Regardless of their impetus for participating in drug treatment—internal drive or external pressure—men had similar outcomes in the long term.

A group of men who completed court-ordered treatment for alcohol and drug problems reported lower intrinsic motivation at the beginning of treatment, but, 5 years later, reported the same rates of abstinence, employment, and rearrest as peers who sought help on their own. The findings from a NIDA- and Department of Veterans Affairs (VA) Health Services Research and Development Service-supported analysis of data on treatment outcomes affirm the results of shorter term studies that have shown similar therapeutic outcomes for voluntary and legally mandated patients. The new study also included an important, but largely unstudied, comparison group: people who had been in court, but were not mandated to enter treatment.

Mandated Treatment Works – Graphic
Click to enlarge

“Once in a therapeutic environment, mandated patients seem to reflect on their situation and accept the need for treatment,” says Dr. John Kelly, lead investigator of the study, conducted at the VA Palo Alto Healthcare System and Stanford University School of Medicine. “Our findings suggest that people can learn from the ‘teachable moment’ offered by a judicial mandate, even though the initial motivation for treatment is external. Judicial mandates may provide an opportunity for offenders to gain access to and benefit from needed treatment.”

Drs. Kelly, Rudolf Moos, and John Finney analyzed data, gathered by Drs. Moos and Finney and Dr. Paige Ouimette, on 2,095 men who were treated for alcohol and drug problems in 15 VA programs and followed for 5 years. About half the men (54 percent) were addicted to drugs; 80 percent were dependent on alcohol. Most (82 percent) had no criminal justice system involvement and entered treatment voluntarily (No-JSI); 7 percent were on probation or parole and were required to participate in treatment by order of a court or criminal justice official (JSI-M); 11 percent had been before a court, but not mandated to treatment (JSI). About half (49 percent) of the participants were African-American; 45 percent were White; and the remaining 6 percent were Hispanic, Native American, or Asian. Most (74 percent) were unemployed when they started treatment.

Arrest Rate Falls, Employment Rate Rises After Treatment – Graphic

The men completed 21 or 28 days of residential treatment, which took one of three therapeutic approaches: group psychotherapy and individual activities based on the 12-step approach, cognitive-behavioral therapy, or a mix of both. When they completed treatment, the men were urged to participate in outpatient programs and self-help activities.

At the beginning of treatment, each man completed a questionnaire that assessed characteristics considered important to recovery: motivation, self-efficacy, coping skills, 12-step participation, psychiatric symptoms, history of negative consequences of alcohol and drug problems, number of previous treatment episodes, and whether they considered themselves to be addicted. They also reported any prior year arrests and any judicial mandate for treatment. At the end of the treatment program, participants repeated the assessment and reported their perceptions of the therapeutic experience. Most also received a self-administered assessment in the mail at the 1- and 5-year follow up points, with the rest contacted by telephone or in person. Research assistants telephoned patients when necessary to complete or clarify information.

In the initial assessment, men in the JSI-M group reported experiencing fewer negative consequences of alcohol and drug consumption, fewer symptoms of depression and anxiety, and less desire to abstain than No-JSI or JSI participants. Fewer mandated (45 percent) than voluntary patients (58 percent) met the standard clinical criteria for drug addiction. Voluntary patients more frequently recognized their addictions, connected them to other problems, and reported a readiness to change.
REARREST RATES FALL , REMAIN LOW

At the end of treatment, all three groups of patients demonstrated enhanced coping skills and expressed more confidence that they could resist alcohol or drugs in high-risk situations. Symptoms of psychological distress improved for participants in all groups. At the 1-year followup, larger proportions of JSI-M participants reported abstinence, successful moderation in their use of alcohol, and freedom from drug-related consequences (for example, missing work or fighting with a family member because of drugs) than JSI and No-JSI participants (see chart). Arrest rates for the two JSI groups fell dramatically after treatment. Mandated patients showed arrest rates similar to those of their No-JSI peers (about 20 percent) and lower than those of their JSI peers (32 percent) at the 1-year followup. Five years after treatment, most outcomes among the three groups did not differ (see chart).

The investigators believe that, in addition to the other positive effects of treatment, mandated patients may acquire motivation to change. “The high level of camaraderie in VA residential treatment, where these individuals interacted with self-motivated peers, may have contributed to a shift in attitude,” says Dr. Kelly.

The implications of Dr. Kelly’s findings go beyond the criminal justice population, says Dr. Beverly Pringle, formerly of NIDA’s Division of Epidemiology, Services and Prevention Research. “The idea that patients must want to change seems to permeate current practice, but the drug abuse treatment field may need to reexamine its definition of motivation,” she says. Clinical measures of motivation mostly indicate intrinsic drive to change, but extrinsic motivators as well as rewards can increase treatment entry and improve long-term outcomes.

SOURCE

Kelly, J.F.; Finney, J.W.; and Moos, R. Substance use disorder patients who are mandated to treatment: Characteristics, treatment process, and 1- and 5-year outcomes. Journal of Substance Abuse Treatment 28(3):213-223, 2005. [Abstract]

Posted August 27, 2009

Original article by Lori Whitten, NIDA NOTES Staff Writer

From:

http://www.nida.nih.gov/NIDA_notes/NNvol20N6/Court.html

A solid body of research has shown that raising the taxes and price of alcohol leads to a decrease in consumption by youth, and reduces alcohol-related deaths and illness. Increasing the total price of alcohol has also been shown to decrease drinking and driving among all age groups.

The level of alcohol taxes and the rules for serving alcohol make a difference in underage and high-risk drinking. The taxes on beer, the drink of choice for the vast majority of underage drinkers, vary from $.02 per gallon in Wyoming to $1.07 per gallon in Alaska.

The five states with the highest beer taxes have significantly lower rates of teen binge drinking than the states with the lowest taxes.

Although raising alcohol taxes has proven to be effective, it is rarely used by states. According to the Center for Science in the Public Interest, most states’ alcohol taxes have not been raised in decades. With the effects of inflation taken into account, the current value of most state alcohol taxes is very low. For example, in California alcohol taxes have fallen 49 percent in inflation-adjusted dollars since the last increase in 1991, according to the Marin Institute.

Some states that have raised alcohol taxes dedicate the proceeds to public health programs, including substance use treatment programs, prevention campaigns, and other public education efforts.

Posted August 21, 2009

From:

http://www.jointogether.org/keyissues/taxes/alcohol-taxes-readmore.html

Many crimes are rooted in alcohol and drug addictions. Yet, too often, nonviolent offenders are simply sent to jail and not treated for the addiction problems that led them there.

When we release individuals with untreated addictions back into communities, they usually return to their friends, their habits, and their crimes.

More than half of those in the criminal justice system who complete treatment programs and participate in aftercare do not commit new crimes. Most prisoners who serve mandatory sentences, but get no treatment, commit new crimes and start using drugs or alcohol soon after release.

Drug courts are designed to help people with addictions who are facing criminal charges get through treatment and recover from their addiction. Their basic premise is to leverage the authority of the criminal-justice system to keep defendants in treatment, recognizing that the recovery process may well include lapses and relapses, but the longer a person stays in treatment, the greater chance he/she has for sustained recovery.

While the participant is enrolled in the drug court, final disposition of the criminal charges is suspended and — depending upon the participant’s ultimate success or failure — may be dismissed or otherwise changed.

It is widely recognized that drug courts result in varying degrees of reduced recidivism and cost savings for the criminal-justice system, and are most effective with high-risk, defendants with a long history of addictions.

In addition, drug courts produce many other societal benefits, including increased coordination and delivery of public health and mental health services, vocational training and job placement which increase the likelihood of sustained recovery.

Posted July, 29, 2009

From:

http://www.jointogether.org/keyissues/incarceration/treatment-vs-incarceration-readmore.html

Vol. 22, No. 2 (December 2008)

Low-risk offenders do equally well with and without regularly scheduled court appearances.

Adjusting the frequency of mandatory drug court monitoring sessions according to offenders’ risk of lapsing into criminal activity, including drug abuse, can enhance program success rates while conserving resources, according to a recent NIDA-supported study. Researchers found that high-risk drug offenders—those with antisocial personality disorder or prior histories of drug abuse treatment—achieved better outcomes when ordered to attend a judicial status hearing every 2 weeks, rather than at the 4- to 6-week intervals that drug courts typically impose. In contrast, lower risk offenders’ treatment success was not compromised when courts required them to appear only if they committed serious or repeated infractions of program rules.

“Our research represents a first step in tailoring adaptive supervision interventions to drug-abusing offenders,” says Dr. Douglas Marlowe of the Treatment Research Institute and the University of Pennsylvania, Philadelphia. Dr. Marlowe, Dr. David Festinger, and colleagues conducted the study as part of a broader effort to improve the efficacy and cost-effectiveness of drug court interventions by identifying which components of the model work best for various groups of drug offenders.
CUSTOM TAILORING COURT SUPERVISION

Drug courts are intensive, community-based programs that substitute judicially supervised treatment and case management for prosecution or incarceration. Defendants who complete the drug court program and remain arrest-free for 6 months after graduation have their charges dropped and their arrest records expunged. The judicial status hearing, during which a judge rewards achievements and punishes infractions with sanctions that progressively increase in severity, is among the costliest components of drug court programs.

Drs. Marlowe and Festinger designed their study to answer two questions: Would high-risk drug offenders benefit from hearings held more frequently than usual, and would low-risk drug offenders still experience treatment gains if their hearings were held less often than the norm? The researchers had reason to predict the answers would be “yes” to both questions because of observations they had made in a previous study. That study’s design and small participant population, however, had not allowed definitive findings on these issues.

Participants in the new study were recruited from a misdemeanor drug court in Wilmington, Delaware. Among the drugs that they reported abusing at the time of their assignment to drug court, cannabis was the most common, followed by alcohol, stimulants or cocaine, opiates, sedatives, and hallucinogens. Each participant was assigned to a clinical case manager who coordinated treatment referrals, submitted monthly reports to the judge, and appeared at the participant’s judicial status hearings.

Ninety-two of the 279 participants were classified as high-risk because they had an antisocial personality disorder or had relapsed after previous treatment for drug abuse. Within the high-risk group, 42 were assigned to report to drug court biweekly, and 50 reported every 4 to 6 weeks. In the low-risk group, 92 were put on the 4- to 6-week schedule, and 95 were told to appear in court only after serious rule infringements—most commonly failure to attend counseling appointments or provide drug-free urine specimens.

Within a year, 75 percent of the high-risk participants who attended hearings every 2 weeks graduated from the program, compared with 56 percent of high-risk participants assigned to follow the standard schedule. The former group also provided more drug-free urine samples and reported less alcohol intoxication (see table), as well as less criminal activity.

Among the low-risk participants, outcomes were similar regardless of how often hearings took place. For example, program graduation rates were 75 percent among the offenders who appeared in drug court every 4 to 6 weeks and 72 percent among those who appeared in court only when a problem arose, averaging less than two hearings during the study year. “Reducing the number of court hearings for these individuals could permit a program to conserve costly resources without sacrificing client outcomes or public safety,” Dr. Marlowe says.

DRUG COURT FREQUENCY CAN AFFECT TREATMENT OUTCOME Participants who were considered high-risk provided more drug-free urine samples when they were required to appear in drug court every 2 weeks (gray-green) rather than according to the standard schedule of every 4 to 6 weeks (gold). In contrast, participants who were at lower risk of relapse did comparably well on the standard schedule (blue) and when court appearances were scheduled only in response to treatment-rule infractions (red).
DRUG COURT FREQUENCY CAN AFFECT TREATMENT OUTCOME – line graph. Week in Drug Court in relation to the percentage of drug-free urine samples. See previous text for additional information. Source: Marlowe, D.B., et al. Matching judicial supervision to clients’ risk status in drug court. Crime and Delinquency 52, 52-76, 2006.
ROOM FOR IMPROVEMENT

“Adjusting the frequency of court hearings to participants’ risk status will make a difference, but there still will be considerable room for improvement in drug court outcomes,” Dr. Marlowe notes. For high-risk participants who continue to have drug or alcohol problems, the program needs further tailoring, he explains. Those who are not compliant with the program—for example, those who fail to attend counseling sessions or to deliver urine specimens—might respond to more frequent judicial supervision or to sanctions such as home curfews. In contrast, increasing the scope of treatment services might be more effective with high-risk participants who are compliant with program rules but fail to achieve abstinence because of the severity of their drug addiction or a related difficulty, such as a co-occurring mental disorder, family problems, unemployment, or homelessness. Dr. Marlowe notes that even low-risk drug offenders need more effective interventions.

“Dr. Marlowe is helping us fill our knowledge gap about drug courts by identifying the elements that make them effective,” says Dr. Redonna K. Chandler, chief of NIDA’s Services Research Branch. “We may eventually be able to match criminal justice supervision and treatment services to the needs of individual offenders, making drug courts both more effective and more costeffective.” Dr. Marlowe says, “We hope that drug court programs eventually become flexible enough to allow participants doing poorly to be switched to a more intensive track and allow those doing well in an intensive program to move to a lower supervision regimen.”

SOURCE

Marlowe, D.B., et al. Adapting judicial supervision to the risk level of drug offenders: Discharge and 6-month outcomes from a prospective matching study. Drug and Alcohol Dependence 88(Suppl. 2):S4-13, 2007. [Abstract]

Drug Courts Add Value

Studies have shown that drug courts significantly increase the time drug abusers stay in treatment. An average of 60 percent of drug court clients complete at least 12 months of treatment, whereas only 10 percent of probationers and parolees typically remain for a year in community-based drug treatment programs, says Dr. Douglas Marlowe of the University of Pennsylvania, summarizing several research reports. A 1998 review of 13 drug court studies found that drug court clients abuse substances less frequently than comparable probationers (10 percent of urine tests were positive, compared with 31 percent). What’s more, drug courts reduce re-arrest rates by 8 to 24 percent, according to five meta-analyses in 2005 and 2006. Although drug courts tend to be more expensive than other programs, the reduction in recidivism decreases later judicial costs and financial loss to crime victims, according to a U.S. Government Accountability Office report published in 2005.* It cited net predicted benefits of $1,000 to $15,000 per participant.

*Adult Drug Court: Evidence Indicates Recidivism Reduction and Mixed Results for Other Outcomes, GAO-05-219, February 2005.

By:  NIDA Notes Staff

Posted July, 28 2009

From:

http://www.nida.nih.gov/NIDA_notes/NNVol22N2/HighRisk.html#insert

More than 25 states as well as Washington, D.C., are exploring alternative-sentencing methods and revamping probation and parole programs to cut the rising cost of keeping inmates in prison, the Washington Post reported July 13.

Governors and legislatures are particularly investing in drug courts, which offer low-level drug offenders treatment and weekly meetings with a judge as a way of keeping them from serving prison time.  States are also turning to the 500 courts nationwide designated for people arrested for driving under the influence, so that offenders will be sent to treatment programs and undergo random tests instead of being sent to jail.

Probation time in some states is also being reduced, as is the number of people sentenced to prison for minor violations such as failing to appear for scheduled court appointments.

“The economy is bringing a lot of states to the table,” said Adam Gelb, who directs the Pew Center on the States Public Safety Performance Project. “The research has pointed to a path for them to [provide] more public safety at less cost.”

The average cost to keep an inmate in prison is $79 per day, whereas the daily cost to monitor that person through probation or parole is $3.50, according to the Pew Center.

In an effort to reduce its prison spending, New York has eased mandatory-minimum drug laws enacted during the Rockefeller era, and Virginia is currently seeking sentencing alternatives for its nonviolent offenders.  President Barack Obama has requested more than $200 million from Congress for prisoner-reentry programs.

Posted July 24, 2009

From:

http://www.jointogether.org/news/headlines/inthenews/2009/states-exploring-drug-courts.html?log-event=sp2f-view-item&nid=53970334

1.      Why do people involved in the criminal justice system continue abusing drugs?

The answer to this perplexing question spans basic neurobiological, psychological, social, and environmental factors.

The repeated use of addictive drugs eventually changes how the brain functions. Resulting brain changes, which accompany the transition from voluntary to compulsive drug use, affect the brain’s natural inhibition and reward centers, causing the addict to use drugs in spite of the adverse health, social, and legal consequences (Volkow, Fowler, Wang, et al., 1993; Volkow, Hitzemann, Wang, et al., 1992; Volkow and Li, 2004). Craving for drugs may be triggered by contact with the people, places, and things associated with prior drug use, as well as by stress. Forced abstinence without treatment does not cure addiction. Abstinent individuals must still learn how to avoid relapse, including those who have been incarcerated and may have been abstinent for a long period of time.
Addictive Drugs Can Cause Long-Lasting Changes in the Brain
Addictive Drugs Can Cause Long-Lasting Changes in the Brain
PET scans showing glucose metabolism in healthy brain and cocaine-addicted brains. Even after 100 days of abstinence, glucose metabolism has not returned to normal levels.

Potential risk factors for released offenders include pressures from peers and even family members to return to drug use and a criminal lifestyle. Tensions of daily life—violent associates, few opportunities for legitimate employment, lack of safe housing, even the need to comply with correctional supervision conditions—can also create stressful situations that can precipitate a relapse to drug use.

Research on how the brain is affected by drug abuse promises to help us learn much more about the mechanics of drug-induced brain changes and their relationship to addiction. Research also reveals that with effective drug abuse treatment, individuals can overcome persistent drug effects and lead healthy, productive lives.

2.     Why should drug abuse treatment be provided to offenders?

The case for treating drug abusing offenders is compelling. Drug abuse treatment improves outcomes for drug abusing offenders and has beneficial effects for public health and safety. Effective treatment decreases future drug use and drug-related criminal behavior, can improve the individual’s relationships with his or her family, and may improve prospects for employment.

Outcomes for substance abusing individuals can be improved when criminal justice personnel work in tandem with treatment providers on drug abuse treatment needs and supervision requirements. Treatment needs that can be assessed after arrest include substance abuse severity, mental health problems, and physical health. Defense attorneys, prosecutors, and judges need to work together during the prosecution and sentencing phases of the criminal justice process to determine suitable treatment programs that meet the offender’s needs. Through drug courts, diversion programs, pretrial release programs conditional on treatment, and conditional probation with sanctions, the offender can participate in community-based drug abuse treatment while under criminal justice supervision. In some instances, the judge may recommend that the offender participate in treatment while serving jail or prison time or require it as part of continuing correctional supervision postrelease.

3.     How effective is drug abuse treatment for criminal justice-involved individuals?

Treatment is an effective intervention for drug abusers, including those who are involved with the criminal justice system. However, the effectiveness of drug treatment depends on both the individual and the program, and on whether interventions and treatment services are available and appropriate for the individual’s needs. To amend attitudes, beliefs, and behaviors that support drug use, the drug abuser must engage in a therapeutic change process. Longitudinal outcome studies find that those who participate in community-based drug abuse treatment programs commit fewer crimes than those who do not participate.

4.     Are all drug abusers in the criminal justice system good candidates for treatment?

A history of drug use does not in itself indicate the need for drug abuse treatment. Offenders who meet drug dependence criteria should be given higher priority for treatment than those who do not. Less intensive interventions, such as drug abuse education or self-help participation, may be appropriate for those not meeting criteria for drug dependence. Services such as family-based interventions for juveniles, psychiatric treatment, or cognitive-behavioral “criminal thinking” interventions may be a higher priority for some offenders, and individuals with mental health problems may require specialized services (see FAQ Nos. 6 and 12).
Outcomes can be improved when criminal justice personnel work in tandem with treatment providers.

Low motivation to participate in treatment or to end drug abuse should not preclude access to treatment if other criteria are met. Motivational enhancement interventions may be useful in these cases. Examples include motivational interviewing and contingency management techniques, which often provide tangible rewards in exchange for meeting program goals. Legal pressure that encourages abstinence and treatment participation may also help these individuals by improving retention and catalyzing longer treatment stays.

Drug abuse treatment is also effective for offenders who have a history of serious and violent crime, particularly if they receive intensive, targeted services. The economic benefits in avoided crime and costs to crime victims (e.g., medical costs, lost earnings, and loss in quality of life) may be substantial for these high-risk offenders. Treating them requires a high degree of coordination between drug abuse treatment providers and criminal justice personnel to ensure that treatment and criminogenic needs are appropriately addressed.

5.     Is legally mandated treatment effective?

Legal pressure can increase treatment attendance and improve retention.

Often the criminal justice system can apply legal pressure to encourage offenders to participate in drug abuse treatment; or treatment can be mandated, for example, through a drug court or as a condition of pretrial release, probation, or parole. A large percentage of those admitted to drug abuse treatment cite legal pressure as an important reason for seeking treatment. Most studies suggest that outcomes for those who are legally pressured to enter treatment are as good as or better than outcomes for those who entered treatment without legal pressure. Those under legal pressure also tend to have higher attendance rates and to remain in treatment for longer periods, which can also have a positive impact on treatment outcomes.

6.     Are relapse risk factors different in offender populations? How should drug abuse treatment deal with these risk factors?

Often, drug abusing offenders have problems in other areas. Examples include family difficulties, limited social skills, educational and employment problems, mental health disorders, infectious diseases, and other medical problems. Treatment should take these problems into account, because they can increase the risk of drug relapse and criminal recidivism if left unaddressed.

Stress is often a contributing factor to relapse, and offenders who are re-entering society face many challenges and stressors, including reuniting with family members, securing housing, and complying with criminal justice supervision requirements. Even the many daily decisions that most people face can be stressful for those recently released from a highly controlled prison environment.
Returning to environments associated with drug use may trigger cravings and cause a relapse.

Other threats to recovery include a loss of support from family or friends, which incarcerated people may experience. Drug abusers returning to the community may also encounter family, friends, or associates still involved in drugs or crime and be enticed to resume a criminal and drug using lifestyle. Returning to environments or activities associated with prior drug use may trigger strong cravings and cause a relapse. A coordinated approach by treatment and criminal justice staff provides the best way to detect and intervene with these and other threats to recovery. In any case, treatment is needed to provide the skills necessary to avoid or cope with situations that could lead to relapse.

Treatment staff should identify the offender’s unique relapse risk factors and periodically re-assess and modify the treatment plan as needed. Generally, continuing or re-emerging drug use during treatment requires a clinical response—either increasing the “dosage” or level of treatment, or changing the treatment intervention.

7.     What treatment and other health services should be provided to drug abusers involved with the criminal justice system?

One of the goals of treatment planning is to match evidence-based interventions to individual needs at each stage of drug treatment. Over time, various combinations of treatment services may be required. Evidence-based interventions include cognitive-behavioral therapy to help participants learn positive social and coping skills, contingency management approaches to reinforce positive behavioral change, and motivational enhancement to increase treatment engagement and retention. In those addicted to opioid drugs, agonist/partial agonist medications can also help normalize brain function, and antagonist medications can facilitate abstinence. For juvenile offenders, treatments that involve the family and other aspects of the drug abuser’s environment have established efficacy.

Drug abuse treatment plans for incarcerated offenders can anticipate their eventual re-entry into the community by incorporating relevant transition plans and services. Drug abusers often have mental and physical health, family counseling, parenting, educational, and vocational needs, so medical, psychological, and social services are often crucial components of successful treatment. Case management approaches can be used to provide assistance in obtaining drug abuse treatment and community services.

Posted July, 23, 2009

From:  NIDA Information for Medical and Health Professionals

http://www.drugabuse.gov/PODAT_CJ/faqs/faqs1.html#1