and society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents.

38. General Findings & Recommendations
1. Duration, Setting, Training: fundamental for In-prison TC (ITC) programs
ITC = 9-12 months in a residential (segregated) treatment unit
Staff training is a must
On-going monitoring & evaluation
2. Engagement in transitional aftercare is crucial for effectiveness
3. ITC is most cost effective for high-risk offenders
4. Boot camps & periodic drug-focused counseling have poor outcomes
5. Risk assessments should guide selections for treatment

39. Thank you