1 The Need for a Substantial Increase in Funding for Addiction Treatment How big should the + sign be? The shortage of addiction services in NZ The Law Commission released its Issues Paper on liquor legislation last month. Among many other matters, the Commission s report highlights the link between excessive alcohol consumption and crime, especially violent crime. In a press statement accompanying the release of the report, Sir Geoffrey Palmer said: District Court judges estimated that up to 80% of offenders have drug and alcohol problems but there are insufficient programmes to treat all the offenders who need it (1). According to the Corrections Department, the figure is closer to 90% (2). Whichever way you look at it, the impact of alcohol and drugs on crime is enormous. Youth Court Judge, Jane McMeeken describes the impact on young people as absolutely astronomical (3). The Commission suggests that a lack of programmes for offenders with substance abuse problems means current treatment facilities are struggling to cope. It states: During the course of the Law Commission s initial inquiries, we have become concerned at the lack of policies, facilities and programmes around the country in relation to assessment and treatment for people with alcohol problems. The District Court Judges have made clear to the Law Commission their grave concerns about the absence of assessment facilities and programmes to which they can refer people who appear in front of them (4). While the adequacy of treatment services is not in itself a legal matter, it is a key problemlimitation measure that cannot be divorced from any discussion about reducing alcohol-related harm. Gaps in treatment availability have been identified as a problem for people with alcoholuse disorders coming into contact with the courts, corrections system, social welfare system, primary care and emergency department services (5). The report offers a number of suggestions on the kind of treatment programmes that might help and then states: Most of the policy suggestions to improve treatment would require additional government investment, possibly from multiple sectors (6). However, the Commission makes no comment on how big that investment should be. NCAT recommends 100% increase in funding Judges and the Law Commission are not the only groups concerned about a lack of treatment options. The National Committee for Addiction Treatment, which represents the views of the addiction treatment sector, is also concerned. One of NCAT s most recent position papers states that at current levels of funding, less than 25,000 New Zealanders are able to access substance abuse treatment each year (7). The problem has been compounded by the closure of over ten residential treatment centres in the last few years, mainly because of a lack of government funding (8). This includes the closure of Queen Mary hospital at Hanmer, which used to have an international reputation for treating alcoholics. In its paper, NCAT recommends that funding for addiction at least needs to be doubled (9). Presumably this would allow up to 50,000 people to access treatment.
2 How realistic is NCAT s recommendation? In many respects this is a strange recommendation because NCAT claims there are actually 160,000 New Zealanders who need treatment for substance abuse (10) and even this is probably a conservative estimate. The BERL report on harmful alcohol and drug use says there are approximately 667,000 Kiwis who engage in harmful levels of alcohol and drug use each year (11). Even this figure may be on the low side. The Alcohol Advisory Council says there are 760,000 Kiwis who binge drink regularly, 125,000 of them under the age of seventeen (12). ALAC s figures don t even begin to take into account those who have problems with cannabis, methamphetamine and other drugs. The figures provided above describe the potential number of people in the wider community who abuse alcohol and drugs - although what level of intervention or treatment is required for such large numbers is less obvious. The statistics for those who end up in the Justice system needing treatment for substance abuse are more specific. Justice Department statistics show that 95,440 people were convicted last year for a huge variety of offences (13). Since we know that at least 80% of these offenders were affected by alcohol and drugs at the time of their crimes, that s well over 76,000 people in the Justice system alone that need some kind of intervention. However, out of the 76,000 who need help, last year judges were able to order only 6,321 (just under 7% of the total) to attend a substance abuse program as part of their sentence (14). These figures confirm the comments made by judges that there is a lack of treatment facilities available. The figures also suggest that doubling the funding for addiction treatment will not be enough to enable all those in the Justice system who need help to access treatment, let alone the thousands of alcoholics, addicts and substance abusers in the wider community. The roadblock at the intersection of justice and health A lack of readily available treatment programmes inevitably makes the task of recovery a great deal more difficult than it needs to be for the individuals and their families suffering from addictions. However, it has added repercussions for substance abusers who end up in Court. Without some kind of intervention, many if not most offenders who are given community-based sentences continue to drink, continue to take drugs and continue to commit crime. The frequency of repeat drink driving in New Zealand is a typical example. One third of those convicted for drink driving each year are repeat offenders (15). Up to 75% of drink drivers are on their 3 rd, 4 th or 5 th conviction before judges even order an alcohol and drug assessment (16). This is partly because there are so few alcohol and drug counsellors available to the Courts to screen and assess offenders - in addition to a shortage of treatment programmes. Out of 63 Courts in New Zealand, only half a dozen have an alcohol and drug counsellor permanently positioned in Court to assist judges determine which offenders need what kind of treatment or education programme (17). The lack of treatment programmes combined with a shortage of trained personnel in the Courts has created a massive roadblock at the intersection of the justice and health systems. This roadblock is so wide, only a small percentage of offenders get past it (18). Most turn back and reoffend and this is one of the underlying causes of New Zealand s high rates of recidivism and re-imprisonment (19). 2
3 The financial commitment required to remove the roadblock Although there is a lack of addiction treatment available in the community, over the last few years there has been a significant increase in addiction treatment facilities in prison. In 2005, the Ombudsman reported that only 174 inmates were able to attend residential treatment in prison (20). Since then, the Labour Government increased the number of places available in Drug Treatment Units (DTUs) to approximately 500. The National Government has committed further funding to the Corrections Department to double this figure again so that eventually up to 1040 inmates a year may receive treatment. Going from 174 places to 1040 represents an increase of nearly 600%. While this may be good news for offenders who end up in prison, it doesn t help the vast majority of people with substance abuse problems in the community nor does it help judges trying to get offenders into treatment on community based sentences. The reality is that if judges suddenly ordered 600% more offenders to attend AOD treatment programmes in the community, treatment services which are already struggling, would be totally overwhelmed. However, if funding for addiction services in the community was also increased by 600%, that would allow AOD counsellors to be positioned in every District Court in the country and also allow 160,000 people to access treatment a year about the same number that NCAT says need help. The effectiveness of alcohol and drug treatment The underlying assumption behind any recommendation that funding for substance abuse treatment should be increased is that such programmes will actually make a difference which begs the question, how big a difference do these programmes make? The Corrections Department estimates that one adult male lifetime offender generates $3 million in cost to the taxpayer and to victims (21). The Department says: If a rehabilitative programme could reform just one person in the high-risk range of re-offending, that success would be worth at least $500,000 of benefit in the next five years alone - in the form of avoided costs to Police, Courts, Corrections and victims (22). Clearly, there are significant economic benefits to the taxpayer as well as increased safety for the community if rehabilitation programmes are successful. However, not all rehabilitation programmes are created equal. The Corrections Department s evaluation of the Drug Treatment Units shows that drug treatment in prison reduces the risk of re-offending more effectively than any of the Department s other rehabilitation programmes (23). In saying that, the DTU outcomes are very moderate. They reduce an inmate s risk of offending only by 13% (24). However, community-based residential treatment for substance abuse has been found to reduce re-offending by high-risk, multiple offenders by between 33% (25) and 43% (26). In other words, residential treatment in the community is more than three times more effective than the most effective rehabilitation programme offered by the Corrections department in prison. 3
4 There are a number of factors which contribute to the relatively poor success rate of prison programmes. The main drawback is a lack of re-integrative support once the treated inmate is released into the community. New Zealand relies mostly on unpaid volunteers to provide such support (27). The Corrections Department itself provides only three half-way houses with a total of about 35 beds to assist over 5,000 inmates released from prison each year (28). International research on reintegration indicates that the best outcomes are achieved when inmates attend rehabilitation programs in prison and then attend follow-up programmes on release (29). This approach reinforces prison based learning, provides a supportive reintegration process and significantly reduces the risk of reoffending. Cost benefit analysis (value for money) Variations in effectiveness lead to significant differences in the cost benefit ratios between prison-based treatment and community-based treatment. International research into the economic benefits to the community indicates that the financial gains which derive from treatment in prison are as little as $2 to $3 for every dollar spent (30). However, for every dollar spent on treatment programmes based in the community, there is a $4 to $7 benefit, most of which is derived from reductions in the cost of alcohol and drug related crime (31). The cost-benefit ratios of community-based programs are derived from analysis of a variety of different types of outpatient programmes including individual counselling, intensive day programmes and residential programmes. However, residential treatment programmes in particular have been found to be twice as effective as most other outpatient programmes and frequently yield financial benefits to the community of up to $12 per dollar spent (32). Some studies of long term residential treatment programmes even show gains of up to $23 (33). Fences are cheaper than hospitals From a cost-benefit perspective, it is not the least bit surprising that prison based programmes are less financially viable than community-based rehabilitation programs. In addition to relatively poor treatment outcomes (compared with community-based treatment), there are so many overheads in the prison environment that the cost of providing rehabilitation programmes in prison is substantially higher than the cost of providing similar programmes in the community. There is a simple analogy which applies to this situation. Providing substance abuse programmes in the community is like building fences at the top of the cliff. Providing similar programmes in a prison is like building an expensive hospital at the bottom of the cliff. Even when the inmate gets out of hospital, they still have to get back to the top of the cliff. This is the process of reintegration and currently there are many pitfalls along that path. In New Zealand, going in and out of prison has become a vicious cycle for up to 50% of offenders. The reality is that this cycle is maintained and exacerbated by the lack of funding for communitybased rehabilitation and an absolutely minimal investment in supported accommodation for inmates trying to re-integrate. 4
5 How big should the + sign be? New Zealand now spends around $100 million a year on addiction services (34). Taking the most conservative estimate of $4 of potential benefit for every dollar spent, if Government increased funding by 600% that would lead to around $2.4 billion in reduced costs to society ($600 million multiplied by 4). If the bulk of the money was channeled into residential programmes in the community where the potential benefit is twice as high, the savings to the taxpayer could be in the vicinity of $4.8 billion. In other words, for a $600 million investment there would be somewhere between $2.4 billion and $4.8 billion in economic benefit - mainly in reduced costs related to crime. Such an investment not only makes sound economic sense, by reducing crime it would also make a massive contribution to community safety. Conclusion Piecemeal solutions to addressing alcohol and drug-related harm in society are almost guaranteed to fail. All of the 5+ solution recommendations need to be implemented to make a difference. Unless government is also willing to make a substantial increase in funding for addiction services in the community, not much is likely to change. This may require up to a 600% increase in funding for treatment services in the community, including more supported accommodation for inmates coming out of prison - similar to the commitment that has already been made to provide alcohol and drug treatment within in the prison system. However, even the 100% increase recommended by NCAT would be a good start. Roger Brooking, Wellington, August,
6 Footnotes 1) NZ Law Commission Alcohol in our Lives, An Issues Paper on the Reform of New Zealand s Liquor Laws, July 2009, Wellington. 2) About Time, Report by the Department of Corrections, Wellington, 2001, p 50. 3) Ibid, Alcohol in our Lives, p ) Ibid, Alcohol in our Lives, Para ) Ibid, Alcohol in our Lives, Para ) Ibid, Alcohol in our Lives, Para ) Investing in Addiction Treatment, A Resource for Funders, Planners, and Policy Makers, NCAT 2008: 8) Addicts dying on waiting lists, NZ Herald, Nov 10, ) NCAT Press release: Double Addiction Treatment Services, Nov, ) Ibid, Investing in Addiction Treatment. 11) Adrian Slack et al, Costs of Harmful Alcohol and Drug Use, BERL, Wellington, March 2009, p31. 12) Alcohol Facts, ALAC website: 13) An Overview of Conviction and Sentencing Statistics in New Zealand 1999 to 2008, July 2009, Justice Department website. 14) Obtained under the Official Information Act from Katrina Casey, General Manager Probation Service, Corrections Dept, in a personal letter dated July 20, ) Figures supplied by Ministry of Justice. 16) Obtained under the Official Information Act from Lianne Egli, Acting General Manager, District Court in personal letter, February 1, ) Judges get expert help in drug cases: NZ Herald June 6, ) How New Zealand encourages repeat drink driving, Scoop January 27, ) Around 50% of prison inmates are re-imprisoned within 4 years of release. Source Department of Corrections website. 20) Ombudsmen s Investigation of the Department of Corrections in Relation to the Detention and treatment of Prisoners, 2005, p ) About Time, Report by the Department of Corrections, Wellington, 2001, p25. 22) About Time, Report by the Department of Corrections, Wellington, 2001, p44. 23) Corrections Department Annual Report p17. 24) Corrections Department website. 25) About Time, Report by the Department of Corrections, Wellington, 2001, p ) The Economic Case for and against Prison, The Matrix Knowledge Group, London 2007 p 7. 27) NZ 'has most prison volunteers in the world', NZ Herald, June 19, ) Te Ihi Tu in Taranaki, Salisbury St Foundation in Christchurch, and Montgomery House in Hamilton. The Department places less than 100 inmates in these houses in a given year. 29) Differential effectiveness of residential versus outpatient aftercare for parolees from prison-based therapeutic community treatment programs: Substance Abuse Treatment, Prevention, and Policy, William M Burdon, Jeff Dang, Michael L Prendergast, Nena P Messina and David Farabee, May 15, ) What are the Average Costs of Substance Abuse Treatment in the Public Sector? US Department of Human Services, December ) NIDA National Institute on Drug Abuse, ) Investing in Addiction Treatment, A Resource for Funders, Planners, and Policy Makers, NCAT 2008: 33) Rich Daly, Substance Abuse Treatment: A Great Investment, Psychiatric News, December, 2005, Volume 40, Number 24, p19. 34) Jim Anderton, Speech to launch NCAT s addiction resource Nov 6,