behind bars ii: substance use and america’s prison population

BEHIND BARS II:

SUBSTANCE USE AND

AMERICA’S PRISON

POPULATION

A Report by

CASAColumbia®

February 2010

© CASAColumbia 2013

Purpose of Study

• Define size and characteristics of prison population—particularly

substance-involved offenders

• Identify promising practices to reduce substance-related crime and

its costs

• Assess costs and benefits of providing treatment

2


Reviewers

• Steven Belenko, Ph.D., Professor of Criminal Justice, Temple University

• James R. McDonough, former Director of Strategy, White House Office of National Drug Control Policy, and former Secretary, Florida Department of Corrections

• Faye S. Taxman, Ph.D., Professor, Administration of Justice, George Mason University

3


Methodology

• Analyzed 11 federal data sources on offenders

• Reviewed > 650 articles/publications

• Examined practices in prevention, intervention and treatment for substance-involved offenders

• Reviewed accreditation standards

• Analyzed costs and benefits of treatment for offenders with substance use disorders

4


Substance-Involved Offenders

• Had history of using illicit drugs regularly or of alcohol treatment

• Met medical criteria for alcohol and/or other drug abuse and/or dependence

• Were under the influence of alcohol or other drugs at time of crime

• Committed crime to get money to buy drugs

• Were incarcerated for an alcohol or drug law violation, or

• Shared some combination of these characteristics

5


Key Findings

• Only 11% get treatment

• In 2006, 85% (1.9 million) inmates substance-involved

• 65% (1.5 million) inmates meet medical criteria for a substance use disorder

• Failure to prevent and treat addiction in the justice system increases crime and government costs

6


Growth in Inmate

Population 1996-2006

7

12.5

32.8

43.2

% Increase in USPopulation

% Increase in US InmatePopulation

% Increase in USSubstance-Involved

Inmate Population

Substance-Involved Inmate Population Increasing

Faster Than U.S. and Total Inmate Populations

Source: CASA analysis of U.S. Census Bureau (2000 and 2008); CASA analysis of the Survey

of Inmates in Federal Correctional Facilities (1991 and 2004), Survey of Inmates in State

Correctional Facilities (1991 and 2004), Survey of Inmates in Local Jails (1989 and 2002) [Data files], and U.S. Bureau of Justice Statistics Reports, Prisoners in (1996 and 2006).


Substance-Involved Inmates

8

2006

Total Substance

Involved

% Substance

Involved

Federal Prison 190,884 164,521 86.2

State Prison 1,302,129 1,101,779 84.6

Local Jail 766,010 648,664 84.7

Total 2,258,983 1,914,964 84.8


Inmates by Type of Crime

9

37.0

29.2

19.2

13.3

Violent Alcohol/Drug Property Other

Note: An additional 1.3% of Inmates committed crimes that were not specified.

Source: CASA analysis of the Survey of Inmates in Federal Correctional Facilities

(2004), Survey of Inmates in State Correctional Facilities (2004), Survey of Inmates in

Local Jails (2002) [Data files], and U.S. Bureau of Justice Statistics Reports, Prisoners

in 2006.

Percent of Federal, State and Local Inmates

by Type of Crime Committed


Inmates Committing

Violent Crimes

10

77.5

57.7

Substance Involved Alcohol Involved

Percent


(2004), Survey of Inmates in State Correctional Facilities (2004), Survey of Inmates

in Local Jails (2002) [Data files], and U.S. Bureau of Justice Statistics Reports, Prisoners in 2006.


Inmates Committing

Property Crimes

11

83.4

55.9


Percent





Inmates Committing

Other Crimes

12

76.9

51.6


Public Order, Immigration or Weapons Offenses or Supervision Violations

Percent





Few Incarcerated for Marijuana

Possession Only

13

2.0

1.10.9

Total Marijuana Possession asControlling Offense

Marijuana Possession asOnly Offense

Percent of Inmates



in Local Jails (2002) [Data files], and U.S. Bureau of Justice Statistics Reports,

Prisoners in 2006.


Tobacco Use High

Among Inmates

14

24.938.6

51.5

37.8

66.5

GeneralPopulation

Federal*Inmates

Federal*Inmates with

Substance UseDisorders

State* Inmates State* Inmateswith Substance

Use Disorders

* Smoked in month before arrest.

Percent Current Smokers


(2004) and Survey of Inmates in State Correctional Facilities (2004) [Data files]; Substance Abuse and Mental Health Service Administration (2006).


Substance Use/

Mental Health Disorders

15

64.5

32.924.4

Substance Use Disorders Mental Health Disorders Co-Occurring SubstanceUse and Mental Health

Disorders

Inmates 7 times likelier to have an alcohol/other drug disorder than general population.

Percent of Inmates





Substance-Involved

Inmates Are:

• 41% likelier to have family w/criminal history (43% vs. 30%)

• Almost twice as likely to have had at least one parent abuse alcohol/other drugs (35 vs. 18%)

• 29% less likely to have at least a high school education (30% vs. 39%)

…than inmates who are not substance involved

16


Criminal Careers

Substance-involved inmates likelier than non-substance involved inmates to:

• Begin criminal careers at earlier age

• 4 times likelier to receive income through illegal activity (25% vs. 6%)

• Have more contacts with the criminal justice system

• Be re-incarcerated for another offense (52% vs. 31%)

17


Inmate Parents

• U.S. inmates are parents to > 2.2 million minor children

• 74% of inmate children (1.7 million) are age 12 or younger

• Minor children of incarcerated parents at much higher risk of:

Juvenile delinquency

Adult criminality

Alcohol/other drug use

…than minor children of non-incarcerated parents

18


Substance Use

Disorders Among Inmates

By Race

• 73% White (non-Hispanic)

• 70% Native American

• 60% Black (non-Hispanic)

• 58% Hispanic

• 51% Asian, Hawaiian, Pacific Islander, Other

19


Women Inmates

• 8.4% of inmate population

• Compared with male inmates, female inmates have higher rates of:

Substance use disorders (66% vs. 64%)

Mental health disorders (55% vs. 31%)

Co-occurring disorders (41% vs. 23%)

20


Women Inmates

Compared with male inmates, female inmates:

Almost 4 times likelier to have been physically abused before incarceration

58% likelier to have ever been homeless

31% likelier to have had parents/guardians who abused alcohol/other drugs

21


Other Health Conditions

• 60% age 12 and over with FASD have been involved with

justice system

• 19% of veteran inmates have PTSD vs. 7% non-veteran inmates

• Inmate vs. general population:

Almost 3 times rate of HIV

6-7 times rate of Hepatitis C

22


The Treatment Gap

• 1.5 million inmates with substance use disorders

• 11% receive treatment

• Nicotine dependence rarely addressed

• Very little treatment is evidence-based

23


Inmate Participation in

Support Services

• Of inmates with substance use disorders:

23% participated in mutual support/peer counseling

14% received drug education

• Of all substance-involved inmates:

56% participated in religious/spiritual activities

24


Inmates in Education/

Vocational Programs

25

6757

14

57

45

12

Federal Prisons State Prisons Local Jails

1996 2006

Source: CASA analysis of the Survey of Inmates in Federal Correctional Facilities (1991

and 2004), Survey of Inmates in State Correctional Facilities (1991 and 2004), Survey of

Inmates in Local Jails (1989 and 2002) [Data files], and U.S. Bureau of Justice Statistics Reports, Prisoners in (1996 and 2006).

Percent


Professional Standards for

Treating Inmates

• American Correctional Association in cooperation with Commission on Accreditation for Corrections (1990)

• National Institute of Corrections (1991)

• Center for Substance Abuse Treatment (1993 and updates)

• Substance Abuse and Mental Health Services Administration (2004)

• National Institute on Drug Abuse (2006)

ALL Standards except SAMHSA 2004 are voluntary

26


Essential Elements of

Best Practice

• Screening and comprehensive assessment

• Treatment for substance use and co-occuring health/mental health disorders

• Aftercare

• Monitoring/rewards/sanctions

27


Treatment/Aftercare Can

Reduce Recidivism

• Delaware: 5 year re-arrest rates—52% prison-based treatment/aftercare vs. 77% control group

• California: 1 year re-incarceration rates—8% prison-based TC treatment/aftercare vs. 50% control group

• Illinois: 52% lower likelihood of re-incarceration for prison-based treatment/aftercare vs. comparison

28


Diversion Programs

Reduce Recidivism

• Prosecutorial-based Diversion (DTAP)—graduates at 2 years were 87% less likely to return to prison than matched group at half the cost of incarceration

• Drug Courts—all programs tracking costs and savings showed positive net benefits

• DUI Courts—3 times less likely to be rearrested; 19 times less likely to be rearrested for a DUI compared with traditional probation

• Probation (Hawaii)—targeting offenders at high risk of probation revocation; re-arrest rates 3 times lower than comparison group

29


Costs and Benefits of Treatment

• Average cost of comprehensive prison-based treatment and aftercare—$9,745 inmate

• Providing these services to all inmates in need would pay for itself in 1 year if less than 11% remain substance-and crime-free and employed

• Each additional year yields economic benefit of $90,953 per inmate

• Sharp reductions in crime

30


Recommendations for the

Criminal Justice System

Use appropriately trained health care professionals to:

• Screen, assess and treat with evidence-based approaches

• Provide comprehensive support services

• Provide pre-release planning and reentry services

• Expand use of treatment-based alternatives to incarceration

31


Recommendations for Federal,

State and Local Governments

• Require that addiction treatment be provided in criminal justice settings; that it be medically managed; and that behavioral and pharmacological treatments be available

• Require accreditation of prison- and jail-based treatment programs and providers

32


Ending Addiction

Changes Everything

www.casacolumbia.org


Speaker Notes Slide 2: • The purpose of this study was to:

• Identify just how many alcohol and other drug-involved inmates are in our prisons and jails

• Provide as much detail as possible on the characteristics and treatment needs of those

offenders

• Identify promising practices to address this problem

• Examine the costs and benefits of providing treatment--either to incarcerated offenders or as

alternatives to incarceration

Slide 5: • Our study focused on substance-involved offenders, defined as meeting one or more of the

following criteria: 1. Had history of using illicit drugs regularly or of having received alcohol treatment

2. Reported meeting medical criteria for alcohol and/or other drug abuse or dependence (a substance use

disorder defined in the DSM-IV)

3. Were high on alcohol or other drugs at time of their crime—this could be drugs like methamphetamine,

cocaine, heroin or controlled prescription drugs.

4. Committed their offense to get money to buy drugs, or

5. Were imprisoned for an alcohol law violation (such as illegal manufacture, or transport or driving under the

influence) or a drug law violation (such as possession, sale, distribution).

34


Speaker Notes Slide 6: • 85% of all adult inmates in federal, state and local prisons and jails are substance involved--1.9

million of the 2.3 million inmates in 2006. Our earlier report found that 79-80% were substance

involved in 1996 or about 1.7 million inmates.

• Almost 2/3 of all inmates--1.5 million--report meeting medical criteria for a substance use disorder.

• In spite of evidence of cost effective interventions, only 11% of those with such disorders receive

anything even called professional treatment.

• Our nation’s continued failure to provide these needed health care services visits crime on society

and imposes staggering yet preventable costs to taxpayers.

Slide 7: • The U.S. substance-involved inmate population has grown at more than 3 times the rate of the

general population.

• Even faster than the inmate population itself.

35


Speaker Notes Slide 8: • America has the highest incarceration rate in the world.

• With less that 5% of the world’s population, we have almost 1/4 of the world’s prisoners.

• This slide shows where these prisoners are housed.

• Most inmates--1.3 million of them – are in state prisons where more than 84% are substance

involved.

• Another 766,000 are in local jails where about the same percent are substance involved.

• Federal prisons house the fewest offenders--about 191,000--but have the highest percent of

substance-involved offenders.

Slide 9: • This slide shows inmates by the types of crimes they are incarcerated for as their controlling or

most serious offense.

• Much attention has been focused on those incarcerated for drug law violations.

• But the largest group of inmates--37%--are incarcerated for violent offenses.

• The combination of alcohol and other drug law violations are the controlling offenses of 29% of the

inmate population.

• Inmates incarcerated for property offenses equal about 1/5 of the inmate population and

• Another 13% are there for other offenses including public order, immigration and weapons

offenses and supervision violations.

36


Speaker Notes Slide 10: • Substance involvement permeates all types of crime.

• Among those incarcerated for violent offenses, 78% are substance involved.

• While illegal and controlled prescription drugs are involved in 3/4 of the substance-involved crime,

alcohol is a factor in over 1/2 of all inmate crimes.

• 58% of inmates incarcerated for violent crimes are alcohol involved, meaning that the inmate was

either:

• Under the influence of alcohol at the time of the crime

• Had a history of alcohol treatment

• Had an alcohol use disorder, or

• Committed an alcohol law violation

Slide 11: • Of inmates incarcerated for property offenses as their most serious crimes:

• 83% of them are substance involved

• 56% are alcohol involved

37


Speaker Notes Slide 12: • Among those incarcerated for other offenses--the public order, immigration or weapons offenses

or supervision violations:

• 77% are substance involved

• 52% are alcohol involved

• The remaining category of offenses is alcohol and drug law violations. By definition, 100% of

inmates committing these offenses are substance involved.

Slide 13: • Marijuana is involved in many crimes of inmates, but contrary to public perception, only 2% of

inmates are incarcerated for a marijuana offense as their controlling or only offense. This includes

possession, trafficking and other non specified offenses.

• Only a little over 1% of inmates are incarcerated for marijuana possession as their most

serious offense and

• A little less than 1% are incarcerated for marijuana possession as their only offense.

38


Speaker Notes Slide 14: • Smoking rates among inmates are much higher than in the general population, particularly among

inmates with substance use disorders.

• Smoking is both a public health concern in its own right and also is important to address since it is

related to an increased risk for relapse for alcohol use disorders.

Side Note: (Smoking rate for population as a whole 2008--25.5%)

Slide 15: • 65% of inmates report meeting clinical criteria for substance use disorders--that is 7 times the rate

in the general population.

• Another 1/3 of inmates have a mental health disorder as defined by a past diagnosis or history of

treatment

• And a 1/4 have both a substance use and mental health disorder.

Slide 16: • Substance-involved inmates are likelier than those who are not substance involved to come from

families with a history of criminal activity and substance use problems

• And they are less likely to have completed at least high school.

39


Speaker Notes Slide 17: • Substance involved inmates are likelier:

• To start committing crimes at younger ages

• To have earned money illegally

• To come into contact with the criminal justice system more frequently, and

• To be re-incarcerated

than non-substance involved inmates.

Slide 18: • Inmates in America are parents to more than 2.2 million minor children.

• About 3/4 of these children are 12 years old or younger.

• These parents are, for the most part, imprisoned at considerable distance from their children and

• Over half of state inmates haven’t seen their children at all since their imprisonment.

• Without intervention, these children are at high risk of following in the footsteps of their parents.

40


Speaker Notes Slide 19: • Minority inmates have lower rates of substance use disorders than white inmates.

• Blacks and Hispanics report lower rates of drug use in the month prior to their arrest do than

whites.

• Yet incarceration rates for minorities are much higher than for whites:

• 1 in 100 adults is in prison or jail, including

• 1 in 106 white men

• 1 in 36 Hispanic men

• 1 in 15 black men

• 1 in 9 black men age 20-34

Slide 20: • Women comprise 8.4% of the total inmate population--up from 7.7% in 1996.

• Compared with male inmates, women are more likely to have:

• Substance use

• Mental health and

• Co-occurring substance use and mental health disorders

41


Speaker Notes Slide 21: • Women inmates also are far likelier:

• To have been physically or sexually abused and

• To have been homeless before their incarceration

• To have come from families with substance use problems.

• All of these factors are tightly linked with substance use disorders and justice system involvement.

Slide 22: • Caused by exposure to alcohol in utero, individuals with fetal alcohol spectrum disorder (FASD)

are at particularly high risk of justice system involvement both because of:

• Their family history of excessive alcohol use and

• The condition itself--which can includes poor impulse control, poor anger management skills

and poor judgment.

• One in 10 inmates is a veteran—their rates of post traumatic stress disorder (PTSD) are almost 3

times that of non-veteran inmates and PTSD is highly correlated with substance use disorders, as

are HIV/AIDS and hepatitis C.

• The infection rate among inmates for HIV/AIDS is almost 3 times that of the general population,

although progress has been made reducing these rates among inmates

• Rates of hepatitis C are 6-7 times higher in the inmate population.

• All of these groups require treatment for their health conditions and, for those with FASD and

PTSD, to reduce their risks of reoffending.

42


Speaker Notes Slide 23: • Only 11% of inmates with substance use disorders receive any type of professional treatment, and

we have reason to be concerned about the quality of the treatment that is provided.

• Few facilities offer a sufficient complement of evidence-based treatment practices such as

comprehensive assessments, behavioral and pharmacological therapies, treatment for co-

occurring disorders, or assurance of effective aftercare services.

• In fact, between 40-60% of prison and jail medical directors report that they don’t even know if

pharmacological therapies are appropriate for inmates.

• Less than 17% of facilities offer treatment in specialized settings, which can produce the best

results

• Few offer any treatment at all for nicotine dependence.

Slide 24: • More inmates receive some form of support services than receive treatment:

• Less than 1/4 of inmates with substance use disorders report participating in mutual support

or peer counseling services, including Alcoholics Anonymous or Narcotics Anonymous.

• 14% report receiving some form of drug education, and

• Over 1/2 of all substance-involved inmates report participating in religious/spiritual activities.

• While these services can be important adjuncts to treatment, they are not sufficient to meet the

needs of inmates with substance use disorders.

43


Speaker Notes Slide 25: • Since substance-involved inmates frequently lack education and job readiness, educational and

vocational services are very important to their recovery .

• Unfortunately, the percent of inmates participating in these programs has declined overall from

1996 to 2006 -- particularly in federal and state prisons.

Slide 26: • The profound lack of appropriate treatment and support services for substance-involved inmates

is particularly difficult to understand in light of a large body of recommended guidelines and

standards for providing addiction treatment in criminal justice settings dating back almost 2

decades, developed by:

• The American Correctional Association

• And by 4 federal agencies

• With the one exception of federally mandated accreditation standards for facilities that choose to

provide opioid treatment in prisons and jails--the SAMHSA 2004 standards you see here--

• All of these are standards and guidelines are voluntary only.

44


Speaker Notes Slide 27: • Based on the research behind the development of these guidelines, we know the essential

elements of best practice for inmates

• These include using trained health professionals to:

• Conduct screenings for substance related problems

• For those who screen positive, provide comprehensive assessments of their substance use,

health, mental health, job readiness, and their family and social circumstances

• Provide evidence-based treatment in accordance with individualized treatment plans and

including:

• Behavioral and pharmacological therapies

• Treatment for co-occurring disorders

• Patient education in disease management and the necessary education, training, family and

social supports

• In the criminal justice system, it also means:

• Addressing correctional requirements

• Providing case management and integrated reentry and aftercare services

• And closely monitoring compliance using prompt rewards and sanctions.

45


Speaker Notes Slide 28: • There is a body of evidence to show that the combination of prison-based treatment and aftercare

can reduce recividism.

• Examples are Delaware, California and Illinois. All show significantly lower likelihood of re-arrest

or re-incarceration for those receiving such services compared with a control or comparison group

receiving no treatment and aftercare.

Slide 29: • Providing treatment-based diversion programs has the potential to produce even more savings

since additional court and treatment costs generally are lower than costs of incarceration.

• Examples of effective treatment-based alternatives to incarceration include:

• Using a prosecutorial-based model like the DTAP program in Brooklyn, NY

• Using a drug court model or

• Intensive monitoring and treatment based probation.

46


Speaker Notes Slide 30: • In every cost-benefit analysis of criminal justice-based treatments that CASAColumbia found, the

monetary benefits of treatment outweighed the costs--and the returns were striking.

• According to a comprehensive review by the National Institute on Drug Abuse, the return of

investing in treatment for this population may be more than $12 for every $1 spent--as a result of

reduced substance-related criminal justice and health care costs and reduced crime. Studies have

shown that a drug using offender commits conservatively 100 crime per year.

• The cost of incarceration can exceed $65,000 per inmate per year. For an investment of 1/6 of

that amount, we could recoup 100% of our costs in 1 year and sizable returns thereafter.

• CASAColumbia’s own analysis found that if we provided the most intensive and evidence-based

services (prison-based treatment and aftercare) to all inmates with substance use disorders not

receiving treatment and if only 11%--a conservative estimate--remained substance-and crime-free

and employed, the intervention would pay for itself in one year and would reap over $90,000 in

benefits for each additional year the inmate remained substance-and crime-free and employed.

• Investments in treatment can yield returns rarely if ever seen in any other area of public policy.

47


Speaker Notes Slide 31: • We are spending billions of taxpayers dollars because we are not treating the addiction of

inmates--$74 billion per year at last count.

• Addiction is a preventable and treatable health condition for which we have cost effective options

and recommended standards of practice.

• Key recommendations include:

• Using trained health professionals at all levels in the criminal justice system to implement best

practices in screening, assessment, treatment, pre-release planning and aftercare

• Screening all arrestees for substance-related problems and connecting those who screen

positive with appropriate interventions and treatments

• Expanding treatment-based alternatives to incarceration

Slide 32: • We further recommend that federal, state and local governments require:

• That addiction treatment be provided in criminal justice settings

• That it be evidence based and medically managed

• That both behavioral and pharmacological treatments be available, and

• That prison- and jail-based treatment programs and providers be accredited to provide such

services, based on scientific standards of practice.

48

behind bars ii: substance use and america’s prison population

Health & Medicine