A substantial portion of the US prison population is strongly connected to drug-related offenses. While the exact rates of inmates with substance use disorders (SUDs) is difficult to measure, some research shows that an estimated 65% percent of the United States prison population has an active SUD. Another 20% percent did not meet the official criteria for an SUD, but were under the influence of drugs or alcohol at the time of their crime. Many offenders are in prison as a direct result of their untreated addiction.

Decades of science shows that providing comprehensive substance use treatment to criminal offenders while incarcerated works, reducing both drug use and crime after an inmate returns to the community. It also recognizes that treatment while in jail or prison is critical to reducing overall crime and other drug-related societal burdens—such as lost job productivity, family disintegration and a continual return to jail or prison, known as recidivism. Inadequate treatment while incarcerated also contributes to overdoses and deaths when inmates leave the prison system. Yet, drug and alcohol treatment programs are woefully under-funded and absent in way too many jails and prisons around the country. And, even worse, in many count jails and state prisons, incarceration alone is effectively utilized as the method of treatment for underlying substance abuse issues.

What are the challenges in addressing substance use disorders in this population?

To be effective, treatment must begin in prison and be sustained after release through participation in community treatment programs. By engaging in a continuing therapeutic process, people can learn how to avoid relapse and withdraw from a life of crime. However, only a small percentage of those who need treatment while behind bars actually receive it, and often the treatment provided is wholly inadequate.

Inmates with opioid use disorders pose a particular challenge. During their time in prison, many untreated inmates will experience a reduced tolerance to opioids because they have stopped using drugs while incarcerated. Upon release, many will return to levels of use similar to what they used before incarceration, not realizing their bodies can no longer tolerate the same doses, increasing their risk of overdose and death. One study found that 14.8 percent of all former prisoner deaths from 1999 to 2009 were related to opioids. Insufficient pre-release counseling and/or post release follow-up are partially responsible for this alarming increase in mortality.

Why is treatment so critical in this population?

Scientific research since the mid-1970s shows that treatment of those with SUDs in the criminal justice system can change their attitudes, beliefs, and behaviors toward drug use; avoid relapse; and successfully remove themselves from a life of substance use and crime. For example, studies suggest that using medications for opioid use disorder treatment in the criminal justice system decreases opioid use, criminal activity post-incarceration, and infectious disease transmission. Studies have also found that overdose deaths following incarceration were lower when inmates received medications for their addiction.

How are substance use disorders treated in the criminal justice system?

A recent National Academy of Sciences report on Medications for Opioid Use Disorder stated that only 5% of people with opioid use disorder in jail and prison settings receive medication treatment. A survey of prison medical directors suggested that most are not aware of the benefits of using medications with treatment, and when treatment is offered, it usually consists of only behavioral counseling, and/or detoxification without follow-up treatment.

Effective treatment of substance use disorders for incarcerated people requires a comprehensive approach including the following:

  • Behavioral therapies, including:
    • cognitive-behavioral therapy, which helps modify the patient’s drug-use expectations and behaviors, and helps effective manage triggers and stress
    • contingency management therapy, which provides motivational incentives in the forms of vouchers or cash rewards for positive behaviors
  • Medications including methadone, buprenorphine, and naltrexone
  • Wrap-around services after release from the criminal justice system, including employment and housing assistance
  • Overdose education and distribution of the opioid reversal medication naloxone while in justice diversion treatment programs or upon release.

Unfortunately, though, neither the funding, personnel nor treatment facilities are sufficient to meet even a small portion of the ongoing need.

The cost of non-treatment?

Failure to treat substance use disorder in the criminal justice system not only has negative societal implications, but also proves to be expensive. One study of people involved in the criminal justice system in California showed that engagement in treatment was associated with lower costs of crime in their communities in the 6 months following treatment. In addition, the economic benefits were far greater for individuals receiving time-unlimited treatment.

A report from the National Drug Intelligence Center estimated that the cost to society for drug use was $193 billion in 2007, a substantial portion of which—$113 billion—was associated with drug related crime, including criminal justice system costs and costs borne by victims of crime. The same report showed that the cost of treating drug use (including health costs, hospitalizations, and government specialty treatment) was estimated to be $14.6 billion, a fraction of these overall societal costs. It is estimated that the cost to society has increased significantly since the 2007 report, given the growing costs of prescription drug misuse.

Twenty years ago, Norway made a dramatic change of focus in its justice system with several other Western European nations following suit. The idea was to have shorter prison sentences and use the funds that would be saved toward an emphasis on rehabilitation, with a particular spotlight on drug rehabilitation and treatment. As a result, these countries have been rewarded with much lower recidivism rates than those in the US, with Norway leading the trend at a once inconceivably low rate of 20%, as compared to the US at 43%.

Failure to effectively treat substance abuse in prison or as an alternative to prison places a tremendous unseen toll on society. The key problem is that it’s so difficult to rally support behind this issue because the costs are so intangible. It’s not like a clear apples-to-apples case can be made, fostering greater political will to solve the problem. Moreover, who would be the arbiter of which people can be dealt with more effectively through treatment instead of incarceration and how will that determination be made? These thorny issues and more ensure that precious little will change, until we finally wise up as a country and handle things more like our Western European friends.