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Compulsory treatment: A review of findings

Authors:
Compulsory
Treatment of
Drug Abuse:
Research and
Clinical Practice
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service • National Institutes of Health
Compulsory Treatment of Drug
Abuse: Research and Clinical
Practice
Editors:
Carl G. Leukefeld, D.S.W.
Frank M. Tims, Ph.D.
Division of Clinical Research
National Institute on Drug Abuse
NIDA Research Monograph 86
1988
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
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National Institute on Drug Abuse
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Alcohol and Drug Problems Association
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Cornell University Medical College
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The Johns Hopkins University School of
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Washington University School of
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National Federation of Parents for
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Langley Porter Neuropsychiatric lnstitute
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College of Physicians and Surgeons of
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Yale University School of Medicine
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Compulsory Treatment of Drug
Abuse: Research and Clinical
Practice
ACKNOWLEDGMENT
This monograph is based upon papers and discussion from a technical
review on civil commitment for drug abuse which took place on
January 26 and 27, 1987, in Rockville, MD. The review meeting was
sponsored by the Office of Science and the Division of Clinical
Research, National Institute on Drug Abuse.
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National Institute on Drug Abuse
NIH Publication No. 94-3713
Formerly DHHS Publication No. (ADM) 88-1578
Printed 1988 Reprinted 1994
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iv
Contents
Page
An Introduction to Compulsory Treatment for
Drug Abuse: Clinical Practice and Research . . . . . . . . . . 1
Carl G. Leukefeld and Frank M. Tims
The Efficacy of Civil Commitment in Treating Narcotic
Addiction . . . . . . . . . . . . . . . . . . . . . . . . 8
M. Douglas Anglin
Clinical Experience With Civil Commitment. . . . . . . . . . . 35
James F. Maddux
The Criminal Justice Client in Drug Abuse Treatment. . . . . . . 57
Robert L. Hubbard, James J. Collins,
J. Valley Rachal, and Elizabeth R. Cavanaugh
Legal Status and Long-Term Outcomes for Addicts in
the DARP Followup Project . . . . . . . . . . . . . . . . .81
D. Dwayne Simpson and H. Jed Friend
Treatment Alternatives to Street Crime . . . . . . . . . . . . 99
L. Foster Cook, Beth A. Weinman et al.
The Criminal Justice System and Opiate Addiction:
A Historical Perspective . . . . . . . . . . . . . . . . . 108
Herman Joseph
Some Considerations on the Clinical Efficacy of Compulsory
Treatment: Reviewing the New York Experience . . . . . . . 126
James A. lnciardi
v
Identifying Drug-Abusing Criminals . . . . . . . . . . . . . 139
Eric D. Wish
Legal Pressure in Therapeutic Communities . . . . . . . . . 160
George De Leon
Basic Issues Pertaining to the Effectiveness of Methadone
Maintenance Treatment . . . . . . . . . . . . . . . . . 178
John C. Ball and Eric Corty
Civil Commitment—International Issues . . . . . . . . . . . 192
Barry S. Brown
The Costs of Crime and the Benefits of Drug Abuse
Treatment: A Cost-Benefit Analysis Using TOPS Data . . . . . 209
Henrick J. Harwood, Robert L. Hubbard,
James J. Collins, and J. Valley Rachel
Compulsory Treatment: A Review of Findings . . . . . . . . 236
Carl G. Leukefeld and Frank M. Tims
List of NIDA Research Monographs. . . . . . . . . . . . . 252
vi
An Introduction to Compulsory
Treatment for Drug Abuse:
Clinical Practice and Research
Carl G. Leukefeld and Frank M. Tims
INTRODUCTlON
Civil commitment as a form of compulsory treatment for the treat-
ment of drug abusers has been legally possible in the United States
in the last 25 years (California Civil Addict Program, New York State
Civil Commitment, and the Federal Narcotic Addict Rehabilitation Act
(NARA)). The focus of civil commitment procedures has been on the
compulsive drug abusers, especially antisocial addicts responsible for
committing large numbers of criminal acts. Today the concept has
been suggested, by individuals in both the drug abuse and criminal
justice fields, for users of intravenous drugs, who are at risk for
contracting and transmitting the acquired immunodeficiency syndrome
(AIDS) virus and who are unwilling to enter treatment voluntarily.
The concept of compulsory treatment as a mechanism for reducing
the prevalence of drug abuse and the consequences of that abuse, for
both those individuals and U.S. society at large, is not new.
Compulsory treatment may be defined as activities that increase the
likelihood that drug abusers will enter and remain in treatment,
change their behavior in a socially desirable way, and sustain that
change. While the implementation and outcomes of the above civil
commitment programs differ to some extent, their intent and enabling
legislation were quite similar, as were their commitment procedures.
Their purpose was to control and rehabilitate the compulsive drug
abuser by providing drug abuse treatment, monitoring drug use, and
providing reasonable sanctions for program infractions.
Although the Federal and State civil commitment programs were only
in full operation for about a decade, 1965 to 1975, and were replaced
by a system of community drug treatment programs, the desire for
community programs to induce larger numbers of addicts into
1
treatment and the high number of prisoners with addiction histories
suggest that civil commitment be reexamined. Concern about the
spread of AIDS among intravenous drug abusers and from intravenous
drug abusers to their sexual partners and children has given renewed
impetus to such reexamination.
The relationship between heroin addiction and crime is well estab-
lished (Anglin, this volume; Nurco 1986). Likewise, the relationship
of intravenous drug use and AIDS is well established, with 25 percent
of all AIDS cases related to intravenous drug use. This review
presents the convergence of knowledge regarding drug abuse treat-
ment effectiveness with the emergence of the current AIDS problem
among intravenous drug abusers. AIDS is spreading among intra-
venous drug abusers through sharing of needles contaminated with the
human immunodeficiency virus (HIV). Through this sharing of
needles, it is believed that the vast majority of needle-using addicts
are at risk for contracting AIDS.
AIDS AND INTRAVENOUS DRUG USE
Currently, AIDS among intravenous drug abusers is largely confined
to the New York City/northern New Jersey metropolitan area, with
lesser concentrations in California, Florida, and Texas. The current
concentration of AIDS appears to be a temporal phenomenon—rates
are highest in those communities where AIDS was first detected.
Once introduced among intravenous drug abusers in a community,
infection spreads very rapidly. For example, the AIDS virus has been
detected in stored sera. First recognized among intravenous drug
abusers in New York City in 1978, infection rates were established at
40 percent in 1980 from stored blood and 60 percent in the latter
part of 1986. Rates of infection appear to be low in most of the
country, yet significant rates of infection are beginning to emerge in
some areas. With time, AIDS prevalence among intravenous drug
abusers is expected to increase rapidly in cities across the United
States.
The Public Health Service and the National Institute on Drug Abuse
(NIDA) have identified intravenous drug abusers as a major source for
the spread of AIDS to the heterosexual population. While data on
heterosexual AIDS transmission is incomplete, there is some indication
that transmission may occur fairly readily, at least among regular
sexual partners of persons with AIDS. Since many intravenous drug
abusers are sexually active, and since many female abusers resort to
prostitution to support their drug habits, the potential for the spread
2
of AIDS from intravenous drug abusers to the general population is
considerable, especially as HIV infection becomes more widespread
among intravenous drug abusers. This potential is of serious concern
for health-care delivery and drug abuse treatment programs, and for
the criminal justice system as well.
TREATMENT EFFECTIVENESS FOR INTRAVENOUS DRUG USERS
NIDA has sponsored research that suggests that treatment for drug
abuse is effective (Tims 1981; Tims and Ludford 1984). Clients
entering drug-free outpatient (counseling) programs, drug-free
residential (therapeutic community) treatment, and methadone
maintenance treatment generally experience dramatic reductions in
drug use and associated criminality. Many studies also show improve-
ment in employment status and other behavioral outcomes among
treated drug abusers, The question of which treatment is superior
becomes clouded by the prevailing pattern for clients who have
multiple treatment experiences, often in more than one type of
program, before becoming abstinent from their principal drug of
abuse. This pattern of multiple treatments is reflected in a study by
Simpson and Sells (1982), in which opioid addicts were followed over
a 6-year period after admission to treatment. By the sixth year, 61
percent of these addicts were opioid abstinent and had been so for at
least 1 year. Treatment figured prominently in the attainment of
stable abstinence patterns, with about 80 percent of those abstinent
having achieved this status directly in connection with a treatment
episode. In addition to the 61 percent who were abstinent, 18
percent had given up daily opioid use but had other problems such as
occasional opioid use, heavy use of nonopioids or alcohol, or long-
term incarceration. Thus, even though a significant number of clients
had other problems, only one-fifth of those treated continued their
pretreatment levels of opioid use at 6 years after leaving treatment.
Relapse prevention is an important component of treatment program-
ming, and is the subject of ongoing research (Marlatt and George
1984; Tims and Leukefeld 1986). The greatest risk of relapse after
leaving treatment occurs during the first 90 days, at a time when
clients are exposed to drug-related stimuli, without the support of a
structured program to help resolve their conflicts. For this reason,
aftercare programs have been developed to follow up individuals in
the community, and to provide a resource to assist in maintaining the
client’s commitment to abstinence. Aftercare models include self-help
groups, such as Narcotics Anonymous, and approaches that stress the
development of coping skills through professionally guided self-help
3
training groups. Also, cognitive-behavioral models such as those
developed by Brownell et al. (1986) include coping strategies and
development of more effective perspectives on drug use “slips” and
relapse. Civil commitment programs also include a lengthy aftercare
component.
THE ROLE OF CIVIL COMMITMENT IN TREATMENT AND AIDS
CONTAINMENT
Recognizing that about 25 States have an existing civil commitment
statute, a panel of drug abuse treatment researchers met in January
1987 to examine the demand-reduction potential, clinical and thera-
peutic value, as well as costs/benefits associated with civil commit-
ment for drug abusers from a public health perspective. The review
was to be the first meeting. After identifying the scientific base
during this meeting, additional efforts might focus on the pre- and
postadjudicatory mechanisms for mandatory treatment as well as on
national policy implications of compulsory treatment and civil
commitment.
The initial review was organized into five parts. Dr. Douglas Anglin
reviews data from several evaluations he completed on the California
Civil Addict Program. Dr. James Maddux, a former medical officer in
charge of the U.S. Public Health Service Fort Worth Narcotic
Hospital, reviews followup studies that compare compulsory followup
treatment and voluntary treatment of addicts released from the Public
Health Service hospitals in Fort Worth, TX and Lexington, KY. It
was suggested that emphasis be placed on what has been learned from
existing studies. Three major issues suggested for inclusion were:
(1)
When is legal coercion therapeutically useful?
(2)
What is legal coercion’s value in reducing the “contagious”
aspects of the drug-using lifestyle?
(3)
Where and how has compulsory treatment and civil
commitment/legal coercion been used in the past?
It was also suggested that emphasis be placed on background,
overview, settings, and specific methodologies that are available for
better understanding compulsory treatment and civil commitment.
4
The first section, or group of papers, sets the stage with an overview
of compulsory treatment, civil commitment, court referral, and other
forms of legal coercion for drug abuse treatment.
The second section reviews long-term treatment evaluation studies by
focusing on the influence of judicial status—including probation,
parole, and mandatory release—on drug abuse, criminal behavior, and
related outcomes during and after treatment. Presentations included
longitudinal study results pertinent to compulsory treatment. A
description of the rationale, strengths, limitations, and generalizability
of findings is also incorporated. Dr. Robert Hubbard provides an
examination of clients involved in the Treatment Outcome Prospective
Study (TOPS), which confirms previous studies related to retention in
treatment and motivation by clients referred from the criminal justice
system and, more specifically, by Treatment Alternatives to Street
Crime (TASC). Dr. D. Dwayne Simpson reports on the influence of
pretreatment legal status 12 years after treatment for a group of
male addicts.
The third section reviews efficacy studies that focus on civil commit-
ment, legal coercion, and court referral and highlights research
results and findings. The impact of civil commitment on treatment
outcomes and retention in treatment is stressed. Ms. Beth Weinman
describes TASC and discusses several evaluations of TASC.
Dr. Herman Joseph presents an historical perspective which focuses
on probation activities and diversion programs in New York City.
Dr. James lnciardi recalls his personal experiences as a staff member
in the New York Narcotics Addiction Control Commission, which had
responsibility for implementing the New York State Civil Commitment
Program. Dr. Eric Wish describes four approaches for identifying
drug abuse in the criminal justice system. Dr. George De Leon
reports on the linkage of therapeutic communities with the criminal
justice system and reviews data related to the effectiveness of
therapeutic communities. Dr. John Ball completes the presentations in
this group of papers by providing information from his study of
methadone maintenance programs.
The fourth section focuses on the costs and potential benefits from
civil commitment studies and related research. Dr. Barry Brown
examines civil commitment from the international perspective and
reports that little is known about costs and related benefits for civil
commitment internationally. He reviews the status of civil commit-
ment in 43 countries. Dr. Henrick Harwood presents cost-benefit
5
information focused on TASC and other criminal justice system
programs.
Finally, the last section includes consensus statements of current
knowledge. In addition, the final section includes areas for future
research, which were developed during the consensus process.
Consensus development used the following issues as a frame of
reference:
Based upon the literature, how can the civil commitment process
be improved? Are there viable alternative models to civil
commitment which might be more productive/efficient from a
clinical/public health perspective?
What major research questions, strategies, and design features
should be incorporated into evaluative studies of compulsory
treatment and, more specifically, civil commitment?
What is the potential of compulsory treatment and civil
commitment for curbing the spread of AIDS?
REFERENCES
Brownell, K.D.; Marlatt, G.A.; Lichtenstein, E.; and Wilson, G.T.
Understanding and preventing relapse. Am Psychol 42:765-782,
1986.
Marlatt, G.A., and George, W.M. Relapse prevention: Introduction
and overview of the model. Br J Addict 79:261-273, 1984.
Nurco, D. Drug addiction and crime: A complicated issue. Br J
Addict 82:7-9, 1986.
Simpson, D.D., and Sells, S.B. Effectiveness of treatment for drug
abuse: An overview of the DARP research program. Adv Alcohol
Subst Abuse 2(1):7-29, 1982.
Tims, F.M. Effectiveness of Drug Abuse Treatment Programs.
National Institute on Drug Abuse Treatment Research Report.
DHHS Pub. No. (ADM) 84-1143. Washington, DC: Supt. of Docs.,
U.S. Govt. Print. Off., 1981. 181 pp.
Tims, F.M., and Leukefeld, C.G., eds. Relapse and Recovery in Drug
Abuse. National Institute on Drug Abuse Research Monograph 72.
DHHS Pub. No. (ADM) 86-1473. Washington, DC: U.S. Govt. Print.
Off., 1986. 197 pp.
6
The Efficacy of Civil Commitment
in Treating Narcotic Addiction
M. Douglas Anglin
INTRODUCTION
Civil commitment approaches to the control of narcotics addiction are
not new. The United States Public Health Service (USPHS) hospitals
in Fort Worth and Lexington represented an early attempt at
enforced treatment. Findings from the USPHS efforts in this respect
are reviewed by Maddux in this volume.
Before renewed consideration can be given to the compulsory commit-
ment of drug addicts for treatment, it is crucial to determine whether
such treatment can be effective in reducing addiction, or at least in
minimizing the adverse social consequences of addiction. There have
been only a few studies that have addressed this question, and the
empirical evidence derived from most of them has been equivocal.
Most commitment programs implemented over the last 20 years were
based more on the hope that treatment would be effective than on
consistent and objective demonstration of efficacy.
In order to demonstrate conclusively whether enforced, or compul-
sory, treatment is effective, William H. McGlothlin and I conducted
an evaluation of the California Civil Addict Program (CAP), the first
true civil commitment program implemented in the United States
(McGlothlin et al. 1977).
BACKGROUND
The initial study was performed during 1974, 1975, and 1976. Nearly
1,000 individuals admitted to the California CAP from 1962 to 1964
for a 7-year period of commitment were selected for followup. For a
full description of the California CAP, see McGlothlin et al. 1977.
8
For other research results, see Anglin and McGlothlin 1984 and
Anglin, in press. Subsequently, in 1978, the combined effects of civil
commitment and methadone maintenance on another sample of
approximately 300 CAP admissions were studied (Anglin et al. 1981).
The first CAP study took advantage of a natural experiment that was
inadvertently created during the initial years of the program. The
laws creating the CAP were passed in 1961, and the program actually
began late in 1962. However, judges and other officials involved in
the initial implementation of the program were not very clear about
commitment procedures and thus made many procedural mistakes. In
the first 18 months of the program, therefore, nearly half the
individuals admitted were released on a writ of habeas corpus after
minimal exposure to the inpatient component.
This group thus encompassed people who were eligible for the
program and who had the same characteristics as others admitted to
the program, but who, because of what was apparently a semi-
random process, were released after only a short time because of
procedural errors.
To take advantage of these circumstances, a treatment sample of
individuals was selected. These individuals had stayed in the program
for at least one inpatient stay and a subsequent release to supervised
community release, or outpatient status (OPS), and were matched with
individuals from among the group who had writted out. A time series
approach was used to study the data obtained from following up these
two groups.
OVERALL OUTCOMES OF CML COMMITMENT
Figure 1 is a time series graph from the original study. The
dependent variable was the percentage of time during each year that
narcotics were used on a daily basis. The solid line represents the
group that was admitted to the California Rehabilitation Center,
which is the inpatient facility for the CAP. The treatment sample
consisted of those who achieved at least one outpatient release.
Many of these, in fact, remained in the program for the full term.
The broken line represents those admissions who writted out after
minimal exposure to the program. They comprised the comparison
group. The break in the lines corresponds to the admission date to
the CAP. Eight years of preadmission data and 11 to 13 years of
postadmission data were obtained during the followup interviews.
9
FIGURE 1. Percent of nonincarcerated time using narcotics daily: CAP treatment and comparison samples
For part of the preadmission period, the treatment group reported
somewhat less daily narcotic use than did the comparison group. On
the whole, members of the treatment group spent an average of a
little over 40 percent of their time using narcotics daily before the 2
years immediately preceding commitment, compared to an average of
slightly less than 50 percent for the comparison group. For the 2
years before admission to the CAP, however, addiction levels for both
groups were “out of control,” and there was a sharp and converging
rise in the daily use of narcotics.
In the first year after release from treatment (either by writ or by
release to OPS), there was a sharp separation between the two
groups, with the comparison group using narcotics daily at a much
higher rate. Among the treatment group, an immediate and dramatic
drop occurred in daily narcotic use, which was sustained over the 5-
year period when most of the group were under supervision in the
CAP. After year 5, a time-related attenuation was evident, which
was associated with other social interventions and with maturing out
(Winick 1962). The comparison group showed a time-related attenua-
tion over the entire postadmission period, eventually converging
toward the treatment group level by year 5.
Years 6, 7, and 8 show increased daily use levels by both groups.
Chronologically, that period occurred during a heroin epidemic in the
United States in the early 1970s. This concomitant increase in levels
of daily use by both CAP groups provides strong evidence that
consumption of heroin is directly related to availability of the drug.
Based on this time series data, it is clear that civil commitment has
an important and dramatic effect on suppressing daily heroin use by
narcotics addicts. However, the program was not just concerned with
narcotic use per se; it was also intended to affect addiction-related
behaviors, particularly those with adverse social consequences.
Figure 2 is a graph showing the reported percentage of time each
group engaged in property crime activities. Prior to admission, both
groups spent comparable amounts of time involved in the commission
of property crime. As before, a sharp and sustained reduction was
observed after admission for the treatment group, whereas the
comparison group shows only a time-related attenuation.
The differences observed in figures 1 and 2 must be considered as
minimal measures of the effects of civil commitment. In many
11
FIGURE 2. Percent of nonincarcerated time involved in property crime; CAP treatment and comparison samples
cases, individuals in the comparison group were not totally free of
legal supervision. Some were on parole or probation or were subject
to other types of supervision that also suppressed their narcotic use
and criminal behavior. Had this not been the case, their use levels
and crime rate would undoubtedly have been higher. Thus, the
difference between the curves gives only a minimum estimate of the
effectiveness of civil commitment.
Table 1 presents a complete set of dependent variables for both
groups, including employment, time spent dealing drugs, and so forth.
All these measures show similar effects to those observed in figures 1
and 2 for daily narcotics use and for property crime involvement.
However, as the behavior or measure becomes more prosocial, the
effect becomes less dramatic. Statistically significant increases in
employment were observed, for example, but the change was not
nearly as large as were reductions in antisocial behavior.
Table 1 shows the difference between the precommitment to postcom-
mitment change in status and behavior for the treatment group and
the corresponding change for the comparison group. These data take
into account the initial precommitment levels of the variables and
determine the net difference in change scores for the two samples,
i.e., [comparison group postcommitment minus comparison group
precommitment] minus [treatment group postcommitment minus
treatment group precommitment].
Three periods are considered. Period I is the interval from time of
first narcotic use (N1) to civil commitment admission (A). Period II
is the 7 years after commitment, A to (A + 7), corresponding to the
full commitment term. Period Ill is the interval from A + 7 to the
interview (I), when, except for extended commitments, most of the
treatment group had been discharged from the CAP.
It must be noted that period II is defined on a purely chronological
basis, so that it represents the intended period of legal commitment.
Such a definition again gives a minimal estimate of the efficacy of
civil commitment, because a large minority of the treatment group
was released from CAP supervision before the imposed commitment
period expired. Reasons for early release included a determination as
unfit for treatment, incarceration for criminal offenses, and, less
often, graduation in good standing.
To test the sample differences for statistical significance, the data
are expressed in terms of the means of the individual measures. The
13
TABLE 1. Summary of mean precommitment and postcommitment status and behavior for comparison (C) and
treatment (T) samples
TABLE 1. (Continued)
1Data on arrests, self-reported crimes, and income from crime are rates per nonincarcerated person-year. Crime income does not include
drug dealing, gambling. etc.
2Heavy alcohol use is defined as drinking a six-pack of beer, or a bottle of wine, or seven drinks of liquor over a 6-hour period two or
more times per week.
NOTE:
Period I=First narcotic use (N1) to civil commitment (A); Period II=A to (A + 7 years). the legislated period of commitment; Period
Ill=(A + 7 years) to time of interview (I). The percentages in this table are the mean of individual percentages for the
respective periods. not the percentage of the overall parson-months.
SOURCE:
McGlothlin et al. 1977.
right half table 1 shows the difference between the change scores
and the correspon