What are the unique treatment needs of juveniles in the criminal justice system?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center.
What are the unique treatment needs of juveniles in the criminal justice system?

The U.S. Department of Justice’s Office of Justice Programs reports a high rate of drug use among juvenile detainees. One study, for example, found that 77 percent of criminal justice-involved youth reported substance use (mainly marijuana) in the past 6 months, and nearly half of male and female juvenile detainees had a substance use disorder (McClelland et al. 2004a; McClelland et al. 2004b).

Arrest rates for drug-related crimes also remain high among juveniles. A recent report showed that of the estimated 2.1 million juvenile arrests in 2008, approximately 10 percent were for drug abuse or underage drinking violations (Puzzanchera 2009). Juveniles entering the criminal justice system can bring a number of serious problems with them—substance abuse, academic failure, emotional disturbances, physical health issues, family problems, and a history of physical or sexual abuse. Girls make up nearly one-third  of juvenile arrests, a high percentage of whom report some form of emotional, physical, or sexual abuse.

Effectively addressing these problems requires their gaining access to comprehensive assessment, treatment, case management, and support services appropriate for their age and developmental stage. Assessment is particularly important, because not all adolescents who have used drugs need treatment. For those who do, there are several points in the juvenile justice continuum where treatment has been integrated, including juvenile drug courts,community-based supervision, juvenile detention, and community re-entry.

Families play an important role in the recovery of substance abusing juveniles, but this influence can be either positive or negative. Parental substance abuse or criminal involvement, physical or sexual abuse by family members, and lack of parental involvement or supervision are all risk factors for adolescent substance abuse and delinquent behavior. Thus, the effective treatment of juvenile substance abusers often requires a family-based treatment model that targets family functioning and the increased involvement of family members.

Effective adolescent treatment approaches include multisystemic therapy, multidimensional family therapy, and functional family therapy. These interventions show promise in strengthening families and decreasing juvenile substance abuse and delinquent behavior.

What are the unique treatment needs of women in the criminal justice system?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of  Tom Wilson Counseling and Telehealth Center.
What are the unique treatment needs of juveniles in the criminal justice system?
Although women are incarcerated at far lower rates than men,  the number and percentage of incarcerated women have grown substantially in recent years. Between 2000 and 2008, the  number of men in prisons and jails grew by only 5 percent, while the number  of incarcerated women grew by about 15 percent (Sabol et al. 2010). Women in prison are likely to have a different set of problems and needs than men, presenting particular treatment challenges that may call for tailored approaches (Greenfield et al. 2007).
Incarcerated women in treatment are significantly more likely than incarcerated men to have severe substance abuse histories, co-occurring mental disorders, and high rates of past treatment for both; they also tend to have more physical health problems Staton et al. 2003; Messina et al. 2006).
Approximately 50 percent of female offenders are likely to have histories of physical or sexual abuse, and women are more likely than men to be victims of domestic violence. Past or current victimization can contribute to drug or alcohol abuse, depression, post-traumatic stress disorder, and criminal activity.
Treatment programs serving both men and women can provide effective treatment for their female patients. However, gender-specific programs may be more effective for female offenders, particularly those with histories of trauma and abuse  (Pelissier et al. 2003). Female offenders are more likely to need medical  and mental health services, child care services, and assistance  in finding housing and employment.
Following a comprehensive assessment, women with mental health disorders should receive appropriate treatment and case management, including victim services as needed. For female offenders with children, parental responsibilities can conflict with their ability to participate in drug treatment. Regaining or retaining custody of their children can also motivate mothers to participate in treatment. Treatment programs may improve retention by offering child care services and parenting classes.

Is providing drug abuse treatment to offenders worth the financial investment?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center.
13. Is providing drug abuse treatment to offenders worth the financial investment?
In 2007, it was estimated that the cost to society of drug abuse was $193 billion (National Drug Intelligence Center [NDIC], 2011), a substantial portion of which—$113 billion—is associated with drug-related crime, including criminal justice system costs and costs borne by victims of crime. The cost of treating drug abuse (including health costs, hospitalizations, and government specialty treatment) was estimated to be $14.6 billion, a fraction of these overall societal costs (NDIC, 2011).
Drug abuse treatment is cost effective in reducing drug use and bringing about related savings in health care. Treatment also consistently has been shown to reduce the costs associated with lost productivity,crime, and incarceration across various settings and populations. The largest economic benefit of treatment is seen in avoided costs of crime (incarceration and victimization costs).Providing methadone treatment to opioid-addicted prisoners prior to their release, for example, not only helps to reduce drug use but also avoids the much higher imprisonment costs for drug-related crime.
Even greater economic benefits result from treating offenders with co-occurring mental health problems and substance use disorders. Residential prison treatment is more cost effective if offenders attend treatment post-release,  according to research (Martin et al. 1999; Butzin 2006). Drug courts also convey positive economic benefits, including participant-earned wages and avoided incarceration and future crime costs.

What works for offenders with co-occurring substance abuse and mental disorders?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center.
What works for offenders with co-occurring substance abuse and mental disorders?

It is important to adequately assess mental disorders and to address them as part of effective drug abuse treatment. Many types of co-occurring mental health problems can be successfully addressed in standard drug abuse treatment programs. However, individuals with serious mental disorders may require an integrated treatment approach designed for treating patients with co-occurring mental and substance use disorders.

Much progress has been made in developing effective medications for treating mental disorders, including a number of antidepressants, anti-anxiety agents, mood stabilizers, and anti-psychotics. These medications may be critical for treatment success with offenders who have co-occurring mental disorders such as depression, anxiety disorders, bipolar disorder, or schizophrenia. Cognitive-behavioral therapy can be effective for treating some mental health problems, particularly when combined with medications.

Contingency management can improve adherence to medications, and intensive case management may be useful for linking severely mentally ill individuals with drug abuse treatment, mental health care, and community services. A specialized type of treatment—Modified Therapeutic Communities (MTCs)—incorporates features of traditional Therapeutic Communities with a special focus on addressing co-occurring mental health conditions.

How can the criminal justice and drug abuse treatment systems reduce the spread of HIV/AIDS, hepatitis, and other infectious diseases among drug abusing offenders?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center.
How can the criminal justice and drug abuse treatment systems reduce the spread of HIV/AIDS, hepatitis, and other infectious diseases among drug abusing offenders?
Individuals involved in the criminal justice system have disproportionately high rates of substance use disorders and infectious diseases, including HIV/AIDS. In fact, 14 percent of HIV-infected individuals in this country pass through the criminal justice system each year (Spaulding et al. 2009). Other infectious diseases, such as hepatitis B, hepatitis C, and tuberculosis, also are pervasive in the criminal justice system.
This overrepresentation also provides an opportunity to integrate treatment and improve outcomes for both substance use disorders and infectious diseases. Research shows that treatment for drug abuse can lessen the spread of infectious diseases by reducing high-risk behaviors like needle-sharing and unprotected sex (Metzger et al. 2010). Identifying those who are HIV+ and starting them on HAART treatment could not only improve their health outcomes but also decrease HIV spread (Montaner et al. 2010).
It is imperative that offenders with infectious diseases be linked with community-based medical care prior to release. Offenders often have difficulty negotiating access to health services and adhering to complex treatment protocols following release from prison and jail. One study found that simply helping HIV-infected inmates complete the paperwork required to get their prescriptions filled upon release significantly diminished treatment interruption, although improvement was still needed, since fewer than half had filled their prescriptions within 2 months of release (Baillargeon et al. 2009).
Community health, drug treatment, and criminal justice agencies should work together to offer education, screening, counseling, prevention, and treatment programs for HIV/AIDS, hepatitis, and other infectious diseases to offenders returning to the community.

What is the role of medications in treating substance abusing offenders?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center

10. What is the role of medications in treating substance abusing offenders?

Medications can be an important component of effective drug abuse treatment for offenders. By allowing the brain to function more normally, they enable the addicted person to leave behind a life of crime and drug abuse. Although some jurisdictions have found ways to successfully implement medication therapy, addiction medications are underused in the treatment of drug abusers within the criminal justice system, despite evidence of their effectiveness. Effective medications have been developed for treating addiction to opiates/heroin and alcohol:

Opiates/Heroin Treatment  Medications
Long-term opiate abuse results in a desensitization of the brain’s opiate receptors to endorphins, the body’s natural opioids. Opioid agonist/partial agonist medications, which act at the same receptors as heroin, morphine, and endorphins, tend to be well tolerated and can help an individual remain in treatment. For example, methadone, an opiate agonist, reduces the craving that otherwise results in compulsive use of heroin or other illicit opiates.

  • Methadone treatment has been shown to be effective in decreasing opiate use, drug-related criminal behavior, and HIV risk behavior. 
  • Buprenorphine is a partial agonist and acts on the same receptors as morphine (a full agonist), but without producing the same level of dependence or withdrawal symptoms. 
  • Suboxone is a unique formulation of buprenorphine that contains naloxone, an opioid antagonist that limits diversion by causing severe withdrawal symptoms in addicted users who inject it to get “high.” It has no adverse effects when taken orally, as prescribed.

An alternative approach, in previously detoxified opiate users, is to use an antagonist medication that blocks the effects of opiates. 

  • Naltrexone has been available for more than 2 decades, but poor compliance in the face of severe cravings and addiction has undermined its benefits. An extended-release injectable formulation of naltrexone (Vivitrol) was recently approved by the U.S. Food and Drug Administration (FDA) for treating opioid addiction. 
  • Vivitrol requires dosing every few months rather than daily, which stands to improve treatment adherence.
Alcohol Dependence Treatment Medications
  • Disulfiram (also known as Antabuse) is an aversion therapy that induces nausea if alcohol is consumed. 
  • Acamprosate, a medication that helps reduce alcohol craving, works by restoring normal balance to the brain’s glutamate neurotransmitter system. 
  • Naltrexone (and now Vivitrol), which blocks some of alcohol’s pleasurable effects and alcohol craving, is also approved by the FDA for treatment of alcohol abuse.

How can rewards and sanctions be used effectively with drug-involved offenders in treatment?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center

9. How can rewards and sanctions be used effectively with drug-involved offenders in treatment?

The systematic application of behavioral management principles underlying reward and punishment can help individuals reduce their drug use and criminal behavior. Rewards and sanctions are most likely to change behavior when they are certain to follow the targeted behavior, when they follow swiftly, and when they are perceived as fair. It is important to recognize and reinforce progress toward responsible, abstinent behavior.

Rewarding positive behavior is more effective in producing long-term positive change than punishing negative behavior. Indeed, punishment alone is an ineffective public health and safety intervention for offenders whose crime is directly related to drug use (Leukefeld et al. 2002). Non-monetary rewards such as social recognition can be as effective as monetary ones. A graduated range of rewards given for meeting predetermined goals can be an effective strategy.

Contingency management strategies, proven effective in community settings, use voucher-based incentives or rewards, such as bus tokens, to reinforce abstinence (measured by negative drug tests) or to shape progress toward other treatment goals, such as program session attendance or compliance with medication regimens. Contingency management is most effective when the contingent reward closely follows the behavior being monitored.

An intervention tested by CJ-DATS researchers, called “Step’n Out,” used a contingency management approach whereby criminal justice staff monitored specific behaviors (e.g., abstinence, employment searches, and counseling attendance) and rewarded individuals who met agreed-upon goals with social acknowledgement (e.g., congratulatory letter from parole supervisor) and small material incentives (e.g., partial payment for clothes for job interviews). This approach improved parolees’ attendance at integrated community parole and addiction treatment sessions, as well as increased use of treatment and individual counseling services (Friedmann et al. 2009).

Graduated sanctions, which invoke less punitive responses for early and less serious noncompliance and increasingly severe sanctions for more serious or continuing problems, can be an effective tool in conjunction with drug testing. The effective use of graduated sanctions involves consistent, predictable, and clear responses to noncompliant behavior.

Drug testing can determine when an individual is having difficulties with recovery. The first response to drug use detected through urinalysis should be a clinical one—for example, increasing treatment intensity or switching to an alternative treatment. This often requires coordination between the criminal justice staff and the treatment provider. (Note that more intensive treatment should not be considered a sanction, but rather a routine progression in health care practice when a treatment appears less effective than expected.)

Behavioral contracting can employ both rewards and sanctions. A behavioral contract is an explicit agreement between the participant and the treatment provider or criminal justice monitor (or among all three) that specifies proscribed behaviors and associated sanctions, as well as positive goals and rewards for success. Behavioral contracting can instill a sense of procedural justice because both the necessary steps toward progress and the sanctions for violating the contract are specified and understood in advance.

How long should drug abuse treatment last for individuals involved in the criminal justice system?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center.  
8. How long should drug abuse treatment last for individuals involved in the criminal justice system?
While individuals progress through drug abuse treatment at different rates, one of the most reliable findings in treatment research is that lasting reductions in criminal activity and drug abuse are related to length of treatment. Generally, better outcomes are associated with treatment that lasts longer than 90 days, with treatment completers achieving the greatest reductions in drug abuse and criminal behavior. Again, legal pressure can improve retention rates.
A longer continuum of treatment may be indicated for individuals with severe or multiple problems. Research has shown that  treatment provided in prison and continued in the community after release can reduce the risk of recidivism to criminal behavior as well as relapse to drug use.
Early phases of treatment help the participant stop using drugs and begin a therapeutic process of change. Later stages address other problems related to drug abuse and, importantly, help the individual learn how to self-manage the drug problem. Because addiction is a chronic disease, drug relapse and return to treatment are common features of recovery. Thus, treatment may need to extend over a long period across multiple episodes of care.

What treatment and other health services should be provided to drug abusers involved with the criminal justice system?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center.

7. What treatment and other health services should be provided to drug abusers involved with the criminal justice system?

One of the goals of treatment planning is to match evidence-based interventions to individual needs at each stage of drug treatment. Over time, various combinations of treatment services may be required.

Evidence-based interventions include cognitive-behavioral therapy to help participants learn positive social and coping skills, contingency management approaches to reinforce positive behavioral change, and motivational enhancement to increase treatment engagement and retention.

In those addicted to opioid drugs, agonist/partial agonist medications can also help normalize brain function, and antagonist medications can facilitate abstinence. For juvenile offenders, treatments that involve the family and other aspects of the drug abuser’s environment have established efficacy.

Drug abuse treatment plans for incarcerated offenders can facilitate successful re-entry into the community by incorporating relevant transition plans and services. Drug abusers often have mental and physical health, family counseling, parenting, educational, and vocational needs, so medical, psychological, and social services are often crucial components of successful treatment. Case management approaches can be used to provide assistance in obtaining and integrating drug abuse treatment with community services.

Are relapse risk factors different in offender populations? How should drug abuse treatment deal with these risk factors?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center.  
6. Are relapse risk factors different in offender populations? How should drug abuse treatment deal with these risk  factors?
Often, drug abusing offenders have problems in other areas. Examples include family difficulties, limited social skills, educational and employment problems, mental health disorders, infectious diseases, and other medical issues. Treatment should take these problems into account, because they can increase the risk of drug relapse and criminal recidivism if left unaddressed.
Stress is often a contributing factor to relapse, and offenders who are re-entering society face many challenges and stressors, including reuniting with family members, securing housing, and complying with criminal justice supervision requirements. Even the many daily decisions that most
people face can be stressful for those recently released from a highly controlled prison environment.
Other threats to recovery include a loss of support from family or friends, which incarcerated people may experience. Drug abusers returning to the community may also encounter people from their lives who are still involved in drugs or crime and be enticed to resume a criminal and drug using lifestyle. 
Returning to environments or activities associated with prior drug use may trigger strong cravings and cause a relapse. A coordinated approach by treatment and criminal justice staff provides the best way to detect and intervene with these and other threats to recovery. In any case, treatment is needed to provide the skills necessary to avoid or cope with situations that could lead to relapse.
Treatment staff should identify the offender’s unique relapse risk factors and periodically re-assess and modify the treatment plan as needed. Generally, continuing or re-emerging drug use during treatment requires a clinical response—either increasing the amount or level of treatment, or changing the treatment intervention.