Igor Koutsenok, MD, MS Assistant Professor of Psychiatry, UCSD, Director, Center for Criminality & Addiction Resear

1. Treatment of Substance Involved Offenders in Criminal Justice Settings – Challenges & Outcomes Igor Koutsenok, MD, MSAssistant Professor of Psychiatry, UCSD, Director,Center for Criminality & Addiction Research, Training & Application(CCARTA)

2. Let’s start with some bad news

3. California Statistics • 172,785 in prison (1986: 39,373) • Cost – $38 000 per inmate • 117,136 on parole (1986: 19,780) • Cost - $12 000 per parolee • 77% of males and 83% of females incarcerated in California have drug and alcohol problems.

4. Nationwide costColumbia University Report, March 2005 $ 30 billion states spent on adult corrections (incarceration, probation, parole) $24.1 billion of it was on substance involved offenders

5. On Women… • During the 1980s and 1990s, the number of incarcerated women tripled, while the number of men doubled. • 80% of these women have substance abuse problems. “What Works,” Dr. Rudy J. Cypser, CURE-NY, 2000

6. Some Other Sad Facts • Over 2 million inmates inhabited U.S. jails & prisons • They are parents of 3.4 million children • 2 in 3 convicts have been tested positive for drugs at time of arrest. • 2 in 3 inmates have verified drug histories, BUT… Under 15 % receive systematic treatment Deitch, Koutsenok & Ruiz, 2004

7. Recidivism • Within 12 months after release from custody 70- 75% of substance involved offenders are back to institutions • It is clear that criminal-justice sanctions by themselves do not reduce recidivism in this population • Prisons do manage behaviors, but do not shape behaviors

8. Policies for Drug Offenders Diversion Drug Courts Incarceration Intermediate sanctions Probation w/o verdict (Prop 36)

9. Policies for Drug Offenders Public Safety Risks Diversion Drug Courts Incarceration Intermediate sanctions Probation w/o verdict (Prop 36)

10. Policies for Drug Offenders $$$$$$ Costs $$$$$$$$$ Public Safety Risks Diversion Drug Courts Incarceration Intermediate sanctions Probation w/o verdict (Prop 36)

11. Policies for Drug Offenders Over-reliance Diversion Drug Courts Incarceration Intermediate sanctions Probation w/o verdict (Prop 36)

12. Prison Criminal Recidivism in 3 Years • 68% re-arrested • 47% convicted • 50% re-incarcerated Relapse to Drug Use in 3 Years • 95% relapse Marlow D., Treatment Research Institute, 2006

13. Policies for Drug Offenders Diversion Drug Courts Incarceration Intermediate sanctions Probation w/o verdict (Prop 36)

14. Policies for Drug Offenders Over-reliance Diversion Drug Courts Incarceration Intermediate sanctions Probation w/o verdict (Prop 36)

15. Referral to Treatment Attrition • 50% - 67% don’t show for intake • 40% - 80% drop out in 3 months • 90% drop out in 12 months • 70% of probationers and parolees drop out within 2 - 6 months D. Marlow D. & T.McLellan, TRI, 2004

16. Time for some better news What will happen if we combine incarceration and treatment?

17. Types of Substance Involved Offenders From the work of Douglas B. Marlowe, J.D., Ph.D.

18. Criminogenic Risks • Age during rehabilitation < 25 years • Criminal onset < 16 years • Prior rehabilitation failures • History of violence • Antisocial Personality Disorder • Psychopathy • Familial history of crime • Criminal associations

19. Criminogenic Needs Drug Dependence or Addiction

20. Criminogenic Needs Drug Dependence or Addiction • Binge pattern • Cravings or compulsions • Withdrawal symptoms

21. Criminogenic Needs Abstinence is a distal goal Drug Dependence or Addiction • Binge pattern • Cravings or compulsions • Withdrawal symptoms }

22. Criminogenic Needs Abstinence is a distal goal Drug Dependence or Addiction • Binge pattern • Cravings or compulsions • Withdrawal symptoms Drug Abuse or Misuse }

23. Criminogenic Needs Abstinence is a distal goal Drug Dependence or Addiction • Binge pattern • Cravings or compulsions • Withdrawal symptoms Drug Abuse or Misuse Abstinence is a proximal goal } }

24. Criminogenic Needs Abstinence is a distal goal Drug Dependence or Addiction • Binge pattern • Cravings or compulsions • Withdrawal symptoms Drug Abuse or Misuse Collateral needs • E.g., dual diagnosis, HIV+ Abstinence is a proximal goal } }

25. Criminogenic Needs Abstinence is a distal goal Drug Dependence or Addiction • Binge pattern • Cravings or compulsions • Withdrawal symptoms Drug Abuse or Misuse Collateral needs • E.g., dual diagnosis, HIV+ Abstinence is a proximal goal } }

26. Risk & Needs Matrix High Risk Low Risk High Needs Low Needs

27. Risk & Needs Matrix High Risk Low Risk Accountability & Treatment High Needs Low Needs

28. Risk & Needs Matrix High Risk Low Risk Treatment Accountability & Treatment High Needs Low Needs

29. Risk & Needs Matrix High Risk Low Risk Treatment Accountability & Treatment High Needs Accountability Low Needs

30. Risk & Needs Matrix High Risk Low Risk Treatment Accountability & Treatment High Needs Accountability Prevention Low Needs

31. Practice Implications High Risk Low Risk • Frequent meetings with PA • Intensive treatment • Compliance is proximal • Positive reinforcement • Intensive treatment • Treatment is proximal • Positive reinforcement High Needs • Secondary prevention • Abstinence is proximal • Abstinence is proximal • Restrictive sanctions Low Needs

32. Why Therapeutic Community Model? The profile of a successful high risk/high need client in community based therapeutic community is very similar to the one of a substance abusing offender in custody

33. Delaware/Crest Program: 3-Year Re-Arrest & Drug Use Rates *p<.05 Martin, Butzin, Saum, & Inciardi, 2001 (The Prison Journal)

34. Texas In-prison TC Program:Return to custody rates (24 months follow-up), 2001 Aftercare Completers K. Knight, D. Simpson. The Prison Journal, 2002

35. California/Amity Program: 3-Year Return-to-Custody Rates (%) *p<.001 Wexler, Melnick, Lowe, & Peters, 2002 (The Prison Journal)

36. Coercion in the Criminal Justice System A 2000 report from the Institute of Medicine summarized that “contrary to earlier fears among clinicians, criminal justice pressure does not threaten treatment effectiveness, and it improves outcomes”

37. Research FindingsMultiple studies • The length of time spent in treatment is a reliable predictor of post treatment outcomes and recidivism • Coerced patients tend to stay longer and do as well as volunteers overall • Most substance involved offenders would never seek treatment without pressure from the criminal-justice system

38. General Findings & Recommendations 1. Duration, Setting, Training: fundamental for In-prison TC (ITC) programs • ITC = 9-12 months in a residential (segregated) treatment unit • Staff training is a must • On-going monitoring & evaluation 2. Engagement in transitional aftercare is crucial for effectiveness 3. ITC is most cost effective for high-risk offenders 4. Boot camps & periodic drug-focused counseling have poor outcomes 5. Risk assessments should guide selections for treatment

39. Thank you