Substance Abuse Treatment for Criminal Offenders: A Review of the Literature

Transcription

1 Stein (1999) 1 Substance Abuse Treatment for Criminal Offenders: A Review of the Literature David M. Stein, Ph.D. 1 Introduction The association between substance abuse, crime and recidivism following incarceration has been a concern of criminal justice and social scientists for decades. For example, the percentage of arrestees who test positively for drugs varies tremendously across U.S. cities, and in terms of the drug type. However, absolute figures are very high. Male arrestee opiate use for instance, ranged from 18.4% in Philadelphia to 1.3% in Atlanta; for women, positive opiate tests among arrestees ranged from 27% in Chicago to 0% in Laredo. Overall, 1998 national averages for opiates showed a 6.0% rate for male, and a 7.4% rate for female arrestees. (ADAM Annual Report, 1998). Rates for other substances are presented in Table 1. Table 1 Median Rates of Positive Drug Tests Among U.S. Arrestees: 1998 (percentages) Opiates Cocaine Marijuana Males Females Source: ADAM Annual Report, How prevalent is substance abuse among inmates? In 1997, Federal prisons reported that at least 60% of their population were documented drug offenders. This compares to a figure of only 25% in 1980 (U.S. Department of Justice, 1997a, 1997b), suggesting that the problem of substance abuse among inmates is growing dramatically. Additionally, Peters et al (1998) provide one of the most valid prevalence estimates of DSM-IV substance abuse and dependence in a prison system offered to date. They conducted Structured Clinical Interviews For DSM-IV with 400 consecutive, recently-admitted inmates in a Texas prison, as well as repeat interviews of a subsample of the inmates at a later time (to assess reliability). The authors found that during the 30 days prior to being incarcerated, about 56% of all inmates evidenced either alcohol or drug abuse or dependence disorder. Specifically, 28% evidenced drug dependence, and 26.3%, alcohol dependence. Lifetime prevalence estimates for drug dependence and alcohol dependence were 45.5% and 37% respectively.

2 Stein (1999) 2 Lipton et al (1992) also summarized studies showing very high drug use rates among persons with criminal records and arrestees. For example, among persons arrested for income-generating crimes (robbery, burglary, theft), and violent crimes, at least 45% test positive for one or more drugs, according to data from the National Institute of Justice. Also, Wexler et al (1988a) showed that disproportionately high rates of rearrests after release from jail or prison are observed among untreated heroin addict parolees i.e., 60-75% become reinvolved in both heroin use and crime within months. The number and proportion of druginvolved inmates in our prisons is growing. Within state prison populations for instance, drug offenders accounted for over 23% of the population in 1995, up from 6% in Thus, there is a growing belief among criminal justice experts and social scientists that modifications of existing jail, prison, and adjudication programs must occur, as growth in the costs of managing offenders cannot be sustained. For example, the Criminal Justice Institute has reported that it costs an average of $20, to incarcerate one jail inmate for one year. This value is similar to the cost of locking up a state inmate ($19,801.25). Further, housing a Federal prisoner costs about $23,476 per year. In total, U.S. taxpayers were asked to pay $24 billion to incarcerate over 1 million nonviolent offenders (Camp and Camp, 1997). A substantial proportion of these persons had drug and/or alcohol problems, and had never been locked up before. In an attempt to help remedy the high costs associated with drugs, crime and incarceration, prisons began expanding treatment services for inmates in the 1970s, 80's and 90's. According to Lipton et al (1992), most inmate treatment programs around the country involve NA, CA and AA programs or other 12-step meetings, and/or group counseling of diverse types. Less frequent are expensive mileau therapy or therapeutic prison communities (TCs), (where inmates live is drug-free environments apart from the general prison population). For example, Norton (1999) concluded that in the Arizona prison system, substance abusers who consistently attended or completed substance abuse treatment were much more likely to complete probation successfully than inmates who did not have treatment. Does substance abuse treatment per se help cause improved probation completion in this study? It might, but an alternative explanation is that a subgroup of substance abusing offenders are simply highly motivated to complete any program associated with life improvement e.g., drug treatment, probation, etc. Thus, substance abuse treatment completion might merely serve as an early indicator of high, general motivation to fulfill this and other mandated release programs (e.g., probation). Unfortunately, most data on the effectiveness of prison and jail treatment programs lack methodological rigor. Ideally studies that randomly assign substance abusers to treatment and no-treatment conditions would be more helpful in answering the above question. However, such designs are not at all common in the research literature. This present author summarizes the best available published research on the effectiveness of treatments for offenders whose criminal behavior significantly interacts with

3 Stein (1999) 3 their alcohol and drug abuse. The goal of this paper is to provide treatment program planners and policy makers with the evidence upon which to base funding decisions. While treatment approaches in this arena are diverse, the organization of the present paper was necessarily constrained by the number and quality of studies available in the research literature on particular topics, modalities or settings. Thus, the major topics presented include the following: 1. General relapse statistics, and data from recent, large-scale, national studies of treatment programs showing that changes in criminal behavior are correlated with substance abuse treatment. Readers may be interested in basic data on the relapse rates that can be expected without treatment. Further, studies sponsored by the federal government examining pre-post changes in measures of treatment goals, provide basic before-versus-after treatment data on various illegal/criminal behavior in large treatment populations. While such data do not demonstrate that treatment programs are more effective than no-treatment, the likely correlation between treatment and change could be suggestive of effectiveness. 2. A number of quasi-experimental outcome studies have been conducted on Therapeutic Community (TC) models of drug and alcohol treatment within prison settings. Within the therapeutic community settings, a large number of studies have examined factors such as the duration of treatment and its relation to outcome, the importance of aftercare programs, and how behavior change correlates with finishing programs, versus dropping-out. 3. Correlates of outcomes from Drug Courts. Some preliminary data, in conjunction with known principles of behavior change that have been incorporated into drug courts suggest that this approach will eventually prove to be very effective for many offenderaddicts. Controlled outcome studies are beginning to be published. 4. Programs focusing on treatment program outcomes within jail settings will be examined, because such settings present a number of novel and unique challenges to treatment. 5. Controlled outcome studies on treatments for opiate, and cocaine/ methamphetamine dependence are discussed extensively. This section of the paper was adapted from a general review of the literature by Stein (1998) on treatment effectiveness. While the treatments were not specifically designed to be used in prison or jail settings, the populations being treated generally certainly contains large numbers of patient offenders. 6. Urine screening in social support treatment for prison offenders is discussed. Routine or random urine screening is a widely used monitoring strategy for chemically

4 Stein (1999) 4 dependent offenders. However, only one study to date has evaluated its contribution to other treatment components among offenders. 7. The role of contemporary medications in the treatment of substance abuse will be summarized. Many persons with addictions may benefit from use of such medications as methadone, naltrexone, LAAM, and antidepressant medications. 8. Commentaries on treatment program issues for women offenders are just beginning to emerge in the literature, and will be discussed. Women offenders also have many special psychological, health, family and employment needs. They may respond to intensive social support offered by TC programs, and especially, continuation care after incarceration, we well and in many cases, better than men. 9. General drug/hiv education programs are increasingly being used in jail and prison settings. Questions about the value of education-only approaches are worthy of discussion A number of decision-rules guided the present author s selection of documents for the present paper. First, the literature contains hundreds of program descriptions and concept papers on treatment of criminal-addicts in jail and prison settings, as well as aftercare (e.g., Weiner, Silberman, Glowacki & Folks, 1997). These were not generally not included in the present report, because they provided no empirical data bearing on the question of efficacy. Also, more recent studies are emphasized in this report, because the quality of studies has improved significantly in the past 20 years. Additionally, behavior change or psychological treatment approaches for offenders that did not specifically address substance abuse/dependence problems were also not included, as they were beyond the scope of the present review. In identifying research reports for the present review, the author conducted methodical searches of Psychological Abstracts and Medline electronic databases, and perused major government research summaries, abstracts and agency home pages on the Worldwide Web (e.g., NIDA, U.S. Department of Justice homepage). When suitable articles were identified, the reference lists of each article were searched for additional research reports. Further, hand searches of journals commonly publishing drug and alcohol treatment studies were conducted. While the present review is likely not exhaustive, it is most certainly highly representative of the available literature. Any research report worthy of broad citation by experts in this field is likely to have been identified and included in this report. Finally, this paper should be viewed as a companion or complimentary manuscript to the broader literature review on drug and alcohol treatment effectiveness produced by the present author in conjunction with the Salt Lake County Division of Substance Abuse Services (Stein, 1998).

5 Stein (1999) 5 In the first section of this paper, readers are reminded of the typical outcomes observed among persons with serious drug/alcohol problems who receive minimal or no treatment (e.g., detoxification). Such information on natural outcomes over time provides a frame of reference for evaluating the outcomes reported in large scale studies of pre-to-post changes in persons enrolled in typical treatment programs. Next, early attempts to treat offenders in the U.S. are briefly summarized, as the likely reasons for the general failure of these programs has been in the design of many contemporary programs. Such failures are well worth reviewing for the next generation of treatment program planners. Finally, largescale pre-to-post outcome surveys are presented to provide readers with a broad outline of the likely efficacy of general treatment approaches, as demonstrated in typical programs. These surveys are important because they involve conclusions about diverse patient samples and treatment facilities. The present author suggests that such studies may offer the best available insights into what can be typically expected in terms of patient change over time, for different drug problems and treatment settings. The findings of these studies might be generalizable across settings and populations. Thus, treatment programs producing treatment results that are poorer than those reported in these pre-post studies likely need to be carefully evaluated and revised. Further, local recidivism rates of programs can be compared to national statistics, which suggest that at least 45% of defendants convicted of drug possession will be rearrested on a similar offense within two or three years; (Drug Court Clearinghouse and Technical Assistance Project, 1997). General Relapse and Recidivism Base Rates of Offenders: A Frame of Reference for Evaluating Programs It is helpful to compare rates of drug use relapse, re-arrest etc. for offenders participating in treatment programs, versus those assigned general probation and direct release from prison. Certainly, high rates of recidivism are reported by such organizations as the National Institute of Justice (1989) which found that 62.5% of persons released from prison (in 11 states) were rearrested within three years. Of this number, 47% were arrested and convicted of new crimes and 41% were reincarcerated. It is well known that persons with drug/alcohol problems and especially, past arrests for drug involvement, are more likely to be rearrested than those who are not. In addition to the general recidivism rate for crime, relapse to prior levels of drug use is an extreme problem. Vaillant (1973) noted that over a 20 year period, a group of 100 offenders had been incarcerated 447 times, and 91% of these episodes had been followed by a return to narcotic use within one year of their release. Other researchers such as Maddux and Desmond (1981) followed 248 inmates for 15 years, and found that they accounted for 584 jail or prison sentences. Rurther, 66% of the sentences were followed by readdiction within one month of release, and 94% were readdictted by the end of one year. Finally, Nurco (1990) followed the readdiction rates of persons jailed or sent to prison. These offenders had an average of 13 years of narcotic addiction prior to their present incarceration. Upon release, 78% were found to be readdictted within one month, and 88%, within one year. Thus,

6 Stein (1999) 6 without viable treatment, it appears that drug-dependent offenders will almost always (88-94%) return to serious drug use within one year of their release from jail or prison. Such statistics suggest that society faces the problem of almost universal, naturalistic relapse among those offenders with long addiction careers. General Question of the Likely Efficacy of Coercion and Judicially-Enforced Treatment: Some Early Attempts and Failures. Intimately related to attempts to incorporate drug treatment programs into prisons or jail settings is the historical issue of coerced involvement in treatment. Being mandated to enroll in such programs was first tried in the U.S. in the early 1900s, with the first meaningful evaluation reports emerging from U.S. Public Health Service hospitals in Lexington, KY and Fort Worth, TX. (which started in 1935 and 1938 respectively). Interestingly, the first solid data from these efforts was reported in the early 1960s (Inciardi, 1988, Cole, 1967). These early programs were deemed an almost total failure, with over 90% of patients relapsing within a few years of release. One key to their failure was probably the absence of any followup aftercare for inmates. Another major failure involved the ill-conceived and implemented New York Parole Project in (roughly) , which strongly dampened interest in civil commitment of drug-dependent offenders. However, more recent programs (e.g., TASC) have provided guidelines for judicial system treatment programs, and some promising retrospective, correlational data regarding outcome has gradually became available. Fortunately, more recent court-mandated or coerced programs seem to be showing much better outcomes in recent years. For example, Anglin (1988) reports data from the early years (1960s) of the California Civil Addict Program (CAP), (A full description of the California CAP program is available in McGlothlin et al, 1977.) Anglin (1988) notes that the CAP program participants in early 1960 could be readily compared to a semi-random group of opiate-addicted inmates who were also assigned to the program. However for technical/legal reasons, they were released on a writ of habeas corpus shortly after entering the inpatient portion of the CAP program because of procedural errors of judges, (who were slowly becoming familiar with the new laws that made the civil commitments possible). Thus, the control group had the same characteristics as the treatment group, but got released. Figure 1 shows the results of follow-up interviews regarding self-avowed drug use. Years covered by the interviews included daily use in the preadmission years, and use beginning about 1 year after release from the program, (extending to over 11 years). Thus, Figure I presents use data for periods when offenders were not incarcerated. For the years prior to being court-ordered to the CAP program, roughly equal daily use among both control and program inmates was evident for the 1-2 years immediately prior to the start of the CAP program (i.e., roughly 75%+ daily use rates for both groups). The years extending even earlier than those just prior to the program show more variability. However, a very dramatic drop in use relative to prearrest use rates was found for both

7 Stein (1999) 7 groups immediately after release. However, the program group showed a much more substantial drop from the preincarceration period ( i.e., 20% average daily use of narcotics for program subjects, versus about 50% for controls). The author suggests that these declines were probably related to accessory social interventions and treatment attempts, as well as maturing and/or aging of the addict groups. Finally, Figure I implies that the general availability of methadone 7-9 years after release probably contributed to a significant renewal of the rate of decline in daily use for both groups, (though the final daily use rate for program Figure 1 subjects was). Taken together, these data suggest that offenders generally reduced their rates of narcotic use. Rates of arrests also differentiated the two groups as well, and modest differences in employment rates were also found (Anglin,1988) It should be noted that program evaluation study was correlated before cocaine, crack, etc were widely available in society. The present writer suspects that this pattern of outcomes might have been poorer for these particular drugs. In addition to the above data, Anglin (1988) speculated about the most important elements associated with the CAP program. He emphasized that the aftercare components were probably most important. This view is consistent with the post-program trends. In particular, a solid outpatient program with consistent drug-testing produced better outcomes than unsupervised release situation, (no monitoring/testing). Inmates who showed the most

8 Stein (1999) 8 resistance to the program and absconded i.e., were quite uncooperative and left the program had the poorest long-term outcomes. Anglin (1988) recommends that for chronic narcotics addicts, the most helpful program was one accompanied by long-term parole of 5-10 years, plus careful monitoring and regular drug testing. Also, his data show that methadone maintenance can substantially enhance long-term outcomes for offender addicts. Taken together, the data appear to indicate that coerced treatment yields outcomes as good as or better than voluntary treatment. Miller and Flaherty (2000) completed a metaanalysis review of the literature on coerced treatment. They note that...coercion occurs when an alcoholic or drug abuser is given the choice between an opportunity to comply with addiction treatment or to receive alternative consequences prescribed by the enforcement of the law, policy or agency. The alternative may be jail time, loss of child custody, loss of employment, or loss of benefits (p. 1). They found no studies indicated that a coerced addiction treatment regimen was ineffective, and that coercion was commonly associated with decreased medical costs, decreased crime and improved employment and social relationships. Further, Anglin, Prendergast & Farabee (1998) reviewed 11 studies that studied the relationship between coercion or degree of coercion, and treatment outcome. The overwhelming majority of these studies (9 of 11) found either a positive relationship between coercion and treatment effectiveness, or no relationship (i.e., coercion/noncercion did not relate to outcome). Only two studies showed a negative relationship with outcome. Data From Recent, Large-Scale National Studies of Pre-to-Post Treatment Programs Outcomes A number of large scale studies suggest that reduced criminal activity and arrests are strongly correlated with treatment, at least in the short term. Some of the published reports illustrating this relationship involve descriptive and correlational studies of very large, multisite treatment programs. These studies assess clients enrolled in diverse, representative treatment programs around the country, both before, and after treatment. These studies are of value, because they document large-scale, general changes among persons in treatment. For service providers, these studies offer a general benchmark for minimal changes that should be occurring in roughly comparable. Unfortunately, these large-scale descriptive and correlational studies do not tell researchers how such patients compare with similar groups of inmates who never entered treatment, or patients who followed alternative paths toward recovery. Also, the changes reported in these studies do not provide a frame of reference for judging treatment cost-effectiveness, relative to no treatment or less-expensive approaches. Long-term outcomes for addicts: the Drug Abuse Reporting Program (DARP) followup project. Approximately 40% of clients in a large, federal assessment/follow-up program (DARP, ) were involved in criminal justice proceeding of some type (e.g. probation, awaiting trial, parole, etc.) Descriptive data and correlates of change for this group of treated offenders is available (see Simpson and Friend, 1988). It should be pointed out that the data reported here are for opiate abusers and addicts who were using the drug on at least a daily

9 Stein (1999) 9 basis, and who had varying degrees of involvement with the criminal justice system. The major modalities covered by the DARP report are methadone maintenance (MM), Therapeutic Communities (TC), outpatient drug-free treatment programs (DF), and outpatient detoxification (DT). It should be pointed out that level of criminal justice involvement was highest in the TC group (66%); followed by the DF group (52%), and DT modality (45%). The MM modality had the lowest involvement (34%). Thus, the discuss herein is probably least relevant to methadone maintenance programs. Simpson and Friend (1988) report 12-year post-treatment follow-up interview data for a sample of DARP participants. They were primarily interested in the following question: Does legal involvement relate to length of time in treatment, and addicts reasons for leaving treatment? Contrary to the findings of many other studies (discussed in the section that follows), legal status was unrelated to length of stay in treatment, for any treatment modality. Also, reason for discharge was also unrelated to legal status. An attempt by Simpson and Friend to examine whether these relationships might be significant for different age groups of clients also proved to be uninformative. However, in general, length of stay in the major treatment modalities (MM, TC, DF) was related to better outcomes (e.g., opioid use, criminality, employment). For instance in terms of opioid use, about half of the overall sample showed stable use patterns in years #6 and #12 (42% were abstainers, 9% used daily in both of these years). Outcomes of Treatment Alternatives to Street Crime (TASC) programs that were part of the Treatment Outcome Prospective Study (TOPS). The federally sponsored Treatment Outcome Prospective Study (TOPS) reviewed case outcomes across 10 U.S. cities that offered 41 publicly funded outpatient methadone, residential and outpatient drug-free treatment programs (between ). The TOPS study is relevant because about onethird of the residential and outpatient drug-free program recipients were referred through the criminal justice system. Interestingly, less than 3% of the methadone maintenance participants were referred by criminal justice. Indeed, the present writer presents results for a portion of the TOPS data reflecting outcomes for those residential and drug-free treatment programs designed for offenders i.e., TASC guidelines and criteria (Hubbard, Collins, Rachal and Cavanaugh, 1988). The TOPS research team collected baseline data, as well as outcome interviews at the 3 month point in the treatment, and 1, 2, 3 and/or 5 years after treatment. Hubbard et al (1988) compared TASC program inmates with: 1) non-tasc criminal justice drug offenders; and 2) a group of addicts with no legal involvements. Also, these groups had been assigned to one of two treatment settings---either an outpatient drug-free or a residential program. All participants had a history of drug problems but were not abusing opiates or methadone; these offenders were also fairly young and early in their drug use and criminal careers, compared to many offenders in prison populations reported in the literature. Interestingly, at baseline, the three groups were comparable on a number of personal and demongraphic variables, but not others, e.g., number of prior treatment episodes.

10 Stein (1999) 10 Further, comparisons between groups was made even more difficult by the fact that after being assigned to a treatment setting, the overall outpatient and residential groups were quite dissimilar in gender and racial makeup, age and types of drugs/alcohol used. Thus, outcomes can be best discussed within each modality. Despite these questions about group comparability prior to treatment, Hubbard et al (1988) concluded the following: 1. Drug-involved clients tended to be retained in treatment longer if they were assigned to specially-designed programs for this population (TASC programs), and had active involvement in the criminal justice system. Longer retention (more than 3 months) in both residential and outpatient drug-free programs was related to lower rates of predatory acts committed during the year following treatment. That is, offenders were between 2-1/4 and 4-1/3 times as likely to commit such acts if they spent less than 3 months in programs. 2. Clients from criminal justice systems have unique treatment needs that nearly always require more intensive and complex interventions. 3. Irrespective of treatment, the strongest predictors of new, predatory acts during the year following treatment were age (younger than age 25), and pretreatment frequency of committing such acts. Length of retention in treatment was also correlated with reduced predatory behavior post-treatment. 4. Criminal-justice clients referred either to residential or outpatient drug-free programs were about.61 times (more than half, again) as likely to use their primary drug, on a weekly basis or more often, than clients who were self-referred (usually, no criminal involvement). Thus, criminal justice clients coerced into treatment seemed to do as well or better than noncriminal justice clients in treatment on use indices. However, although treatment is correlated with reduced crime generally, participants referred by TASC or the criminal justice system reported rates of predatory behavior similar to those not involved in the criminal justice system. However, despite reduction such behaviors may remain fairly high across the addict population, despite treatment. 5. Longer amounts of time spent in treatment is related to criminal justice involvement. Key Treatment Outcome Prospective (TOPS) Outcomes. In addition to the TASC data associated with the Treatment Outcome Prospective (TOPS) study, general TOPS data are relevant to a discussion about pre-post changes in crime-related behaviors and their correlation with treatment. The TOPS study (Hubbard et al, 1989) followed 10,000 drugabuse treatment clients during 1979, 1980 and 1981 enrolled in 37 programs in the U.S. This was not a random selection of clients or programs. Subjects were interviewed at intake, one month after entering treatment, and then at 3-month intervals. Further, post-treatment interviews were conducted at 3-months, 1 year, 2 years and 3 years. Hubbard et al compiled the outcomes of three different modalities: 1) outpatient methadone; 2) outpatient drug-free treatment; and 3) residential programs. The authors found that clients, treated at least three

11 Stein (1999) 11 months, in any modality evidenced a greater-than-20% decrease in the prevalence of predatory crimes at the 3-5 year follow up period, versus the year before treatment. The strongest predictor of post-treatment criminal activity was pretreatment criminal activity, especially the commission of at least 10 offenses. Pretreatment drug use rates and other demographic features were not correlated with post-treatment crime rates. The National Treatment Improvement Evaluation Study (NTIES) (1997) was a fiveyear, congressionally-mandated study of the (pre-to-post) outcomes of thousands of patients seeking treatment at numerous treatment facilities in the U.S. these programs received federal support dollars. About 82% of the 6,593 clients attending 78 treatment units were interviewed when they entered treatment, when they left treatment, and at a 12-month followup. The NTIES sample includes a large number of persons undergoing drug/alcohol treatment in correctional facilities (25%), making these data on pre-post outcomes at least somewhat relevant to interventions with substance abuse offender populations generally. Outcomes such as substance use, employment status, use of medical services, mental health problems, arrests, etc., were obtained directly from patients, or cooperative informants who knew the patients well. While this study did not specifically focus on treatment outcomes of criminal offenders, general data were provided on the frequency of criminal arrests. Specifically, the frequency of criminal arrests in the 12 months before, versus 12 months after treatment fell from 48.2% to Another outcome measure, the frequency of selling drugs dropped from 64% to 13.9% (n = 4,411 patients). Also, patients obtaining most of their financial support from illegal activities dropped from 17.4% before treatment, to 9% after treatment, and drug-selling dropped from 64% to 13.9% (see Figure 2 below). Figure 2

12 Stein (1999) 12 CALDATA report. Gerstein, Johnson and Larison (1997) summarize data from the large-scale California Drug and Alcohol Treatment CALDATA data collection project. This project summarized the outcomes, benefits and costs of drug and alcohol abuse treatment in California (CALDATA project) during Recipients of treatment were randomly selected from the overall treatment population. They received Medicaid, state/county alcohol and drug treatment funding, public insurance, or Aid to Families with Dependent Children (AFDC). The following conclusions were drawn by Gerstein et al (1997): Relative to pretreatment levels: 1. Criminal activity declined by about 2/3 after treatment, among both men and women patients. 2. Alcohol/drug use declined by about 40%. 3. A reduction of hospitalizations by one-third occurred. 4. Ethnic groups differed in the programs they enrolled in; Hispanics were much more likely to be in methadone programs for heroin addiction; African-Americans were primarily in residential programs, mostly for alcohol and cocaine, compared to non-hispanic Whites and with African Americans in other types of treatment.

13 Stein (1999) 13 Services Research Outcomes Study (SROS, 1989), DHHS. Another important study of pre-post correlates of treatment is the Services Research Outcome Study (SROS), which included a nationally-representative sample of 1799 individuals undergoing outpatient, methadone, inpatient-hospital, and residential treatment in 99 facilities. While treatment programs within correctional facilities were not included in the sample, extensive data were collected on long-term criminal activity of persons in treatment. SROS project respondents were interviewed five years after treatment and asked to provide retrospective information regarding the five-year period before the most current treatment intervention, as well as current status on variables of interest (e.g., criminal behavior, drug/alcohol use, housing, health, psychological status, income/employment). The following are key findings of the study for the period of 5 years before, versus after treatment: 10. Average reduction in drug use ranged from a low of 17% for crack, to high of 53%, 56% and 60% for inhalants, hallucinogens and PCP. Other drugs had intermediate values. These reductions paralleled other measures of use, such as number of use days per month. 11. For every drug type, reductions in drug use were greater among women clients than men. For example, marijuana decreased 39% for women, but only 25% for men; also, cocaine use declined 50% versus 44% respectively, and crack use declined 24% versus 13% for men compared to women. 12. For every drug, younger persons did less well in treatment in terms of declines in use, compared to older persons. Programs appear to be doing an especially poor job addressing crack use among addicts less than 18 years old (e.g., pre post increases in crack and alcohol use over time were noted for adolescents, compared to minimum 20% reductions in use for older clients. In general, drug use did not decline substantially for adolescents who underwent treatment.) 13. For every major drug except crack, length of stay in treatment was correlated with the extent of decrease of drug use. Clients who completed treatment were more likely to show significant decreases than those that did not. 14. Substantial decreases in criminal activity were noted in five years after, versus 5 years before treatment. The largest decreases (56%) were found for vehicle theft, followed by supporting oneself mainly through criminal activity, breaking and entering, theft/larceny, drug sales, public disorders, and DWI. Rare (low base rate) crimes showed no measurable decreases, probably because of their infrequency i.e., armed robbery, arson, rape, homicide.

14 Stein (1999) Lengths of stay in treatment greater than 6 months was the strongest correlate of decreases in criminal activity. Also, if persons relapsed/or needed further treatment, less decrease in criminal activity was observed. 16. Treatment was associated with regaining custody of children, having more reliable housing, and less involvement in fights and suicide attempts. However, no change was found in overall rate of full-time employment. This suggests that full-time employment was not effectively targeted and therefore affected, by most treatment programs or aftercare. Introduction: Summary Several decades of research show that without any intervention, criminal offenders with substance dependence problems will almost certainly return to their pre-arrest drugtaking patterns upon release. Early attempts to coerce or require drug-dependent offenders to receive treatment proved to be failures. These failures were probably because of the unavailability of empirically-based treatment approaches, most importantly, the lack of followup interventions after inmates were released. A generally-accepted theme in the research literature however, is that coerced treatment is at least as effective as voluntary treatment. Large scale national studies of drug and alcohol treatment programs suggest that reductions in drug use and criminal behavior among offenders are meaningfully correlated with treatment. However, the very general, gross categorizations of treatment programs (e.g., residential, drug-free community) used by authors of these studies make it impossible to ascertain whether one type of approach is more strongly correlated with these changes than another. Length of time spent in treatment is related to treatment outcome, especially if offenders remain in treatment three months or longer. No consistent gender or ethnic differences are related to these broad program outcomes. For example, women seem to do at least as well as men and older offenders seem to do better than younger ones. Additionally, adolescent drug use except for cocaine, does not appear to be dramatically improved. This point was noted in an earlier review by Stein (1998). Finally, limitations in the research design of these studies does not allow us to assert unequivocally that treatment per se reduced crime rates and drug-related behavior problems among offenders. Outcomes that are reported could be explained by other factors. For example, staying in treatment might merely be a behavioral marker of the high motivation and recovery momentum inherent among subgroups of successfully-treated offenders. Therapeutic Communities (TC) in Jail and Prison Settings The largest number of studies dealing with treatment in prisons and other correctional settings focus on the efficacy of therapeutic communities (TC). Studies of therapeutic communities have included a number of research designs that have compared various treatment approaches with TCs. Also, efforts have been made to examine treatment or client

15 Stein (1999) 15 factors that correlate with outcome measures (e.g., recidivism). It is extremely important to review detailed descriptions and implementation guidelines of particular programs when one considers the adoption of a program. TCs share some common philosophical elements, but vary tremendously in their components, intensity, quality of staff, etc. It should be noted that the most widely used indices of effectiveness in studies of TCs are return to drug use, and rearrest or reincarceration rates. Discussed below are programs for which the most systematic research has been conducted to date. Oregon Cornerstone Program Field (1985, 1989) reports two studies on the Cornerstone program (Salem, Oregon), based on offenders assigned to the program in the 1970s. This program is similar to other prison TC programs in that it is physically separated from the general prison population (housed on the grounds of a state hospital). Inmates can be referred to the program by their prison counselors if they can spend six months in the program (prior to their release). Field compared polydrug-abuse offenders who graduated between 1976 and 1979 to three other reference groups: 1) inmates who were admitted to the program, but dropped out in less than one month; 2) all Oregon parolees from with a history of substance abuse; and 3) a sample of Michigan parolees. While no significant demographic differences were found between the program and drop out groups, the Oregon parolees evidenced less severe substance abuse and crime problems than the program graduates. However, the Michigan offenders were similar to both the Cornerstone program group and drop-out group. Two key outcome measures were assessed at 3-year follow-up. First, the percent of inmates not reincarcerated (for any reason) following release was assessed. About 71% of program completers were not reincarcerated, compared to only 26% of drop-outs, and 63% of Oregon parolees with similar drug problems. About half of the Michigan sample was reincarcerated. Offense convictions for the three year assessment were. Cornerstone Program graduates=46%; program drop-outs=85%; Oregon prison parolees with drug problems= 64%. In a second study, Field divided program graduates with an average length of stay in the program of 11 months in treatment to three other groups who did not graduate: 1) those spending more than 6 months, but did not graduate; 2) those that spent 2-6 months; and 3) those who participated for less than 2 months. After 3 years, the arrest frequency count for each group was: 63% (graduates); 79% (in treatment more than 6 months, less than 11); 88% (in treatment 2-6 months); and 92% (less than 2 months. For convictions, the figures were 49%, 72%, 76%, and 89% respectively. New York State Stay n Out TC Program. Wexler, Falkin, Lipton and Rosenblum (1992) compared the Stay n Out therapeutic community prison program with two comparison groups: 1) inmates involved with other types

16 Stein (1999) 16 of prison-based drug abuse treatment programs (primarily group counseling; and 2) inmates who sought admission to the Stay n Out program but were not admitted because they did meet the prison time criteria (i.e., more than 12 months, or less than seven months of prison time remaining on their sentence). Also, a female inmate Stay n Out program was present, but no womens mileau treatment comparison group was available for study. All groups were quite comparable on such demographic variables as age, marital status, crime severity measure, race, and education. The main outcome measures centered on re-arrest rates. Both the male and female Stay n Out program members showed substantially lower overall arrest rates compared to the mileau or other (counseling-waiting) groups. For males: a 26.9% rearrest rate for the TC program versus 34-41% for other conditions; for women, rates were: 17.9% versus 24-29% (for TC program and controls respectively). It should be noted that this latter difference among womens groups for rearrests was a nonsignificant statistical trend only. Also, there was no relationship between treatment group membership and: 1) time until arrest----among those persons eventually rearrested; or 2) positive or successful parole discharge. The authors conducted additional analyses involving time-until-rearrest and general arrests. There was a modest trend for persons in the TC program longer to show longer times until rearrest, though the effect disappears for the longest treatment length interval. A similar trend was found between length of TC treatment and positive parole discharge. No such relationships existed between time and the outcome measures for the other reference groups. Finally, the following variables were most strongly associated with increased time until rearrest : age (being older versus younger), less extensive criminal history, time spent in therapeutic programs after release and duration of parole supervision following prison, participation in the Stay n Out program while in prison, and amount of time spent in this latter program. The authors conclude that the optimal period of time for best effects of this TC program was 9-12 months, which is reasonably consistent with other outcome studies of TCs. Ozarks Correctional Program. Hartman et al (1997) present data on outcomes associated with a TC at the Ozarks Correctional Center in Missouri. This program is similar to the Stay n Out program in New York State. In emphasized use of a separate TC community in prison, and a follow-up aftercare program following release. The quasi-experimental design involved program completers who had been out of prison at least 5 months. Also, a control group consisted of inmates matched on eligibility criteria for admission to the program. The groups were quite different however in some demographic characteristics. For example, the control group was about 9 years younger than the experimental group (mean of 27 years old, versus 35), and a far greater proportion of control subjects had never been married. (76.1% versus 48.8%). The groups were roughly comparable in terms of the proportion of each sample scoring in the two highest quartiles of the drug and alcohol problem measures. Controls were released

17 Stein (1999) 17 during the same period as program participants. In terms of outcomes, only 14.6% of the experimental group had been arrested in the prior three months, compared to 28% of control subjects. However, both groups avowed substance abuse in the past 6 month, at comparable frequencies (23% and 28% respectively). Thus, groups did not differ on this outcome measure. Finally, 16.4% of the treatment group and 27.6% of the control group had been reincarcerated. Ohio Department of Corrections Program. Siegal et al (1999) recently assessed re-arrest rates among participants in the Ohio Department of Alcohol and Drug Addiction Services prison-based therapeutic community for prison inmates. Inmates who opted for the TC program (n=487) were compared with 242 who did not participate, but were eligible. Groups were somewhat different on variables that might account for differences in outcome measures e.g., education, age, gender and ethnicity. However, the authors statistically controlled for these variables in assessing outcome (e.g., difference in group rates of rearrest and legal charges following release). They found that inmates appeared to need at least 180 days of experience in the TC to accrue meaningful benefits. Those who spent at least this much time in the program had significantly lower 1- year (post-program) rearrest rates for violent drug-related crimes after 1 year, than those with less time, or no TC involvement. Texas Correctional Substance Treatment Initiative (ITPC) A report that is highly relevant to legislators and criminal justice program planners is that of Eisenberg and Fabelo, The report summarizes evaluation data from the largest correctional substance abuse treatment venture in the nation, The Texas Correctional Substance Treatment Initiative (Texas ITPC). This program which adopted many features of the New York Stay n Out Program. This was a 9-month TC program within a prison. Upon completing the TC program, offenders are released to a transition, community residential facility for 1-3 months. Finally, 3-12 months of counseling at outpatient clinics is provided. Eisenber and Fabelo note that the overall program cost an average of $8,000 above the expense of regular prison and supervision. The initial experimental group (n = 672) was comprised of volunteers (unlike subsequent cohorts) for the program. Outcome measures of major interest were 12-month, post release incarceration, and employment data (collected from state databases). Also, about 58% of offenders admitted to the program were either removed from the inpatient component (30%), and an additional l 28% did not finish the outpatient follow-up portion. However, certain offenders were more likely to complete the program i.e., older offenders with higher than 8 th grade reading level, and who avow serious substance abuse problems. The authors suggest that these clients were more motivated and somewhat more mature than noncompleters. The best predictor of success in various outcome indices was whether subjects completed the treatment regimen. Specifically, treatment was correlated with not being

18 Stein (1999) 18 arrested (87% of treatment completers, versus 69% for noncompleters and 71% for the comparison controls). Only 7% of completers were reincarcerated 12 months following release, while 19% of each of the other groups (noncompleters, controls) were reincarcerated. Also, offenders completing treatment had significantly higher partial/full employment rates (81%) than the other two groups (noncompleters 57%, controls, 53%). Finally, Eisenberg and Fabelo report on cost-savings from the program. Their conservative calculations of costsaving, based only on reincarceration costs, showed that only about 44% of the Program sample would be likely to be back in prison at the end of three years, while data for the general prison population was 55%. Thus, the program helped the state of Texas realize some cost-savings. Differential Importance of Group Counseling, Mileau Therapy and TCs. Wexler et al (1990) compared a therapeutic prison community (Stay n Out) approach with less intensive and structured Mileau Therapy model, Group Counseling, and No Treatment groups, in terms of their effect on rearrest rates following release from prison. These three treatment approaches were offered separately to male and female inmates. Wexler et al found that the male TC group had the lowest rearrest rate (22%) of all of the male groups, followed by the Mileau Therapy group (36%), the Counseling group( 50%) and the no Treatment condition (51%). The data suggest that counseling, in the absence of a more comprehensive living style or lifestyle program is ineffective, and that the differential levels of structure, intensity and quality likely associated with TC programs versus the Mileau approach used in the present study are important contributors to lower rearrest rates. Parallel data were found for the program components for women inmates. Specifically, for the TC group, the rearrest rate was 8%, while it was33% and greater for the other conditions. Importance of Integrated Follow-up Work Release and Outpatient Care to TC Programs Mathias (1995), Martin, Butzin and Inciardi (1995), and Nielsen, Scarpitti and Inciardi (1996) summarize the key results of a NIDA-supported study of a multistage therapeutic community approach to rehabilitating prison inmates (Inciardi, 1994). Offenders have the opportunity to live for up to 12 months in a therapeutic community while in prison (KEY Program). They then enter the CREST program, a work release program that allows residents to work, attend drug rehabilitation session. Finally, inmates are released and attempts are made to get them involved with outpatient treatment. Participants are also encouraged to revisit the TC program for refresher contacts and support sessions. Martin et al (1995) compared outcomes of inmates assigned to the following combinations: 1) KEY-only, no CREST or subsequent treatment; 2) KEY plus CREST; 3) CREST-only; and 4) no treatment; just HIV-AIDS prison education program. The groups were comparable in nearly all ways except that the KEY only and KEY-CREST groups had more African-American participants. Table 2 shows the approximate 6 month outcomes for drug-free status, arrest-free status, and self-reported injection and condom use. It shows the

19 Stein (1999) 19 percentage of participants in each group, for these outcomes. It is clear that the Combined KEY-CREST condition did dramatically better than the other conditions, especially no treatment in both areas. The most important element of the program in terms of enhancing efficacy was the work-release CREST component. Further, there was a gradual deterioration effect among residents who had only the prison TC (KEY) by the end of the 18 months, so that they were little better off than the no-treatment group. Finally, HIV/AIDS education program was present in both the CREST, TC, CREST-TC and no treatment conditions, no differences were found across groups in self-reported condom use at approximately 6 months post-release. It is not possible to assess whether such education or the absence of it, impacted post-release behaviors, in this particular study. However, with regard to the key outcomes of drug-free and arrest-free status, Inciardi notes that,...unless you have that follow-up care in the community, you ve wasted your money (p. 3). The KEY-CREST program also demonstrated a dramatic relationship between time spent in the program and both relapse and recidivism. For example, for inmates participating less than one month versus those who complete 5-7 months, the six-month recidivism rates are 38.7 versus 8.2% respectively. Data for 18 month post-program are 50% verus 34% respectively. Parallel data are observed for drug/alcohol use relapse. (See Table 2) Table 2 Outcomes by Treatment Groups (Percentages) Comparison KEY CREST KEY-CREST P (drug-free) * 94* P (arrest-free) * 97* P (injection-free) * 97 P (condoms) ** * p <.001; **p <.05 versus comparison group, logistic regression Martin, S. S.; Butzin, C.A.; Inciardi, J.A Assessment of a multistage Therapeutic Community for Drug-Involved Offenders. Journal of Psychoactive Drugs 27(1): The notion that follow-up treatment after release from a prison TCs are crucial to success has been reinforced by research from the Amity Therapeutic Community Program (Graham and Wexler, 1997). Graham and Wexler included 720 male inmates in this longitudinal design which utilizes random assignments compared the 6-month TC program

20 Stein (1999) 20 that included a residential half-way house placement, to TC-plus-normal parole, normalparole-only, and a group of program drop-outs. Outcomes were assessed during the treatment process (6 and 12 months) and one year post-treatment. As is the case with all TC programs, drop-outs during the first few months were highly problematic. By the end of the TC portion of the overall program (6 months), about 50% complete the program. The rest are forced to leave or drop out. At the 12-month follow-up period, only about 26% of participants in both the TC and aftercare program are reincarcerated, compared to 43% of TC-only program completers. Further 50% of program drop-outs are reincarcerated, as are 63% of control subjects TC Prison Programs Outside of the United States Three studies conducted in European prisons using TC models should be mentioned. Petterson et al (1986) involved drug-abusing inmates in Sweden in a therapeutic community. The authors examined program graduates i.e., those who spent 12 months in the program, with drop-outs (who had a mean time in program of 5 months). About half of the program participants (47%) dropped out. After two years, 46% of the graduates had been convicted of a crime, while 84% of the program drop-outs were convicted. Also, 46% of graduates evidenced some drug use, while 62% of drop-outs did so. Finally, after one year, 47% of the graduates were involved in meaningful work or study, while only 22% of drop-outs did so. The second study, also conducted in Sweden was of similar design, but divided program participants into smaller subgroups, based on the amount of time spent in treatment. In this program about 10% spent more than 17 months in the program; 16% spent months, 30% spent 9-12 months, and 24% participated for 5-8 months. Finally, 20% spent 0-4 months in the program. Data for convictions were similar to studies mentioned heretofore. For example, 39% of the group with longest program involvement was convicted of a crime during the 2 years of follow-up, while 66% of the group who participated least was convicted again. Unlike the research reports discussed to this point, one drug-free detention treatment jail program assessed in the Netherlands failed to find positive outcome for a therapeutic community. Schippers et al (1998) reports follow-up data from the Noordsingel prison facility in Rotterdam, Netherlands. The authors compared a drug-free program in the prison with outcomes of inmates in a different jail wing. the collected data during the inmates first two weeks of incarceration, and again, between 1-2 years after their release or transfer. One important problem in the present study was the low rate inmate rate of participation in followup interviews (60-66%). thus, a substantial proportion of participants could not be recontacted Schippers et al found that both groups showed modest decreases in substance use from intake to follow-up. No decreases in alcohol or marijuana use were found however.