An Examination of Drug Treatment Programs Needed to Ensure Successful Re-entry
February 08, 2006
presented by Nora D. Volkow, M.D. Director, National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services
Testimony Before the Subcommittee on Crime, Terrorism, and Homeland Security, Committee on the Judiciary, United States House of Representatives
Statement for the Record
Mr. Chairman and Members of the Committee:
Thank you for inviting the National Institute on Drug Abuse (NIDA), a component of the National Institutes of Health (NIH), an agency of the Department of Health and Human Services (HHS), to participate in this important hearing. As the world's largest supporter of research on drug abuse and addiction, we have learned much about the importance of drug treatment in helping people recover from this devastating disease. Our work extends to all segments of society, including the criminal justice system, where our research shows the pivotal role that drug treatment can play in breaking the vicious cycle of drug abuse and criminal behavior - particularly during the vulnerable period of re-entry into the community. In that regard, securing drug treatment for criminal offenders with drug problems extends beyond the individual to become an issue of public health and safety. I am pleased to be here today to present an overview of what the science has taught us about drug abuse treatment and to highlight effective treatment approaches, targeting intervention opportunities presented by the criminal justice system.
Nearly 7 million adults are involved in the criminal justice system in some way, with more than half of the nearly 2.3 million persons incarcerated having used drugs regularly before their incarceration. However, fewer than 18 percent of these incarcerated offenders received drug treatment either during or after their incarceration.
Among juveniles, too, the problem is serious and growing. In 2002, approximately 1.6 million youth were involved in the juvenile justice system1, with 60 percent of boys and nearly half of detained girls testing positive for drug use.
This is the overwhelming reality - but the Administration is proactively working to change it. At NIDA. efforts to integrate evidence-based interventions into practice - in this case drug treatment - reflect a major tenet of our mission. NIDA's research serves to inform important Administration programs such as the Access to Recovery program of HHS's Substance Abuse and Mental Health Services Administration and the Prisoner Re-entry Program, led by the Department of Labor in partnership with the Departments of Justice and Housing and Urban Development. To achieve this aim, our rich criminal justice research portfolio seeks first to understand justice and treatment systems, and then to improve current practice by developing and testing new intervention models.
One old concept has been proven false, for we now know that "forced abstinence" from drug use during incarceration, if abstinence occurs, does NOT alleviate addiction. Research shows that effective treatment of addiction - a chronic, relapsing disease of the brain, characterized by compulsive behavior - requires addressing underlying issues and causes. Because drug addiction compromises the circuits involved in processing punishment and reward and in exerting control over one's actions, the addicted person will compulsively seek drugs despite the threat of severe punishment (e.g., incarceration, loss of child custody), at the expense of natural rewards, such as that from family and friends, and even when they consciously do not want to do it. Comprehensive drug abuse treatment therefore offers the best alternative for interrupting the vicious drug use - criminal justice cycle once a person gets caught up in it.
Why Treatment Should be Provided to Offenders with Drug Disorders
For Public Health and Safety. We know that drug use increases the likelihood of criminal behavior. In fact, offender drug use is involved in more than half of all violent crimes, in 60-80 percent of child abuse and neglect cases, and, not surprising, in 75 percent of drug dealing and manufacturing cases. Moreover, illicit drug use costs this country about $180 billion a year in crime, productivity loss, health care, incarceration, and drug enforcement2. Uninterrupted, the drug abuse-crime cycle jeopardizes public health and public safety and taxes an already over-burdened criminal justice system. It follows then that reducing drug use can reduce crime and improve not just the health, safety, and well-being of the individual, but of communities and society as a whole.
Treatment Works! NIDA's research findings show unequivocally that drug treatment works and that this is true even for individuals who enter treatment under legal mandate. Interestingly, their outcomes are as favorable as those who enter treatment voluntarily. For example, there is evidence that drug courts - by offering offenders the alternative of community-based treatment instead of incarceration - are promising in reducing criminal behavior and substance abuse.
Effective drug abuse treatment for this population progresses along a continuum that begins in prison and is sustained after release through participation in community treatment programs. Stress is a major risk factor for relapse to drug use and must be taken into account when a substance abuser is making the difficult transition back into society. Therefore, developing a continuum of care is essential to get the best results from drug treatment. To illustrate, in a Delaware Work Release study sponsored by NIDA, those who participated in prison-based treatment followed by aftercare were seven times more likely to be drug free after 3 years than those who received no treatment. Moreover, nearly 70 percent of those in the comprehensive drug treatment group remained arrest-free after 3 years - compared to only 30 percent in the no-treatment group. Studies in California and Texas report similar findings. Drug abuse treatment is an effective intervention for many offenders with substance abuse problems because it can help change attitudes, beliefs, and behavior with regard both to drug use and criminality.
What Constitutes Effective Drug Abuse Treatment?
Effective drug abuse intervention programs are individualized and dynamic, attending and adjusting to the multiple needs of people with co-occurring conditions such as mental illness and other issues, involving both behavioral and pharmacological approaches. Because of the relapsing nature of the disease, there must also be an appreciation of recovery as a long-term process that may require multiple treatment episodes.
The following are some specific aspects of drug abuse treatment that should inform customized treatment strategies.
Behavioral Therapy. Evidence-based interventions include cognitive behavioral therapy to help participants learn positive social and coping skills and to utilize contingency management approaches with them to reinforce positive change. Motivational enhancement through the provision of abstinence-based incentives can increase engagement and retention. A goal of treatment planning should be to match evidence-based interventions to individual needs at each stage of drug treatment.
The Case for Pharmacotherapies. Effective interventions often include pharmacotherapies, or medicines targeting drug abuse and addiction. We at NIDA are hopeful that just as psychotropic medications for conditions like depression or psychosis are starting to be used in criminal justice settings, medications proven effective in treating the disease of addiction can also become part of a comprehensive treatment regimen. Presently, though, despite evidence of their effectiveness, addiction medications are under-utilized and are all but absent within offender populations. For the offender with both mental and substance use disorders, effective use of pharmacotherapies can be instrumental in his or her ability to function successfully in society.
Consideration of Co-morbidities. Comorbid mental disorders are major risk factors for drug abuse and addiction. Children and adolescents with depression, conduct disorder, attention-deficit hyperactivity disorder (ADHD), schizophrenia, or learning disabilities are at much higher risk of abusing drugs than other youth. It is important to adequately assess mental disorders to address them as part of effective drug abuse treatment. Early recognition and treatment of mental illness will help prevent drug abuse, and more effective strategies applied with young people who suffer from co-morbid mental and drug abuse disorders will likely improve their prognosis.
Adolescents and the Juvenile Justice System
We now know that age matters when it comes to drug abuse: exposure to drugs during adolescence or childhood may adversely affect brain development and increase vulnerability to drug effects and addiction. Yet, the inherent plasticity during this period of continued development might also present opportunities for receptivity to interventions that can alter the course of addiction and the course of a young life. Adolescents' involvement with the criminal justice system can provide opportunities to intervene and influence a cycle already in motion. For wherever they enter the system, juveniles often bring with them a number of serious issues - including substance abuse, academic failure, emotional disturbances, family problems, and physical or sexual abuse histories.
The Family-Based Model. Effective treatment of juvenile substance abusers often requires a family-based treatment model that targets family functioning and involvement. Evidence-based interventions supported by NIDA research have shown that these therapies decrease substance abuse and delinquent behavior and are significantly more effective than standard therapies (e.g., peer group therapy) in reducing risk, promoting protective factors, and reducing substance use over the course of treatment..
Family-based models can also help heal the severed bonds between parents and their minor children following incarceration. Sadly, 80 percent of women in state prisons have substance abuse problems, and two-thirds of incarcerated women have minor children. When the bond between a mother and child is broken due to forced separation, a tremendous amount of stress is created, frequently with devastating effects on the child. And because stress can turn the cycle of substance abuse and criminal justice system involvement, these children are placed at increased risk of having substance abuse problems themselves. It is therefore critical to pay attention to the entire family unit and to strive to break this destructive cycle. Through our research on family-based treatment models, NIDA is helping to aid this effort to heal broken bonds and increase family stability.
Disparities Among the African American Population
We are also deeply concerned about the disproportionate impact of drug abuse on African Americans, including those in the criminal justice system. Health disparities among this group are troubling. For while African Americans make up just 13 percent of the U.S. population, they accounted for more than half of the total AIDS cases diagnosed in 2004. HIV/AIDS is now the leading cause of death among all African Americans 25-44 years old, ahead of heart disease, accidents, cancer, and homicide. And again, the higher rate of HIV infection is not due to higher rates of drug use in this population.
To address these disparities, NIDA is encouraging research that focuses on the nexus of drug abuse, HIV/AIDS, and criminal justice involvement among African Americans to understand the risk factors and pathways between drug abuse and criminal justice involvement, to determine the extent to which criminal justice involvement and HIV/AIDS risk are interlinked or compounded by drug abuse and addiction, and to develop culturally sensitive prevention and treatment programs for drug abuse and HIV/AIDS.
Continuing to Find Solutions through Research and Collaboration
Treatment for drug addiction works, but this knowledge by itself is not sufficient. Implementing drug abuse treatment into any non-treatment setting is challenging. In the criminal justice system, the translation of science to practice is further compounded by the need to merge two very different cultures; public health that aims to treat the individual and public safety that aims to protect the community. Thus a priority for NIDA has been to develop research to help integrate findings and effective treatment practices from treatment research into criminal justice settings. NIDA supports a robust research portfolio examining the integration of drug treatment into the criminal justice system, including our comprehensive Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) initiative. CJ-DATS is a multi-site set of research studies, in collaboration with Federal, state, and local criminal justice partners, designed to improve outcomes for offenders with substance use disorders by improving the integration of drug abuse treatment with other public health and public safety systems. To successfully re-integrate offenders, we must apply our research results and leverage fruitful collaborations at all levels. Through this comprehensive initiative, we are sponsoring a range of research, looking at everything from adolescents with drug problems to the importance of building interagency cooperation and collaboration.
NIDA research efforts are informing systems everywhere, helping to bridge the gaps between what we know works and what is actually taking place in communities. This includes an initiative to educate judges on the science of drug addiction and treatment to help them better understand and consider the consequences of drug use on the brain and behavior. Reaching out to judges, working with drug courts, optimizing our use of data, and sponsoring a range of research - all are aimed at improving drug abuse services and outcomes for criminal justice populations. Outreach to pivotal members of society helps to educate them about substance abuse disorders and to bring about a more integrated and compassionate system that addresses the reality of co-occurring diseases and other drug abuse consequences.
In closing, NIH findings indicate that by integrating drug abuse treatment into criminal justice settings in a number of different ways - including as a condition of probation, via drug courts, in prison followed by community-based aftercare, and under parole or probation supervision at re-entry - we can take optimal advantage of both systems. The essential idea is to understand the necessity of treatment, particularly during the transition back to community. Just because a person has been kept from using drugs does not mean they have gained the necessary skills to build a successful drug-free life in the community. Drug addiction may re-emerge following release from incarceration, at which time continued care is not only a necessity for the individual's recovery, it becomes a public health and safety issue for us all.
Thank you for allowing me to share this information with you. I will be happy to answer any questions you may have.
1 National estimates of juvenile court processing for delinquency cases, 2002 - Office of Juvenile Justice and Deliquency Prevention, Office of Justice.
2The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004.
Office of National Drug Control Policy (2004). The Economic Costs of Drug Abuse in the United States, 1992-2002. Washington, DC: Executive Office of the President (Publication No. 207303).