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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Drug Treatment in State Prisons Gregory P. Fallin Harry K. Wexler and Douglas S. Lipton Since the 1970s, when retribution replaced rehabilitation as the dominant sentencing philosophy, prison populations have climbed dramatically while crime has continued unabated. The public outcry against sharply rising crime rates during the early 1970s led politicians to call for more certain and severe sentences. A strong belief that corrections could not rehabilitate offenders was fueled by research studies that essentially concluded that "nothing works" (Lipton et al., 1975; Martinson, 1974). As rehabilitation fell into disfavor, determinant sentencing and persistent felony offender laws were enacted. Legislators also responded to the alarming increase in drug abuse during the 1980s by mandating tougher sentences against drug dealers and users. As a result of the new sentencing laws, the nation's prisons became full of serious drug-abusing offenders, many of them recidivists. Looking for ways to reduce recidivism and control overcrowding (and recognizing the close connection between substance abuse and crime), correctional authorities have begun expanding prison-based drug treatment programs during the past few years. In contrast to the viewpoint that nothing works in rehabilitation, the efficacy of a policy of expanding drug treatment for prisoners and parolees can now be supported by social science research. Indeed, there is sufficient scientific evidence to demonstrate that certain types of prison-based drug treatment (e.g., therapeutic communities) can substantially curb recidivism. The need to reduce recidivism is paramount because of the many crimes perpetrated by career criminals and the problems stemming from prison overcrowding. Yet, despite a recognition of this need, sentencing policy during the last decade has led to a tremendous expansion of prison capacity without a commensurate decline in crime. Although this policy may be supported on the basis of "just deserts" for criminals, it is evident that incarceration is not adequate either The authors are social scientists associated with Narcotic and Drug Research, Inc., New York, New York.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment as a deterrent or as a means of controlling recidivism. The majority of inmates, especially the most serious among them, have severe lifestyle problems manifested most significantly by chronic substance abuse. Without appropriate treatment while in prison, a high percentage will relapse to drug use after release and will recidivate. The fundamental issue, then, is whether there are any forms of treatment that can reduce the likelihood of offenders recidivating. There is enough evidence currently to demonstrate that high-rate offenders with chronic polydrug abuse problems can be treated effectively. Our conclusion, based on the available scientific evidence and our best professional judgment of what works, is that drug treatment in correctional settings can curb recidivism provided the programs have the following central features: (1) a competent and committed staff, (2) the support of correctional authorities, (3) adequate resources, (4) a comprehensive, intensive course of therapy aimed at affecting the lifestyle of clients beyond their substance abuse problem, and (5) continuity of care after inmates are paroled. In the absence of any of these features, it would be difficult to expect a drug treatment program to substantially reduce recidivism. Given the current array of treatment programs (many offering only occasional counseling, drug education, or other limited services), the finding of evaluation research that many programs are ineffective is not surprising. To adjudge that drug treatment is unable to control recidivism because many programs do not is to miss the crucial point that some programs have been quite successful. With the proper program elements in place, treatment programs could achieve a significantly greater reduction in recidivism than by continuing a policy of imprisonment without adequate treatment. This conclusion is, of course, tempered by the fact that only a limited number of programs have been scientifically demonstrated to be effective. This finding compels us to call for further research as treatment programs are implemented in correctional settings. Because there is still considerable opposition to rehabilitation in any form, this paper next assesses the validity of the arguments against expanding drug treatment in corrections. The justification for treating prisoners and parolees rests primarily on the fact that there is a high correlation between drug abuse and crime and that certain types of treatment have been found to be effective in controlling relapse to drug use and recidivism. Each of these issues is discussed in subsequent sections. Based on an assessment of what works and what does not work in drug treatment, there are several guidelines we recommend following in establishing prison-based and aftercare drug treatment programs for offenders.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment OPPOSITION TO PRISON-BASED DRUG TREATMENT: A RESPONSE Although the number of prison-based drug treatment programs has increased during the past few years, there is still considerable opposition to them. Funds for prison construction and maintenance have clearly been given priority over funds for treatment. Policymakers who are against expanding drug treatment programs for convicted felons rest their case on several arguments: rehabilitation programs treat criminals too leniently; the public wants more criminals punished rather than more rehabilitation programs; and rehabilitation programs cost too much and do not work. Prisons, many contend, deter criminals and ensure that they receive their just deserts. Each of these arguments warrants serious consideration. To best understand the basis of these beliefs and their implications for drug treatment, a brief explanation of their origin is required. The Belief That ''Nothing Works" in Rehabilitation Perhaps the most important point to note is that much of the opposition to drug treatment for offenders stems from an opposition to correctional rehabilitation in general. During the mid-1970s, after a decade of social strife (antiwar demonstrations, prison riots, rising crime rates, drugs being used openly and their benefits popularly espoused), a consensus developed that reforms needed to be made in criminal justice (Cullen and Gendreau, 1989). The time had come for a social shift from turbulent conditions and libertine lifestyles to greater social order and morality. Indeterminant sentencing, the centerpiece of the rehabilitation philosophy for decades, became the target of both conservatives and liberals. They shared the view that prisons did not rehabilitate and found support for their beliefs in contemporary scientific research. Conservatives by and large perceived the problem as a lack of law and order in society. Their rhetoric focused on sharply rising crime rates, and the solution they sought was to "get tough" with criminals. Determinant sentencing and related policies, such as mandatory minimum sentencing, selective incapacitation, and the abolition of parole, would, in their view, control crime and ensure just deserts. Liberals in the main were disheartened with perceived social injustices and felt that indeterminant sentencing was causing gross inequities. Prisons were seen as "factories of crime" and not places of reform. Determinant sentencing in general, and sentencing and parole guidelines in particular—policies based on the "justice model"—would, according to the liberal prescription, ensure fairness and eliminate the abuses of discretionary authority. Thus, for
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment different reasons and with different reforms in mind, a consensus emerged that rehabilitation was no longer a primary function of the postadjudicatory system. The rhetoric against rehabilitation was bolstered by the fact that opponents of rehabilitation were able to corroborate their deeply held beliefs with scientific research findings. In 1974, Robert Martinson published a highly influential article in The Public Interest entitled "What Works?—Questions and Answers About Prison Reform." His central conclusion was that "[w]ith few and isolated exceptions, the rehabilitative efforts that have been reported so far have no appreciable effect on recidivism" (1974:25). The phrase, "nothing works," was thus coined and became an accepted part of the corrections vocabulary; it was treated as fact. The belief that "nothing works'' still has widespread acceptance and is one of the main reasons drug treatment programs are given low priority despite high recidivism rates, especially among drug-abusing offenders. But how true is it that ''nothing works?" Martinson's article was a more widely read popularization of a scholarly assessment of the outcomes of 30 years of rehabilitation efforts for criminal offenders, a project directed by Douglas Lipton in which Martinson participated. The basic conclusion of their book, The Effectiveness of Correctional Treatment, was that "the field of corrections has not as yet found satisfactory ways to reduce recidivism by significant amounts" (Lipton et al., 1975:627). Other authors reviewing evaluation studies of rehabilitation programs came to essentially the same conclusion (Bailey, 1966). Few people who espoused the view that nothing works questioned the validity of the research on which it was based or understood the problems inherent in the design of most treatment programs and in the methodologies used to evaluate them. They also did not recognize the difference between Martinson's pessimistic viewpoint and the more guarded conclusion of Lipton and colleagues, which left open the possibility that rehabilitation could work. So influential were the research findings in the policy debate about sentencing reform and rehabilitation that they became the subject of a scholarly assessment by the National Academy of Sciences. In its report, The Rehabilitation of Criminal Offenders, the Academy tempered the assessment that nothing works by stating that "we do not now know of any program or method of rehabilitation that could be guaranteed to reduce the criminal activity of released offenders" (Sechrest et al., 1979:3). Rather, it raised the question of whether some programs might work for certain types of offenders. Since that time, a growing body of evaluation studies has come under careful scrutiny, and several authors have concluded that certain rehabilitation programs effectively reduce recidivism (Gendreau, 1981; Gendreau and Ross, 1979, 1983-1984, 1987; Greenwood
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment and Zimring, 1985; Palmer, 1975; Van Voorhis, 1987). Ironically, a few years after publishing his "What Works?" article, Martinson revised his conclusion, based on further review of the research, in which he found that "some treatment programs do have an appreciable effect on recidivism" (1979:244). As Cullen and Gendreau state, "the doctrine of nothing works is best seen not as an established scientific truth, but as a socially constructed reality" (1989:30). Just the same, the generalized belief that nothing works has been, as we suggested earlier, a major factor in the reluctance of many policymakers to support prison-based drug treatment. Accordingly, we later present a detailed review of the evaluation research on drug treatment programs for offenders, focusing on what has been found to work. This research, all of it conducted since the studies reported by Lipton and coworkers, demonstrates that there are promising approaches to the treatment of drug-abusing offenders. In fact, a major outcome evaluation study conducted during the 1980s by Lipton and the present authors (Wexler et al., 1988b) demonstrates that the prison-based therapeutic community is a highly effective modality; this research in particular (summarized below) illustrates the profound changes that have taken place since the earlier assessment of rehabilitation. Indeed, there is sufficient scientific evidence for us to conclude that there are now, to quote the earlier statement of Lipton and associates, "satisfactory ways to reduce recidivism by significant amounts." Belief in Imprisonment The belief that nothing works is, as the evaluation literature demonstrates, a misconception. Just the same, it is often used to justify a policy of imprisonment for convicted felons. For many, this policy is based on a retributive ideology, which stems fundamentally from a desire to see offenders receive their just deserts. Policymakers who support imprisonment usually believe that the public wants offenders punished and that supporting treatment would be a show of leniency. This belief is supported by the argument that incarceration is the most, perhaps the only, effective means of controlling crime. Imprisonment, it is thought, will keep criminals off the streets (the incapacitation argument) and prevent them from recidivating afterwards (individual deterrence); in addition, others will refrain from crime, fearing the consequences (general deterrence). Because longer and more certain sentences lead to increases in prison populations and because court orders limit overcrowding, more prisons must be built. Thus, resources should be allocated for prison construction, not treatment programs.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Our basic response to these beliefs is that support for drug treatment programs is consistent with the goals of a policy of incarceration. In other words, offenders can be punished and society protected by placing them in drug treatment programs while they are in prison and on parole. Indeed, to alter the criminal proclivities of some offenders, it may be necessary for them to both serve a term in prison and receive treatment for their substance abuse. Furthermore, the fact that recidivism rates continue to be high gives one reason to question the belief that incarceration is an effective deterrent. Thus, the issue is whether drug treatment programs for prisoners and parolees can reduce recidivism better than the current practice, which limits treatment. Because of the high correlation between drug abuse and recidivism, we believe it is in the public interest to place offenders in the kinds of prison-based and community treatment programs that have been found to be effective. During the past decade, the number of inmates in the nation's prisons doubled, approaching nearly three-quarters of a million. The vast majority (more than 80 percent) are recidivists; about three-quarters previously used drugs (Innes, 1988). Many of these prisoners have severe substance abuse problems. Indeed, about one-third of the inmates previously used a major drug (heroin, methadone, cocaine, LSD [lysergic acid diethylamide], PCP [phencyclidine]) on a regular basis; more than half reported using drugs during the month prior to committing the crime for which they were incarcerated (Innes, 1988). Slightly more than half were under the influence of alcohol or drugs, or both, at the time of the offense for which they were incarcerated. Some of these inmates are predatory criminals with severe substance abuse problems; they are responsible for an extraordinary amount of crime and are involved in a variety of violent crimes, property offenses and drug deals. Indeed, the extensive research on the relationship between drug abuse and crime (summarized in the next part of this paper) provides convincing evidence that a relatively few severe substance abusers are responsible for an extraordinary proportion of crime (Gropper, 1985, based on the work of Johnson et al., 1985; Ball et al, 1983; and Inciardi, 1979). Because of the seriousness of their crimes and their criminal records, many of these drug-abusing offenders are incarcerated; therefore, a logical, cost-effective, and convenient point of intervention is while they are in prison and on parole. Without treatment in prison, a high percentage will relapse to drug use after release and will return to crime. These behaviors are part of a lifestyle that is both highly destructive and resistant to change. In fact, about one-quarter of the drug users in prison were previously in treatment (Bureau of Justice Statistics, 1983). There is, however, enough evidence (described later) to demonstrate that even the most severe offenders, that
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment is, career criminals with chronic polydrug abuse problems, can be effectively treated. Yet despite this evidence, corrections has, for the most part, made limited attempts to institute programs aimed at treating substance abusers in prison and on parole. Some legislators oppose drug treatment in prisons because they believe that correctional officials do not want these programs in their institutions. Although there are some wardens who do not believe in treating inmates with drug abuse problems, the issue is really more a matter of priorities. Currently, the overriding concern of correctional authorities is to ensure that they have adequate space to house inmates. Their budgetary needs reflect a priority for additional prison space over rehabilitation programs. In some cases, correctional officials may also be in conflict among themselves as to where to treat offenders; that is, they may disagree over whether resources should be allocated to community-based or prison-based programs. Furthermore, prison administrators may sometimes feel that prison-based treatment programs make it more difficult for them to manage inmate housing. (This problem occurs when they dedicate a separate housing unit to the program in an attempt to separate general population inmates from program residents.) Although correctional officials do have legitimate concerns about the priority of prison-based drug treatment programs, we believe they are more than offset by the programs' advantages. In addition to their effect on recidivism, the major benefit of prison-based drug treatment programs is that they enhance security in institutions. Drug use and drug dealing (which are rampant in many prisons) decline with the introduction of drug treatment programs and random urinalysis testing (Vigdal and Stadler, 1989). Infractions of prison rules as well as violence and threats of violence also decline, and the danger of prison riots is reduced. In fact, there have been instances in which inmate leaders in drug treatment programs quelled disturbances that could have led to rioting. Correctional authorities evidently recognize the value of treating prisoners for their drug abuse and have given it increasing priority during the past decade. Between 1979 and 1987, the percentage of inmates in some form of treatment tripled. Many policymakers, especially legislators, oppose funding for prison-based drug treatment programs because they believe that the public wants offenders punished and that treatment programs coddle criminals. Although it is true that Americans want criminals punished and that there has been a substantial decline in public support for rehabilitation since the late 1960s, Cullen and Gendreau (1988) provide evidence that "support for rehabilitation remains surprisingly strong." For example, although only 12 percent of Michigan policymakers assumed that citizens favored prison rehabilitation, 66 percent of the public believed rehabilitation should be
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment a primary goal of prisons (cited in Cullen and Gendreau, 1988). This is not an isolated finding; Cullen and Gendreau note several other national and state surveys that show that the public still believes in prison rehabilitation. According to a study commissioned by the Edna McConnell Clark Foundation, citizens want "assurances of safety much more than they want assurances of punishment," and they "want prisons to promote rehabilitation as a long-term means of controlling crime" (Public Agenda Foundation, 1987:5; cited in Cullen and Gendreau, 1988). As we conclude from the evidence on the relationship between drug use and crime and the existence of effective treatment programs (described in the next two parts of this paper) prison-based drug treatment is essential as a means of protecting society. Furthermore, good drug treatment programs do not coddle criminals; residents usually find these programs quite demanding because of the profound changes in attitudes and behaviors they require. THE NEED FOR DRUG TREATMENT IN PRISONS Although a small percentage of the nation's prisoners receive drug treatment, there is still a considerable need for effective treatment programs. Estimates by social science researchers and correctional authorities indicate that as much as 70 to 80 percent of the nation's prisoners used drugs prior to incarceration; however, only about 10 percent are in prison-based treatment programs (Chaiken, 1989; Innes, 1988). Drug-dependent offenders are responsible for a substantial, indeed disproportionate amount of crime in comparison with offenders who do not use drugs. Studies of serious substance abusers, in particular, offenders who use heroin and cocaine, show that they have extremely high crime rates. As the extent of abuse increases, the frequency and severity of their crimes escalate. Furthermore, many of these drug users are also involved in drug dealing, an enterprise that also has an attendant effect on other forms of crime, especially crimes of violence. A review of the empirical studies of the association between drug use and crime provides an appreciation of the enormous impact of drug abuse on crime. The Relationship Between Drug Use and Crime Numerous studies consistently report exceedingly high crime rates among substance abusers, especially heroin and cocaine abusers. Although cocaine and crack use have increased dramatically in the past few years and many prisoners are dependent on these drugs, only a few research studies of the relationship between crack and crime have been completed. Thus,
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment the following discussion focuses primarily on the connection between heroin use and crime, highlighting the effects of cocaine and crack use where research evidence is available. Inciardi (1979) has reported that active heroin users commit an average of 423 crimes per arrest. Johnson and colleagues report that the average heroin abuser in New York City commits more than 1,000 crimes (including crimes for money, drug dealing, and minor offenses such as shoplifting) per year (1985:77). During periods of daily heroin use, the average offender commits 100 to 300 crimes a year, including robbery and a variety of property crimes (Johnson et al., 1985). Such users commit thousands of crimes during their drug abuse careers, according to studies in New York, Miami, Baltimore, California, Michigan, and Texas (Chaiken, 1986; Johnson et al., 1985). Not only do drug-dependent offenders commit a substantial amount of crime, but as the frequency of abuse increases, so does the frequency of crime (Ball, 1986; Ball et al., 1981; Chaiken and Chaiken, 1983; Johnson et al., 1985; McGlothlin et al., 1977). During times when offenders use heroin or cocaine daily, they commit two to six times as much crime as when they use these drugs less frequently (Ball et al., 1982; Speckart and Anglin, 1986). Ball and coworkers (1981) found that daily heroin users commit more than six times as much crime as offenders who use heroin less than daily. In this study, daily heroin abusers reported an average of 248 "crime-days" (24-hour periods in which an individual commits one or more crimes) per year at risk, whereas nondaily users reported only 40.8 crime-days per year at risk. Similarly, Johnson and associates (1985) reported that daily heroin users (six or seven days per week) claimed an average of about 1,400 crimes (including crimes for money, drug dealing, and minor offenses such as shoplifting) per year; however, regular heroin users (three to five days per week) committed about 1,200 crimes, and irregular users (one or two days per week) committed only about 500 crimes. Research on the relationship between crime and cocaine use demonstrates that, as the frequency of cocaine use increases, criminal activity also increases (Collins et al., 1985; Hunt et al. 1986). As the frequency of drug use increases, the severity of the crimes committed also increases. Criminal income is approximately $55,000 annually during periods of daily cocaine or heroin use, but it is less than half as much during periods of less regular use (Collins et al., 1985; Johnson et al., 1985; Speckart and Anglin, 1986). The most serious crimes (robbery, burglary, aggravated assault) are common during daily cocaine or heroin use but rare during periods of nondaily use (Ball et al., 1983; Chaiken and Chaiken, 1982; Hunt et al., 1984; Speckart and Anglin, 1986). A study of career criminals found that a majority of the most violent criminals were heroin users, and most of these were daily users with high-cost heroin habits (more than $50 per day, Chaiken, 1986). Crack abusers
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment appear to commit an equal if not greater number of crimes than heroin abusers. Whereas heroin abusers tend to commit more property crimes (e.g., burglary, larceny), crack abuse seems to have accelerated the rates of violence, drug dealing, and sexual crimes, as well as robbery (Goldstein et al., 1989, 1990; Johnson et al., in press). In addition to property crimes and crimes of violence, drug-dependent offenders are also heavily involved in drug dealing. Estimates range from 100 to more over 1,000 drug distribution crimes per year, depending on the location and type of heroin abuser studied. Chaiken and Chaiken (1982) found that their sample of incarcerated felons claimed 90 to 160 drug sales per year. Johnson and colleagues (1985) report that daily heroin users commit about 1,000 drug distribution crimes each year. In addition to direct sales of drugs, illegal drug distribution activities include directing customers to dealers ("steering"), recruiting customers for dealers ("touting"), and buying drugs for customers ("copping"). Involvement in drug dealing perpetuates criminal activity of all sorts. Drug dealing and drug use often involve violence, as reported in the ethnographic work of Goldstein (1985, 1989). According to Goldstein, violence and threats are utilized to enforce and maintain smooth operations of the drug distribution system. Lower level dealers are controlled by threats of violence, and upper level distributors are often targets for violent "rip-offs" by drug users and dealers. Statistical reports indicate that 20 to 30 percent of homicides are drug related (McBride, 1981; New York City Police Department, 1983). Estimates in 1988 are that more than 50 percent of New York City's homicides are drug related (Goldstein et al., 1989). The prevalence of drugs and alcohol in criminal populations has recently been studied. Wish and associates pioneered the use of urinalysis in a series of studies of male arrestees in New York City to reveal the presence of illegal drugs at the time of arrest (Wish et al., 1984). (It is assumed that most of the arrests occurred shortly after the crime.) They found that 80 percent of arrestees charged primarily with serious nondrug crimes tested positive for one or more drugs (primarily cocaine and heroin). This basic finding has been replicated in 12 large cities that participate in the National Institute of Justice's Drug Use Forecasting (DUF) system (1988). Between April and June 1988, 50 percent or more of male arrestees in 10 of the cities tested positive for one or more drugs (excluding marijuana). In New York City, 83 percent tested positive for cocaine, and 27 percent tested positive for heroin. Several other studies have provided information on the actual utility of drugs in criminal activity among samples of hard drug users (Goldstein et al., 1990; Strug et al., 1984). Large amounts of alcohol, cocaine, and heroin are often ingested by criminals before and after a crime to reduce
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment their anxiety and enhance their courage. The proceeds from the crime are then used to obtain additional drugs and alcohol. Assessing the Drug-Crime Connection from a Treatment Perspective Although the relationship between drug use and crime illustrates the need for prison-based treatment, the precise nature of causality is more of theoretical interest than of practical value as far as treatment is concerned. In other words, one does not have to debate whether crimes are committed because of the pharmacological properties of drugs or whether they are economically motivated (to finance drug habits or to enhance power in the drug distribution system). The important point is that, for many prisoners, both crime and substance abuse (including alcohol as well as illicit drugs) are inextricably tied into a lifestyle characterized by hedonistic, self-destructive, and antisocial behaviors. The most significant manifestation of this lifestyle is polydrug use (but it also includes problems related to poor interpersonal skills, a lack of job skills, dependency on others, and frequent conflict with criminal justice authorities). The use of expensive drugs (heroin and cocaine, in particular) is highly related to crime; discerning whether the use of other substances (such as PCP, marijuana, and alcohol) causes crime is less important than understanding that for many offenders the use of these substances is also part of an antisocial lifestyle, which often involves polydrug use (Collins et al., 1985). Although a large proportion of the nation's prisoners lead a lifestyle associated with problems of drug abuse, only a small percentage receive treatment while in prison. Few of these programs, however, are intensive enough to have a significant effect on relapse and recidivism (most programs offer only drug education, Alcoholics Anonymous meetings, occasional counseling, or other limited services). Without effective treatment for their drug use and related lifestyle problems, the likelihood that they will recidivate is quite high. Can treating them in prison reduce their criminality after they return to the community? As the next section demonstrates, there is enough evidence that drug treatment is an effective means of controlling recidivism and that intensive programs such as therapeutic communities are well suited to serious drug abusers in prisons.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment PROJECT REFORM: A NATIONAL PROJECT TO ESTABLISH DRUG TREATMENT PROGRAMS IN CORRECTIONS Project REFORM (Comprehensive State Department of Corrections Treatment Strategy for Drug Abuse) was funded by the Bureau of Justice Assistance in July 1987 and attempts to develop drug treatment programs in corrections settings based on the guidelines described in the previous section. As such, this project provides a rare opportunity to bridge the realms of abstract concepts and concrete reality. Narcotic and Drug Research, Inc., was asked to serve as the national coordinator for the REFORM technical assistance project, with the goal of assisting states to plan for and then implement or expand statewide drug treatment and rehabilitation strategies in state departments of corrections. The project provides funding, guidance, technical assistance, training, and monitoring for two phases: (1) a planning phase (lasting 6 months to a year) in which a comprehensive state plan for correctional substance abuse treatment is developed; and (2) an implementation phase (approximately 18 months) for states that successfully complete the planning phase. Currently, seven states (Alabama, Connecticut, Delaware, Florida, New Mexico, New York, and Oregon) have completed the planning phase and are engaged in implementation; California, Hawaii, New Jersey, and Washington are currently participating in the planning phase. Overall, then, this program assists states in developing a comprehensive set of drug treatment programs through a statewide correctional strategy for dealing with drug offenders. The strategies are developed on the basis of research that has demonstrated effective models of drug treatment. A major goal of the project is to reduce recidivism; other goals relate broadly to improving drug treatment in corrections. A major target group of the project is inmates with chronic drug abuse problems. CONCLUSION: THE FUTURE OF DRUG TREATMENT IN CORRECTIONS The trend in corrections during recent years has been for more prisoners to receive some form of drug treatment. Because policymakers and the public are concerned about drug abuse and crime, it is likely that this trend will continue. In this conclusion, we suggest a direction for the future that is likely to be a constructive, if only partial, solution to the crime problem. The complexity of the problem and the limitations in both the current state of knowledge and practice suggest that a period of experimentation
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment with treatment interventions is needed and that new techniques should be thoroughly evaluated. The guidelines presented earlier represent our best judgment as to what approaches offer promise for the future of correctional drug treatment. Our assessment of the situation, however, is constrained by the fact that the evidence of effective interventions is limited, as is the current state of the art in correctional treatment. Accordingly, corrections should expand on what currently works, and it should attempt innovative approaches in the future. These interventions should be carefully evaluated so that drug treatment in correctional settings can be modified based on the best available scientific knowledge. As our guidelines suggest, a logical starting point is to increase the number of chronic polydrug abusers in intensive prison-based treatment programs and enable them to continue their recovery in residential programs after they are released. Currently, corrections offers a variety of treatment options, such as Alcoholics Anonymous meetings, counseling, and drug education. We need to know much more about the effectiveness of these and other approaches. In particular, what kinds of treatment are appropriate for different types of offenders? Moreover, emphasis should be placed on developing cooperation between drug treatment providers and custodial staff. This effort can be assisted, for example, by cross-training treatment staff in security and correctional officers in treatment. Coordination between correctional treatment providers and other human services providers (educational, vocational, medical, social, and psychological) needs to be improved. Similarly, community resources need to be mobilized and integrated into an improved continuity of care system. In addition to expanding on current practice, new program innovations should be attempted. For example, there is some evidence that shock incarceration is effective with youthful offenders (MacKenzie and Shaw, 1988); combining shock incarceration with an intensive drug treatment program for addicts might be a valuable approach. New techniques in intensive parole supervision can also be implemented. Developments in community-based drug treatment should be considered for their possible inclusion in correctional settings. Chemotherapy treatment is another possibility. For example, research currently under way at a methadone program in the jail on Rikers Island suggests that this might be an effective intervention (Magura et al., 1989). Although there are no methadone maintenance programs in prisons at this time, an experiment to see if such a program could stabilize heroin addicts in prison so that they can continue treatment in community-based programs after release might be worth trying. Regardless of the specific innovations that are attempted, they must all be properly tested. Evaluation research should search especially for cost-effective strategies for reducing recidivism (that is, strategies that do
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment not negatively affect other policy goals such as maintaining security and controlling overcrowding). Our ability to reduce recidivism among drug users depends almost entirely on our ability to develop effective intervention techniques and our ability to reach agreement on which programs to fund. ACKNOWLEDGMENT This project was supported in part by Grants No. 87-DD-CX-K060 and 88DD-CX-0008 awarded by the Bureau of Justice Assistance, Office of Justice Programs, U.S. Department of Justice. REFERENCES Allison, M., and R.L. Hubbard (1985) Drug abuse treatment process: a review of literature. International Journal of the Addictions 20(9):1321-1345. Anglin, M.D., and W.H. McGlothlin (1984) Outcome of narcotic addict treatment in California. In F.M. Tims and J.P. Ludford, eds., Drug Abuse Treatment Evaluation: Strategies, Progress and Prospects. NIDA Research Monograph 51. Rockville, Md.: National Institute on Drug Abuse. Anglin, M.D., M.L. Brecht, J.A. Woodward, and D.G. Conett (1986) An empirical study of maturing out: conditional factors. International Journal of the Addictions 21:233-246. Annis, H., and C.S. Davis (1987) Self-efficacy and the treatment trial. In T.B. Baker and D. Cannon, eds., Addictive Disorders: Psychological Research in Assessment and Treatment. New York: Praeger. Bailey, W.C. (1966) Correctional outcome: an evaluation of 100 reports. Journal of Criminal Law, Criminology and Police Sciences 57:153-160. Bale, R.N. (1979) Outcome research in a therapeutic community for drug abusers: a critical review . International Journal of the Addictions 14(8):1053-1074. Ball, J.C. (1986) The hyper-criminal opiate addict. Pp. 81-104 in B.D. Johnson and E. Wish, eds., Crime Rates Among Drug Abusing Offenders: Final Report to the National Institute of Justice. New York: Narcotic and Drug Research, Inc. Ball, J.C., L. Rosen, S.A. Flueck, and D.N. Nurco (1981) The criminology of heroin addicts when addicted and when off opiates. Pp. 39-65 in J.A Inciardi, ed., The Drugs-Crime Connection. Beverly Hills, Calif.:
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Goldstein, P.J. (1985) Drugs and violent crime. Pp. 16-48 in N.A. Weiner and M.E. Wolfgang, eds., Pathways to Criminal Violence. Beverly Hills, Calif.: Sage Publications. Goldstein, P.J., H.H. Brownstein, P.J. Ryan, and P.A. Bellucci (1989) Crack and Homicide in New York City, 1988: A Conceptually-Based Event Analysis. New York: Narcotic and Drug Research, Inc. Goldstein, P.J., P.A. Bellucci, B. Spunt, and T. Miller (1990) Frequency of Cocaine Use and Violence: A Comparison Between Men and Women. New York : Narcotic and Drug Research; Inc. Greenwood, P.W., and F.E. Zimring (1985) One More Chance: The Pursuit of Promising Intervention Strategies for Chronic Juvenile Offenders. Santa Monica, Calif.: The Rand Corporation. Gropper, B.A. (1985) Probing the Links Between Drugs and Crime. Washington, D.C.: U.S. Department of Justice. Hubbard, R.L., J.V. Rachel, S.G. Craddock, and E.R. Cavanaugh (1984) Treatment outcome prospective study (TOPS): client characteristics and behaviors before, during, and after treatment. Pp. 29-41 in F.M. Tims and J.P. Ludford, eds., Drug Abuse Treatment Evaluation: Strategies, Progress and Prospects. NIDA Research Monograph 51. DHHS Pub. No. (ADM) 84-1349. Rockville, Md.: National Institute on Drug Abuse. Hubbard, R.L, J.J. Collins, J.V. Rachel, and E.R. Cavanaugh (1988) The criminal justice client in drug abuse treatment. Pp. 57-80 in C.G. Leukefeld and F.M. Tims, eds., Compulsory Treatment of Drug Abuse: Research and Clinical Practice. NIDA Research Monograph 86. Rockville, Md.: National Institute on Drug Abuse. Hunt, D.E., D.S. Lipton, and B. Spunt (1984) Patterns of criminal activity among methadone clients and current narcotics users not in treatment. Journal of Drug Issues Fall:687-702. Hunt D.E., B.J. Spunt, D.S. Lipton, D.S. Goldsmith, and D.L. Strug (1986) The costly bonus: cocaine related crime among methadone treatment clients. Advances in Alcohol and Substance Abuse 6(2, Winter):107-122. Inciardi, J.A. (1979) Heroin use and street crime. Crime and Delinquency 25(3):335-346. Innes, C.A. (1988) Profile of State Prison Inmates: 1986. Bureau of Justice Statistics Special Report. Washington, D.C.: U.S. Department of Justice. Johnson, B.D., P. Goldstein, E. Preble, J. Schmeidler, D.S. Lipton, B. Spunt, and T. Miller (1985) Taking Care of Business: The Economics of Crime By Heroin Abusers. Lexington, Mass.: Lexington Books. Johnson, B.D., D.S. Lipton, and E.D. Wish (1986) Facts About the Criminality of Heroin and Cocaine Abusers and Some New Alternatives
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment to Incarceration. New York: Narcotic and Drug Research, Inc. Johnson, B.D., T. Williams, K.A. Dei, and H. Sanabria (in press) Drug abuse in the inner city: impact on hard-drug users and the community. In J.Q. Wilson and M Tonry, eds., Drugs and Crime. Crime and Justice Series, Vol. 13. Chicago: University of Chicago Press. Kalish, C.B., and W.T. Masumura (1983) Prisoners and Drugs. Bureau of Justice Statistics Bulletin. Washington, D.C.: U.S. Bureau of Justice. Kassebaum, G., D. Ward, and D. Wilner (1971) Prison Treatment and Parole Survival: An Empirical Assessment. New York: John Wiley & Sons, Inc. Leukefeld, C.G., and F.M. Tims (1988) Compulsory Treatment of Drug Abuse: Research and Clinical Practice. NIDA Research Monograph 86. Rockville, Md.: National Institute on Drug Abuse. Lipton, D. (1983) Important conditions for successful rehabilitation. Paper presented at the Bellevue Forensic Psychiatry Conference, New York City. Lipton, D.S. (1989) The Prevention of Recidivism: A Manifesto Regarding the Role of Rehabilitation for Drug Abusing Offenders. New York: Narcotic and Drug Research, Inc. Lipton, D.S. (1990) Principles of successful correctional intervention. Paper presented at the Bureau of Justice Statistics/State Justice Institute Regional Seminar: Drugs and the Judicial Response, Washington, D.C. Lipton, D.S., and H.K. Wexler (1988) Breaking the drug-crime connection—rehabilitation projects show promise. Corrections Today 50(5):144-147. Lipton, D., R. Martinson, and J. Wilks (1975) The Effectiveness of Correctional Treatment. New York: Praeger Publishers. Magura, S., H. Joseph, and A. Rosenblum (1989) Methadone Maintenance in the New York City Jails. New York: Narcotic and Drug Research, Inc. Macdonald, D.G., and K. Canestrini (1987) Follow-up Study of a Sample of Participants in the Stay'n Out Drug Program. Albany, N.Y.: New York State Department of Correctional Services. MacKenzie, D.L., and J.W. Shaw (1988) Inmate adjustment and change during shock incarceration. Paper presented at a meeting of the American Society of Criminology, Chicago. Maltz, M.D. (1984) Recidivism. Orlando, Fla.: Academic Press, Inc. Martinson, R. (1974) What works? Questions and answers about prison reform. The Public Interest 35:22-45. Martinson, R. (1979) New findings, new views: a note of caution
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment regarding sentencing reform. Hofstra Law Review 7:243-258. McBride, D. (1981) Drugs and violence. In J.A Inciardi, ed., The Drugs/Crime Connection. Beverly Hills, Calif.: Sage Publications. McGlothlin, W.C., D.M. Anglin, and B.D. Wilson (1977) An Evaluation of the California Civil Addict Program. Rockville, Md.: National Institute on Drug Abuse. McGlothlin, W.H., M.D. Anglin, and D.B. Wilson (1978) Narcotic addiction and crime. Criminology 16:293-315. Nash, G. (1973) The Impact of Drug Abuse Treatment Upon Criminality: A Look at 19 Programs. Upper Montclair, N.J.: Montclair State College. National Institute of Justice (1988) Drug Use Forecasting (DUF): April Through June 1988 Data. Washington, D.C.: U.S. Department of Justice. National Institute on Drug Abuse (1981) Drug Abuse Treatment in Prisons. Treatment Research Report Series. DHHS Pub. No. (ADM) 81-1149. Rockville, Md.: National Institute on Drug Abuse. New York City Police Department (1983) Homicide analysis: 1981. New York. New York State Division of Substance Abuse Services (1980) Prison drug program evaluation report. Albany, New York. Nietzel, M.T. (1979) Crime and Its Modification: A Social Learning Perspective. Elmsford, N.Y.: Pergamon Press. Palmer, T. (1975) Martinson revisited. Journal of Research in Crime and Delinquency 12:133-152. Platt, J., C. Labate, and R. Wicks (1977) Evaluative Research in Correctional Drug Treatment. Lexington, Mass.: Lexington Books. Platt, J.J., G.M. Perry, and D.S. Metzger (1980) The evolution of a heroin addiction treatment program within a correctional environment. In R.R. Ross and P. Gendreau, eds., Effective Correctional Treatment. Toronto: Butterworths. Public Agenda Foundation (1987( Crime and Punishment: The Public's View. New York: Edna McConnell Clark Foundation. Quay, H.C. (1977) The three faces of evaluation: what can be expected to work? Criminal Justice and Behavior 4:341-354. Ross, R.R., and P. Gendreau (1980) Effective Correctional Treatment. Scarborough, Ont.: Butterworths. Ross, R.R, E.A. Fabiano, and H.B. McKay (1978) Treatment in corrections: requiem for a panacea. Canadian Journal of Criminology 20:279-295. Sechrest, L, S.O. White, and E.D. Brown (1979) The Rehabilitation of Criminal Offenders: Problems and Prospects. Washington, D.C.: National Academy of Sciences.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Sells, S.B., D. Simpson, G. Joe, R. Demaree, L. Savage, and M.A. Lloyd (1976) National follow-up study to evaluate the effectiveness of drug abuse treatment: A report of cohort 1 of the DARP five years later. American Journal of Drug and Alcohol Abuse 3(4):545-556. Shearer, A, and J.B. Moore (1978) Personality dimensions of felonious probationers in Texas. Paper presented to the American Society of Criminology, Dallas, Texas. Simpson, D.D. (1979) The relation of the time in drug abuse treatment to post treatment outcomes. American Journal of Psychiatry 136:1449-1453. Simpson, D.D. )1980) Follow-up Outcomes and Length of the Time Spent in Treatment for Drug Abuse. Ft. Worth, Tex.: Institute of Behavioral Research, Texas Christian University. Simpson, D.D. (1984) National treatment system evaluation based on the Drug Abuse Reporting Program (DARP) followup research. Pp. 2941 in F.M. Tims and J.P. Ludford, eds., Drug Abuse Treatment Evaluation: Strategies, Progress and Prospects. NIDA Research Monograph 51. DHHS Pub. No. (ADM) 84-1239. Rockville, Md.: National Institute on Drug Abuse. Simpson, D.D., and J.H. Friend (1988) Legal status and long-term outcomes for addicts in the DARP followup project. Pp. 81-98 in C.G. Leukefeld and F.M. Tims, eds., Compulsory Treatment of Drug Abuse: Research and Clinical Practice. NIDA Research Monograph 86. Rockville, Md.: National Institute on Drug Abuse. Simpson, D.D., and S.B. Sells (1982) Effectiveness of treatment for drug abuse: an overview of the DARP research program. Advances in Alcohol & Substance Abuse 2(1):7-29. Speckart, G., and M.D. Anglin (1986) Narcotics use and crime: a causal modeling approach. Journal of Quantitative Criminology 2:3-28. Strug, D.L, E.D. Wish, B.D. Johnson, K. Anderson, and T. Miller (1984) The role of alcohol in the crimes of heroin abusers. Crime and Delinquency 30(4):551-567. System Sciences, Inc. (1973) A comparative analysis of twenty-four therapeutic communities in New York City. Prepared for the Addiction Services Agency of the City of New York, December. Tims, F.M., and J.P. Ludford (1984) Drug Abuse Treatment Evaluation: Strategies, Progress and Prospects. NIDA Research Monograph 51. DHHS Pub. No (ADM) 84-1349. Rockville, Md.: National Institute on Drug Abuse. Toborg, M.A., J.B. Bellassai, A.M.J. Yezer, J. Carver, J. Clarke, and E. Pears (1986) The Washington, D.C. urine testing program for arrestees and defendants awaiting trial: a summary of interim findings. Toborg Associates, Washington, D.C.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Van Voorhis, P. (1987) Correctional effectiveness: the high cost of ignoring success. Federal Probation 51(March):56-62. Vigdal, G.L., and D.W. Stadler (1989) Controlling inmate drug use: cut consumption by reducing demand. Corrections Today 51(3):96-97. Wexler, H.K. (1986) Therapeutic communities within prisons. Pp. 227-237 in G. De Leon and J. Ziegenfuss, Jr., eds., Therapeutic Communities for Addictions. Springfield, Ill.: Charles C Thomas. Wexler, H.K., and J. Chin (1981) Evaluation of a system to evaluate prison based drug treatment. Paper presented at the Eastern Evaluation Research Society Conference, Philadelphia. Wexler, H.K., and V.A Lostlen (1979) Implementation of a prison therapeutic community for substance abusers: an environmental evaluation. Paper presented at the Eastern Psychological Association, Philadelphia. Wexler, H.K, and R. Williams (1986) The Stay'n Out therapeutic community: prison treatment for substance abusers. Journal of Psychoactive Drugs 18(3):221-230. Wexler, H.K., D.S. Lipton, and B.D. Johnson (1988a) A Criminal Justice System Strategy for Treating Cocaine-Heroin Abusing Offenders in Custody. Washington, D.C.: U.S. Department of Justice. Wexler, H.K, G.P. Falkin, and D.S. Lipton (1988b) A Model Prison Rehabilitation Program: An Evaluation of the Stay'n Out Therapeutic Community. New York: Narcotic and Drug Research, Inc. Wexler, H.K., G.P. Falkin, and D.S. Lipton (1990) Outcome evaluation of a prison therapeutic community for substance abuse treatment. Criminal Justice and Behavior 17(1):71-92. Wish, E.D., E. Brady, and M. Cuadrado (1984) Drug use and crime in arrestees in Manhattan. Paper presented at the 47th Meeting of the Committee on Problems of Drug Dependence. Narcotic and Drug Research, Inc., New York. Wish, E.D., and B.D. Johnson (1986) The impact of substance abuse on criminal careers. Pp. 52-58 in A. Blumstein et al., eds., Criminal Careers and Career Criminals, Vol. 2. Washington, D.C.: National Academy Press.
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Representative terms from entire chapter: