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SUBSTANCE USE AND RELATED DISORDERS (JR MCKAY, SECTION EDITOR)
Treating Substance Use Disorders in the Criminal
Justice System
Steven Belenko &Matthew Hiller &Leah Hamilton
Published online: 17 October 2013
#Springer Science+Business Media New York 2013
Abstract The large number of individuals with substance use
disorders involved in the nation’s criminal justice system
(CJS) represents a unique opportunity, as well as challenges,
in addressing the dual concerns of public safety and public
health. Unfortunately, a low proportion of those who could
benefit from treatment actually receive it while involved in the
CJS. This article presents a review of recent research on the
effectiveness of major substance abuse treatment interventions
used at different possible linkage points during criminal jus-
tice case processing, including diversion, jail, prison, and
community supervision. This is followed by a discussion of
key research and practice issues, including low rates of treat-
ment access and under-utilization of medication-assisted treat-
ment. Concluding comments discuss principles of effective
treatment for offenders and identify key gaps in research and
practice that need to be addressed to improve and expand
provision of effective treatment for offenders.
Keywords Criminal justice .Drug treatment .Substance abuse .
Offenders .Implementation .Psychiatry
Introduction
The number of individuals involved in the US criminal justice
system (CJS) is among the highest in the developed world. In
2011, there were an estimated 12.4 million arrests, including
1.5 million for drug offenses (possession or sale) [1]. Nearly 4
million adults are under probation supervision (one out of
every 60 adults in the USA) and 854,000 on parole [2]. There
were 11.6 million persons admitted to jails during a recent 12-
month period [3]. At the end of 2012, there were about 2.3
million incarcerated adults, including 736,000 in local jails
(on an average day), 1,382,418 in state prisons, and 216,362
in federal prisons (48 % of the latter were convicted of drug
crimes) [4].
Most individuals entering the CJS are using illegal drugs at
the time of their arrest and/or have substance abuse problems
[5,6•,7]. Further, many commit property crimes to obtain
money to buy drugs, and participation in drug-dealing orga-
nizations often places individuals in situations where other
crimes are likely to occur. Stimulants, such as cocaine or
methamphetamine, have psychopharmacological effects that
can increase the likelihood of engaging in violent crime [8].
More than 80 % of state prison and local jail inmates have
used an illegal drug—about 55 % in the month before their
arrest [4,5,9]—with high lifetime usage of cocaine (42 %),
crack (24 %), methamphetamine (23 %), or heroin (19 %).
BasedonDiagnosticandStatisticalManualofMentalDisor-
ders IV criteria, 53.4 % of inmates meet the criteria for drug
abuse or dependence, compared with an estimated 13.0 % of
men and 5.5 % of women in community populations aged
18 years or older [4,10]. Among offenders on probation, 69 %
reported ever using illegal drugs, including 32 % using in the
month before their current offense [11]. In addition, 32 % of
state prison inmates were under the influence of drugs at the
time of the offense, and 16.5 % reported committing their
crime to get money to buy drugs [4].
Illegal drug use increases the likelihood of continued in-
volvement in criminal activity, with high rates of relapse and
recidivism found among drug-involved offenders; 68 % of
drug offenders are rearrested within 3 years of release from
prison [12]. Because there are effective treatment models for
offenders [13•,14•], expanding access to these is likely to help
break the links between drug use and crime. This article,
This article is part of the Topical Collection on Substance Use and
Related Disorders
S. Belenko (*):M. Hiller :L. Hamilton
Department of Criminal Justice, Temple University, 1115 Polett
Walk, Philadelphia, PA 19122, USA
e-mail: sbelenko@temple.edu
Curr Psychiatry Rep (2013) 15:414
DOI 10.1007/s11920-013-0414-z
therefore, reviews current knowledge about treatment access
and effectiveness at each stage of the criminal justice process,
and key issues for improving access to effective treatment.
Treatment Linkage Points in the CJS
There are several stages in criminal case processing at which
linkages to treatment are possible. Following arrest and filing
of formal charges by the prosecutor based on sufficient evi-
dence of a crime, the defendant has an initial hearing at which
the charges are formally presented and the judge decides
whether to detain the defendant in the local jail pending trial,
or release him or her with or without bail. After one or more
procedural or evidentiary hearings, the defendant may plead
guilty, or a trial will occur in the misdemeanor or felony court.
If the defendant is convicted (which occurs by plea for the vast
majority of cases), the judge sentences the defendant to op-
tions ranging from a fine or community service, incarceration
in the local city or county jail (for less than a year on a
misdemeanor conviction) or state prison (sentence of longer
than 1 year for a felony conviction), or probation. Once an
inmate has completed a minimum term in a state prison, many
inmates are released to parole supervision until the full sen-
tence is completed.
Models for linking offenders to treatment have been im-
plemented and tested at all of the stages of CJS processing.
Shortly after arrest, a defendant might receive a screening,
brief intervention and referral to treatment [15], or be diverted
to community treatment under pretrial supervision conditions
[16,17], or as an alternative to an incarceration sentence [18,
19]. Many jurisdictions have special drug treatment courts
into which offenders may be diverted prior to trial or placed
in following conviction [20–22]. After the sentence, treatment
access may be available in jails [23], prisons [24,25], or under
probation or parole supervision [26•,27]. For the latter linkage
points, treatment is often mandated as a condition of the
individuals’sentence.
Depending on the state, treatment at any of these stages
may be offered through local public health systems,
contracted providers, or referred through a brokerage model
in which services are offered by various providers, usually
through referral by a case manager. Options include outpa-
tient, intensive outpatient, residential, and medication-assisted
treatment (MAT). In state prisons, the typical residential
treatment is in a modified therapeutic community (TC); TCs
are much less common in local jails because these inmates are
usually incarcerated for brief periods. TCs provide an inten-
sive, highly structured pro-social environment in which treat-
ment staff and peers interact to influence attitudes, percep-
tions, and behaviors associated with drug use [28].
Nonresidential or outpatient treatment in correctional settings
is less intensive and usually involves a combination of
individual and group counseling, several times per week.
Finally, despite its well-established evidence base, MAT is
rarely used in the CJS, as discussed later in this article.
Even with these numerous potential linkage points, relative-
ly few offenders with substance abuse problems receive drug
treatment [5,26•]. Among new arrestees, between 7 and 26 %
have ever been in outpatient treatment and 13–32 % residential
or inpatient treatment, but only 2–9%hadbeeninoutpatient
and 3–11 % residential or inpatient in the 12 months prior to
their arrest, suggesting high rates of treatment failure because
the individuals have been arrested again [7]. Only about 10 %
of state and 6 % of jail inmates reported receiving any clinical
treatment [9]. Only 25 % of probationers with histories of drug
use, and 17 % overall, receive treatment [11], and treatment
linkages that do occur tend to be sporadic, inappropriate, and
poorly monitored [6•,11,29,30]. Finally, despite their popu-
larity, drug courts are estimated to serve only about 5 % of
offenders with drug problems [31,32].
CJS Models
Diversion to Treatment
In the typical model, new arrestees are offered an opportunity
to have their cases put on hold while they attend drug treat-
ment. Successful completion of treatment typically results in
the original criminal charges being dismissed (for pre-plea
models), the withdrawal of the guilty plea and dismissal of
the charges or plea to lower charges (post-plea model), or a
reduction in the sentence from incarceration to probation (in
the post-plea, post-sentencing model). With the exception of
drug courts, diversion programs are nearly always operated
and controlled by the district attorney, who has overall respon-
sibility for screening cases for eligibility and monitoring indi-
viduals’treatment progress.
Treatment Accountability for Safer Communities
(TASC) was one of the earliest treatment diversion models
[17], and 220 TASC programs currently operate in the USA
[33]. TASC integrates treatment into the CJS, providing
assessment, treatment referral, case management, and mon-
itoring. A multisite national evaluation of TASC was
conducted in five states in the late 1990s [34], using both
experimental (two sites) and quasi-experimental designs
(three sites). Relative to control/comparison groups, TASC
participants received significantly more treatment in four
out of five sites. Compared with control conditions, drug
use significantly declined from baseline to follow-up in
three sites, as did recidivism in two of the sites.
The Drug Treatment Alternative-to-Prison program
(DTAP) was established by the Kings County (NY) District
Attorney in 1990 to divert offenders into long-term residential
treatment [19]. Although most prosecutorial diversion
414, Page 2 of 11 Curr Psychiatry Rep (2013) 15:414
programs opt for the politically safe strategy of accepting only
low-risk offenders, DTAP targets high-risk felony drug sellers
who also have drug problems and are facing mandatory prison
sentences. DTAP participants have their sentence deferred and
are placed in community-based residential TC treatment for
18–24 months. Program completers have their sentence va-
cated, guilty plea withdrawn, and original charges dismissed;
dropouts are brought back to court for sentencing on the
original charges. From the beginning of the program through
October 2012, DTAP had admitted 3,022 participants, of
whom 1,377 successfully completed the program; the average
one-year retention rate is 76 %, far higher than typically found
in residential treatment [18,19].
A prospective quasi-experimental evaluation of DTAP
found positive impacts on retention, recidivism, and CJS
economic benefits compared with a matched sample of sen-
tenced inmates [35]. Over 4-year follow-up, significantly
fewer DTAP participants were rearrested (57 % versus 75 %
for the comparison sample), reconvicted (34 % for DTAP,
62 % for comparisons), or reincarcerated (7 % of DTAP
versus 18 % of comparisons received a new prison sentence,
30 % versus 51 % received a new jail sentence) [35]. DTAP
decreased the rearrest odds by 42 %, after controlling for other
factors. The cumulative 6-year CJS economic benefits per
DTAP participant were $88,554, with a benefit–cost ratio of
2.17, adjusting for treatment costs [36].
California’s Proposition 36 (Substance Abuse and Crime
Prevention Act; SACPA), was enacted in 2001 to reduce jail
and prison crowding by diverting all non-violent drug of-
fenders from incarceration to community-based supervision
and treatment. It marked a major paradigm shift from crime
control to the implementation of a public health model [37,38].
During 2006 and 2007, nearly 44,000 offenders entered treat-
ment under Proposition 36 [39]. Overall, SACPA resulted in
significant decreases in drug use and criminality from baseline
to 12-month follow-up [37]; the more treatment received, the
better the outcomes [40]. However, offenders with a more
serious criminal history and parolees (relative to probationers)
showed poorer outcomes, perhaps attributable to a mismatch
between need severity and level of treatment [41,42].
Jail-based Treatment
Given their high admission volume, jails represent a significant
potential treatment intervention point in the CJS. With rapid
turnover and short average stays, however, there are challenges
for providing treatment in jails [3,23,43]. Treatment options
such as long-term residential or intensive outpatient treatment,
needed by many offenders [5], are not viable in jail settings, and
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
interventions may be more appropriate [6•].
Recent studies suggest promising models for engaging jail
inmates in treatment. The Jail In-Reach Intervention was
recently tested in a randomized controlled trial (RCT) with
female jail inmates [44]. Implementing an SBIRT model, this
intervention uses evidence-based screening tools to identify
those with a serious substance abuse problem. Following
randomization, women in the intervention group completed
a motivational interview with feedback on their drug use, and
a timeline follow-back interview. Women in both intervention
and control groups also received a resource folder with infor-
mation about community-based treatment. The intervention
group had significantly lower alcohol and drug use at a 12-
month follow-up. Women who used the resource folder, re-
gardless of study condition, were three times more likely to
seek community-based treatment [45].
Building on the Transtheoretical Model of Change and
Motivational Enhancement Therapy, interactive journaling
was tested in a jail [46]. This approach has been tested in
other settings and could be well-suited for jails because it is
time-efficient and requires few resources. Inmates were ran-
domly assigned to complete a journal, designed to help the
individual recognize the problems caused by substance abuse,
to understand their motivations for using drugs, and to intro-
duce them to drug treatment resources. Compared with the
control condition, the interactive journaling group had signif-
icantly lower recidivism. The study did not assess whether the
intervention increased engagement in community treatment
after release.
The importance of linking jail inmates to continuing care
after release has received increasing attention. One recent
study found that community-based drug treatment following
release from jail reduced recidivism [47]. The Recovery Man-
agement Check-ups (RMC) intervention was tested in a RCT
with female inmates in the Cook County (IL) jail [48]. For the
first 3 months following release, women in the RMC had
monthly contact from a “linkage manager”who, using moti-
vational interviewing, discussed recent substance abuse, mo-
tivation to change, and barriers to entering treatment. The
linkage manager also made appointments and accompanied
the women to the treatment admission process. RMC partic-
ipation resulted in a higher proportion of women seeking
community-based treatment, faster treatment access, and an
increased likelihood to abstain from drug use during follow up
[48].
Prison-based Treatment
Research on prison TCs, including several meta-analyses, sug-
gests that these interventions can reduce post-prison recidivism
and relapse when combined with aftercare treatment following
release. A systematic review examined 26 published and un-
published studies of prison drug treatment in North America or
Western Europe since 1979, including counseling and drug
education programs, in addition to TCs [13•]. Three-quarters
of the studies had outcomes that favored the treatment group
Curr Psychiatry Rep (2013) 15:414 Page 3 of 11, 414
over the comparison group, with an overall mean odds ratio of
1.25 (equivalent to a modest reduction in recidivism from 50 %
to 44.5 %). TC programs showed the strongest overall effect
(mean odds ratio =1.47).
1
Several recent single-site evaluations of prison TCs indicated
positive effects for prison TCs, especially when aftercare is
completed. A quasi-experimental study of Delaware’sKey-
Crest program (in-prison TC, following by a TC-based work-
release program and outpatient aftercare) found significantly
lower recidivism rates among those who completed a work-
release TC [25]. Those who attended outpatient aftercare had
the best outcomes (69 % arrest-free after 3 years, 35 % drug free);
only 17 % of those completing just the in-prison TC remained
arrest-free and only 5 % of the untreated comparison group
remained drug free. Another quasi-experimental study in Penn-
sylvania examined post-release outcomes for inmates who par-
ticipated in TCs compared with a matched sample of inmates
who were TC-eligible, but participated in less intensive treatment
(e.g., short-term drug education or outpatient treatment) [49].
Over a post-release follow-up up to 26 months, TCs significantly
reduced reincarceration (30 % versus 41 % for the comparison
sample) and rearrest (24 % versus 33 %), but not drug relapse
(35 % versus 39 %) [49]. Finally, a retrospective propensity score
matched study of prison releasees in Minnesota found that prison
TC participation reduced the hazard ratio of rearrest by 17 % and
reincarceration by 25 % over the 3–4yearfollow-upperiod[50].
However, multiple reviews have noted that many prison TC
studies have methodological weaknesses that suggest caution for
drawing causal inferences about prison TC impacts [13•,51–53].
Mitchell et al. [13•] noted that only three studies (9 %) had the
highest quality (randomized experimental designs), and eight
(25 %) were rated in the second highest quality category (rigor-
ous quasi-experimental designs). Threats to internal validity in
prison TC research include self-selection and/or attrition bias,
lack of full randomization, lack of detailed descriptions of the
treatment delivered, and concerns about treatment implementa-
tion. One exception was a study of federal prison residential
treatment, that controlled for selection bias, but still found a
significant reduction in post-release rearrest after 6 months
(3.1 % of treated inmates rearrested, 16.7 % of untreated inmates)
and reduced drug or alcohol use (20.5 % of treated inmates using
drugs or alcohol compared with 36.7 % of untreated inmates)
[54]. A systematic review of prison treatment aftercare research
could not draw definitive conclusions about the effectiveness of
aftercare owing to inconsistent definitions and methodological
weaknesses [51].
Treatment in Community-based Corrections
In a national probability survey of community-based correc-
tions (i.e., probation and parole), it was found that the most
common approach to addressing substance abuse was drug
and alcohol education (53.1 % of jurisdictions) [26•]. Sub-
stance abuse counseling of up to 4 hours per week was
provided in just over half (47.0 %) of jurisdictions, and
21.2 % offered 5–25 hours of treatment per week. Only
3.7 % of jurisdictions offering segregated TCs and 3.4 %
offering non-segregated TCs. Similar to other studies, treat-
ment was accessed by only a small percentage; between 1 and
9 % are in any type of program on a given day [26•].
Research on the comparative effectiveness of different
treatment modalities or treatment delivery models for of-
fenders under community-based correctional supervision is
limited. Only one meta-analysis compared substance abuse
treatment outcomes for offenders in prisons or jails with those
under community supervision [55]. This study found that both
types of programs were almost equally effective; however,
this study was limited to European programs. A quasi-
experimental study of a 6-month modified TC for offenders
on probation examined program retention and recidivism [27,
56]. More serious criminal history, higher hostility and risk-
taking, and cannabis dependence were related to higher drop-
out rates; greater social conformity and employment were
associated with lower likelihood of dropout [56]. Age and
the number of lifetime arrests were the only significant pre-
dictors of reincarceration after 2 years. However, TC treat-
ment did not reduce recidivism over a 2-year follow-up rela-
tive to the comparison sample [27].
The Serious and Violent Offenders Reentry Initiative
(SVORI) for parolees in ten states found that between 32
and 34 % of adult men surveyed expressed some health
service needs (including substance abuse) [57]. However, in
recent analyses of the SVORI data we found that only 25.5 %
of adult male parolees reported receiving any type of sub-
stance abuse treatment in the first 3 months after release.
Drug Courts
Drug courts have received much attention and expanded rapid-
ly over the last 20 years [20,22,58,59]; 1,317 adult drug courts
wereinoperationattheendof2009intheUSA[60]. Core
components of the drug court include linkage to long-term
substance abuse treatment under close judicial supervision; case
management and team decision-making; and use of sanctions
and incentives to enforce drug court requirements [21,61].
Depending on the drug court, offenders may be diverted before
conviction (with charges dismissed upon successful comple-
tion), or placed in the drug court after pleading guilty or being
sentenced (with dismissal of charges or reduction in the sen-
tence after successful program completion).
1
The effectiveness of non-TC prison drug treatment remains largely
unknown [13•,52]. An earlier systematic review of prison programs
reviewed seven studies of prison-based outpatient or group counseling
programs [107]. Methodological weaknesses were present in most of
these studies, but the authors concluded that group counseling programs
were not effective in reducing recidivism [107].
414, Page 4 of 11 Curr Psychiatry Rep (2013) 15:414
Substantial research over the last 15 years, including sev-
eral RCTs and meta-analyses, indicates that adult drug courts
reduce drug use and criminal behavior during program partic-
ipation, and reduce post-program recidivism [59,62,63,64•,
65]. A meta-analysis of 55 studies found a mean recidivism
reduction of 26 % in adult drug courts [65]. A recent updated
meta-analysis found on average that drug courts reduced
recidivism from 50 % to 38 % [64•].
However, the evidence base for the drug court model
should be interpreted with some caution. Many studies used
relatively non-rigorous evaluations, or had small sample sizes,
inconsistent measures, short follow-up periods, or inappropri-
ate comparison samples [58,66]. Little is known about the
long-term post-program impacts of drug courts on recidivism,
drug use, or other outcomes [59,66]. Aside from the broad
guidelines codified in the consensus-driven Ten Key Compo-
nents of drug courts [21,61], the drug court model is not well-
defined nor have the specific effective components been de-
termined through adequately controlled studies.
Key Issues in Research and Practice
Lack of Treatment Penetration into the Target Population
Despite the evidence summarized above, penetration of effec-
tive treatment models into the target population of drug-
involved offenders is low [5,26•,32,67,68]. Findings from
national surveys demonstrate that non-treatment approaches
to substance abuse, such as drug education, are the most
common form of service provided for substance abusing
offenders [5,26•]. The second most common form of treat-
ment within prisons, jails, and probation services is low in-
tensity counseling, which has a minimal evidence base. Al-
though group counseling can be effective [13•,69], longer and
more intensive programs tend to be more effective for offend-
er populations [14•]. Despite some evidence base for prison
TCs [13•], these programs are relatively expensive and treat-
ment slots are scarce both in prison facilities, as well as the
community. MAT, with a fairly strong evidence base, is rarely
used in the CJS [26•,70,71].
Although guidelines for integrating evidence-based prac-
tices (EBPs) into the CJS are available [6•,14•,72•], numer-
ous barriers exist for implementing such treatment programs
[53,68,73,74]. These include knowledge gaps among crim-
inal justice staff, as well as their beliefs and attitudes about
treatment and specific EBPs. Skepticism toward treatment
effectiveness in general has been noted among police and
prosecutors, which might undermine efforts to place individ-
uals into diversion programs [38]. Many CJS officials and
staff may also not be comfortable with the concept of addic-
tion as a brain disease, viewing it as more of a behavioral
problem over which offenders have some control [6•].
Significant communication and collaboration problems, both
within and between criminal justice and community-based
treatment and health agencies, can thwart implementation of
high quality services [73]. Resource constraints make the
adoption of “expensive”EBPs unattractive and unlikely [70,
71,73]. Criminal justice organizational cultures also can be
highly resistant to change. And, finally, organizational
changes and high rates of staff turnover make it difficult to
begin new and maintain existing treatment services [75–77].
Under-utilization of MAT
An illustration of the failure to expand use of EBPs for drug-
involved offenders is the relatively limited use of MAT. Evi-
dence supporting the efficacy and effectiveness MAT is based
largely on studies of methadone, although recent studies with
buprenorphine and naltrexone have shown some promise
[78–81]. Recent systematic reviews of MAT with offenders
have concluded that methadone maintenance and naltrexone
reduce reoffending and relapse [55,82]. For example, in a
RCT with inmates it was found that those assigned to mainte-
nance treatment during incarceration were less likely to drop
out from treatment and less likely to test positive for illicit
drugs after release than those in non-MAT during incarcera-
tion or those who were only transferred onto methadone
maintenance after release [83•]. Post-release drug use was
reduced for inmates receiving counseling plus methadone,
but MAT had no significant effect on recidivism. In a com-
panion study, it was found that inmates randomly assigned to
methadone maintenance in prison were most likely to enter
treatment, followed by those transferred to methadone main-
tenance after release and then counseling only [84]. Mainte-
nance patients were also most likely to complete prison treat-
ment and counseling only the least likely.
MAT begun during jail can improve community-based
MAT treatment engagement and outcomes. A recent study
randomly assigned opioid-dependent inmates in a large urban
jail to either buprenorphine or methadone [85]. In-jail treat-
ment completion rates were similar, but the buprenorphine
group was significantly more likely to continue medication
treatment in the community; groups had similar rates of self-
reported criminal involvement and substance use at 3-month
follow-up [85]. Higher doses of methadone in jail were found
to significantly increase linkage to continuing care in
community-based treatment following release [86].
A preliminary retrospective evaluation of extended release
naltrexone (Vivitrol) with alcohol-dependent clients in three
drug courts found that volunteers for Vivitrol had significantly
lower rearrest likelihood than matched controls (8 % versus
26 %) [87]. Studies of California’s Proposition 36 found that
opioid-dependent offenders who received MAT showed better
outcomes than those who received only outpatient or residential
care [88]. Injectable sustained release naltrexone has also
Curr Psychiatry Rep (2013) 15:414 Page 5 of 11, 414
shown positive effects on retention in community treatment
[89].
Many staff hold negative views toward methadone main-
tenance treatment for opioid dependence, viewing it as
substituting one addiction for another [70,90]. A recent
national survey of corrections staff in 14 states found very
limited use of MAT [70]. Although 83 % of prisons and 83 %
of jails offered some type of MAT; most of this was limited to
detoxification, and typically only for pregnant women. Only
37.5 % of drug courts and 17 % of probation or parole
agencies offered MAT. Methadone maintenance, when of-
fered, was usually limited to pregnant women, or, occasional-
ly, for individuals previously on methadone maintenance at
the time of their incarceration or arrest. The lack of uptake of
MAT in the CJS reflects state and local regulations, security
concerns, institutional philosophy (i.e., belief in abstinence-
based treatment), and availability and resources (financial and
staffing) [70]. In a recent national survey of 103 drug courts,
56 % reported having some type of MAT available (although
the percentage of drug clients receiving such treatment was
not reported) [71]. About half of the drug courts have a
specific policy against use of MAT. Lack of funding, treatment
program resistance, and risk of diversion were other common
reasons cited for the limited use of MAT.
Principles of Effective Treatment for Offenders
The delivery of effective drug treatment in the CJS can be
much more challenging than in standard community settings.
In response, consensus and research-driven efforts have
established a set of principles for providing effective treatment
for offenders [14•,91]. Such principles incorporate the unique
characteristics of the offender populations that can greatly
complicate treatment delivery. These include high rates of
psychological conditions and personality disorders, such as
low impulse control, cognitive deficits, risk-taking, and crim-
inal thinking patterns. Treatment for offenders that incorpo-
rates the risk–needs–responsivity (RNR) principle has been
shown to be more effective [30,92]. Under the RNR frame-
work, evidence-based principles for effective treatment should
incorporate 1) comprehensive actuarial assessment of static
and dynamic risk factors with periodic reassessment; 2) prior-
itizing treatment resources for higher-risk offenders; 3)
targeting interventions for criminogenic needs, such as crim-
inal thinking and errors in judgment; and 4) provide treatment
that is responsive to an offender’s temperament, learning style,
motivation, culture, and gender [68,93].
The National Institute on Drug Abuse (NIDA) has developed
a monograph summarizing key principles for effective treatment
in the CJS. Building on the original set of NIDA treatment
principles [94], this guide is based on a review of the research
literature and consensus from experts in addiction research and
practice. Most of the principles reflect what the field considers to
be evidence-based practice or principles, rather than specific
programs. In addition to the principles noted above, NIDA
recommends that treatment for offender populations should 1)
be of sufficient length, especially for those with co-occurring
mental health disorders and other social and health problems; 2)
increase motivation and build skills for resisting drug use and
criminal behavior; 3) include on-going monitoring through urine
testing, and use of structured rewards and sanctions to manage
behavior; 4) involve collaboration and communication between
treatment clinicians and CJS staff to monitor client progress; 5)
provide continuity of care as offenders move through the CJS
and back to the community; 6) integrate treatment for offenders
with co-occurring mental health disorders; and 7) use MAT
where clinically appropriate, with careful attention to monitoring
adherence [14•].
Conclusion
Several conclusions can be drawn from this brief review. First,
drug use disorders and related problems are quite common
among offenders throughout the CJS, indicating a need to
integrate and expand effective treatment linkages. Second, a
number of potentially effective models exist for linking of-
fenders to treatment both within correctional institutions and
in the community, at all points in the process from arrest
through sentencing. Diversion models such as TASC, DTAP,
and SACPA have been shown to reduce drug use and recid-
ivism, and diversion-model drug courts have also shown to be
effective for reducing recidivism, especially when higher-risk
offenders are targeted. Legally mandated treatment can im-
prove retention [18], and treatment outcomes can be similar to
outcomes in non-mandated treatment for offenders.
For local jail inmates, brief psychosocial interventions to
increase self-awareness and treatment motivation, treatment
referral monitoring, and in-jail initiation of and/or referral to
community-based MAT can link jail inmates to community
treatment and improving post-release outcomes. SBIRT
models may be well-suited for the highly transitory jail set-
ting, where short stays preclude implementing longer-term
drug treatment programs. Longer-term programs in jails can,
however, be suitable for offenders sentenced to jail terms of
3monthsorlonger.
A number of prison TC studies show positive impacts on
recidivism and relapse when combined with continuing com-
munity care, but caution is needed in drawing conclusions
owing to methodological problems with some of the research,
and the relatively low proportion of inmates who access
aftercare following release. More research, using stronger
designs and controlling for selection bias, is needed on the
types and length of aftercare that are most effective for reduc-
ing relapse and recidivism [51]. There has been relatively little
414, Page 6 of 11 Curr Psychiatry Rep (2013) 15:414
research on the impact of other types of prison treatment.
Recent pilot studies suggest that MAT (included extended
release naltrexone) may have promise for improving out-
comes for offenders with opioid dependence. There has been
very little research on effective treatment models or modalities
for offenders on probation or parole, despite the fact that a
majority of offenders are under such supervision.
Given this demonstrated treatment need, and numerous
linkage points, the challenge for researchers and clinicians is
to increase knowledge about how best to integrate treatment
into the criminal justice process at all stages, and reduce the
substantial existing gap in treatment access. Although of-
fenders (especially those charged with felonies) are under
the supervision of the CJS for a relatively long time [95], the
fragmented nature of the CJ process presents difficulties in
implementing integrated treatment that provides continuity of
care and regular, evidence-based assessment. The importance
of a continuum of care, and the crucial need to link jail and
prison inmates to community treatment after release has been
amply noted in the literature [29,51,96•]. Resources to
support increased treatment capacity for offenders are needed,
as well as mechanisms for reducing gaps in Medicaid insur-
ance coverage when offenders are incarcerated.
New research on staff, organizations, and systems is needed to
understand the barriers to treatment access, and to develop and
test strategies for increasing implementation and sustainment of
EBP for offender drug treatment [68,97]. Taxman and Belenko
[68] have argued that criminal justice services should act as a part
of a “seamless service delivery system,”wherein offenders with
substance abuse problems are treated within the CJS or linked to
service providers offering evidence-based treatment. The limited
penetration of treatment services into the CJS is all the more
problematic given that a number of economic studies, in multiple
criminal justice areas (community treatment [98], prison TCs
with after care [99], other prison-based treatment [100] and drug
courts [101,102]), have demonstrated that criminal justice-based
drug treatment is cost effective and provides net economic
benefits for the CJS, primarily from reduced incarceration and
victimization.
Organizational and implementation studies are needed to
understand how best to increase the adoption, implementation,
and sustainability of evidence-based treatment for offenders
[68]. The emerging field of implementation science seeks to
understand how programs and practices are implemented into
organizations, and new theories and conceptual frameworks
are being developed to identify the key factors that drive
successful implementation and sustainability of EBP, helping
to guide new research on these processes [97,103,104].
Matching service needs and the level and type of service
provided is another important consideration [105]; the RNR
principle suggests that improving such alignment, addressing
criminogenic factors, and matching treatment to the cognitive
abilities of offenders, will improve outcomes. Offenders also tend
to have a high likelihood of economic and social disadvantage,
and other comorbid health problems; this raises the importance of
delivering treatment to offenders, and increases the challenges of
implementing appropriate and effective treatment [6•].
There is also limited knowledge about the comparative
effectiveness of different treatment modalities or linkage
models for different types of offenders at each stage of the
criminal justice process. More research, using strong designs
and measures to facilitate causal inferences, can help elucidate
the optimal and most cost-effective interventions in terms of
length and intensity of treatment, modalities, types of services,
and supervision models [106]. For existing interventions with
some evidence of effectiveness, such as drug courts, diversion
programs, and prison TCs, new research is needed on the
effective operational components of these programs to im-
prove replication and monitoring of fidelity.
A new research, practice, and policy agenda can provide the
impetus to build on the existing evidence and clinical practice
base to expand access to effective drug treatment for offenders.
Given the enormous need to address substance abuse problems
among offenders, the potential for improving both public health
and public safety is substantial.
Acknowledgments This paper was supported in part by NIDA grant
U01DA025284.
Compliance with Ethics Guidelines
Conflict of Interest Steven Belenko has received research support
from NIDA and royalties from Springer.
Matthew Hiller declares that he has no conflict of interest.
Leah Hamilton has received research support from NIDA.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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