Shift from Punishment to Treatment Approach

Introductory Paragraph

A significant number of inmates suffer from substance use disorder, a mental health disorder, or a combination of the two. When proper treatment is made during incarceration there is a decrease in inmate misconduct. When treatment is followed through to post-release, there is documented lower risk for relapse and recidivism.

The United States has the highest incarceration rate in the world. There is substantial evidence that shows how detrimental it is to overcrowd jails and prisons and to turn a blind eye to the revolving door effect that happens when individuals are incarcerated without adequate support to change behaviors. Although evidence shows that substance use disorder is a treatable disease of the brain, many people never receive treatment. As a result too many end up involved in the criminal justice system from illegal drug-seeking behavior. Recent data shows a significant correlation between criminal justice involvement and substance use. This highlights the importance of identifying a different approach to the problem and the need to shift from a punishment to a treatment approach.

More than half of the prison population in the United States, about 65%, is estimated to have an active substance use disorder. About 20% who did not fully meet the criteria for a substance use disorder were under the influence of substances at the time of their arrest. Many of the individuals in prison who need treatment are not receiving it. Thus, they have a high risk of reoffending once released. Treatment has impacts that can last for decades -- on an individual’s quality of life, reduced likelihood of recidivism, and future relapse. Failure to provide adequate and high-quality substance use treatment is not only detrimental to the individuals who are incarcerated but also has negative implications for their families, society, and the economy.

It should be a priority to offer treatment to individuals within the criminal justice system who have a substance use disorder. The National Institute on Drug Abuse has increased its efforts to find solutions. It supports social workers, counselors, and others who work within the court system to provide services to individuals involved in the criminal justice system due to drug use. This helps both to decrease substance use and to reduce crime. There are evidence-based strategies that play a role in transforming traditional punishment-based approaches which may be used within the criminal justice system. Moving from a punishment to treatment approach improves both public health and public safety while decreasing rates of future incarceration.

Key Information

The Substance Abuse and Mental Health Services Administration (SAMHSA) identified eight principles to assist community-based behavioral health providers and criminal justice professionals to collaborate most effectively. These principles provide a strong foundation for understanding re-entry programs, evidence-based practices, the risk of recidivism, pre-arrest and diversion programs, and medication assisted therapy:

• Community providers are knowledgeable about the criminal justice system. This includes the sequence of events, terminology, and processes of the criminal justice system, as well as the practices of criminal justice professionals.
• Community providers collaborate with criminal justice professionals to improve public health, public safety, and individual behavioral health outcomes.
• Evidence-based and promising programs and practices in behavioral health treatment services are used to provide high quality clinical care for justice-involved individuals.
• Community providers understand and address criminogenic risk and need factors as part of a comprehensive treatment plan for justice-involved individuals.
• Integrated physical and behavioral health care is part of a comprehensive treatment plan for justice-involved individuals.
• Services and workplaces are trauma-informed to support the health and safety of both justice-involved individuals and community providers.
• Case management for justice-involved individuals incorporates treatment, social services, and social supports that address prior and current involvement with the criminal justice system and reduce the likelihood of recidivism .
• Community providers recognize and address issues that may contribute to disparities in both behavioral health care and the criminal justice system.

Ongoing research has suggested that substance use can be associated with poorer outcomes among individuals who have been incarcerated, including those under supervision in the community. A study by Pew Trusts study shows that more imprisonment does not reduce drug related issues. This study reinforces a large body of research that casts doubt on the theory that tough prison terms deter drug misuse, distribution, and other drug-law violations. The evidence strongly suggests that policymakers should pursue alternative strategies which the research shows work better. There have been two major avenues that have proven successful in shifting a from a punishment to treatment approach. The first is through by-passing incarceration with therapeutic alternatives. The second is through increasing treatment options inside jails and prisons.

By-passing Incarceration

Community-based behavioral health providers play a key role in ensuring that every individual they serve has the treatment, support, skills, and opportunity for recovery they need in order to live productively with dignity and respect. People who simply need access to quality community-based care may be arrested instead. In many communities, people with behavioral health disorders cannot access adequate community-based services and find themselves channeled into the justice system. This may happen when a person is arrested for behaviors related to their untreated mental illness or when a law enforcement officer believes that a person could benefit from healthcare services that are provided in the jail. Arrest and even brief incarceration can destabilize an individual’s life in many ways, including housing, health care, employment, and disruptions in family life and social connections. Once in the criminal justice system, individuals with mental and substance use disorders stay in jails longer, have an increased risk for self-harm, and receive more frequent punitive responses to infractions. Due to funding and staffing limitations, many people with mental illnesses do not receive the services that they need, and their conditions often worsen inside jail settings. For individuals already receiving medications and treatment in the community, these services may be interrupted during incarceration, creating lapses in treatment and difficulties in resuming treatment upon reentry to the community. Without continuous coordinated care throughout and following incarceration, these individuals are at risk for re-incarceration. Programs to improve outcomes of those in recovery within the criminal justice system includes community-based diversion programs, drug/treatment courts, treatment while incarcerated, and re-entry resources and services. For more detailed information on re-entry, please see the SAFE wiki titled "Improve Reentry After Incarceration."

Increasing Treatment Options

Treatment services for people within the criminal justice system, give society an opportunity to better the lives of the individuals and to improve public health and safety. Without treatment, individuals are more likely to commit crimes at a higher rate once released from prison when compared to those who are not using substances. The provision of drug treatment inside the prisons and jails while the offenders are incarcerated has shown promise. Since the 1990’s researchers have discovered highly effective interventions that can be implemented while offenders are incarcerated and after they are released. A critical component of this approach is adequate pre-release and post-release counseling and support. This reduces detrimental impacts of individuals returning to a stressful home-life or environments with negative peer influences. Lack of access to treatment upon release increases the likelihood of relapse. The risk of overdose is amplified due to the changes in an individual’s tolerance after being incarcerated, leading to a higher probability of death. Common treatments include the following proven evidence-based approaches:

• behavioral counseling
• medication assisted treatment (MAT)
• evaluation and treatment for co-occurring mental health issues such as depression and anxiety
• long-term follow-up to prevent relapse

Well-designed prison treatment programs reduce relapse, criminality, inmate misconduct and recidivism. They also increase levels of education, mend relationships, boost employment opportunities upon release and improve overall health. Cost-benefit analysis indicates that residential prison treatment is cost-effective if prisoners continue treatment after their release. There are immediate and long-term fiscal benefits. In a direct and immediate cost comparison, the cost of treatment pales in comparison to the cost of incarceration. In a longer-term vantage point, when prisoners overcome drug use, it reduces the economic burden of recidivism. In general, the criminal justice system supports treatment during incarceration by offering inmates with substance use problems a mix of psychotherapy sessions, religious ministry meetings, and 12-step programs, such as Alcoholics Anonymous.

Medication-Assisted Treatment (MAT) can be utilized for drug-dependent individuals within the criminal justice populations. Currently, within the criminal justice system, MAT is used primarily for pregnant women to detoxify and is minimally used for reentry. There are ongoing studies surrounding MAT, as well as efforts to expand the use of MAT within the current correctional infrastructure. Efforts to expand MAT include training, education, reducing stigma, and increasing funding. Expansion of MAT within community correctional settings will also require increased collaboration with community providers in order to enhance the appropriate pharmacotherapy for individuals under community correction supervision. Concerns of correctional facilities surrounding MAT have included liability, staffing, regulation, and funding. More information can be found at the SAFE wiki article titled, "Expand the Use of MAT/MAR in Correctional Facilities."

The federal prison system utilizes four primary types of programs to assist inmates in overcoming a substance use disorder:

• The Residential Drug Abuse Program (RDAP) is the most intensive program that the Federal Bureau of Prisons will provide and is normally nine months in length. Inmates in this program live in their own separate community from the rest of the population. Inmates take part in daily half-day programming and a half-day of work, school, or vocational activities. Research has shown that inmates that take part in RDAP are significantly less likely to recidivate and relapse to drug use compared to those inmates who do not take part in RDAP.

• Nonresidential Drug Abuse Treatment. This involves a 12-week cognitive behavioral therapy (CBT) program that is organized in group sessions that address criminal lifestyles while increasing skills in the areas of rational thinking, communication, and institution-to-community adjustment. Inmates that are enrolled in this program normally have short sentences, do not meet the Residential Drug Abuse Program, are waiting to be enrolled in RDAP, are in transition back into the community, or have a positive urinalysis test

• Drug Abuse Education entails a series of classes that educate inmates on substance use disorder and the effects it has on your body and mind.

• Community Treatment Services (CTS) provides continued care to inmates who have been released and put into Residential Reentry Centers or on Home Confinement. Evidence shows that the period after being released is the most vulnerable time for inmates to relapse back to drug use or criminal activity. So, continued treatment after release is vital to the success of the offender completing their treatment.

Relevant Research

• This article reviews therapeutic alternatives to incarceration, such as judicial oversight in drug courts, and documents their effectiveness in transitioning offenders back into the community where they can address their illness and live productive lives. Research has shown the positive impact community-based drug treatment has on criminal behavior and may result in 1.8 times better outcomes in reducing drug use and the chances of reoffending. Drug courts that combined judicial supervision and treatment in place of incarceration had half the rearrests rates than those who did not participate in said programs.

• SAMHSA has published Treatment Improvement Protocol (TIP) titled, "Substance Abuse Treatment: For Adults in the Criminal Justice System." In addressing the need for trauma-informed care, the report distinguishes between historic trauma as root cause of criminality and trauma associated with incarceration. The panel that made the report, reached consensus on the recommendation that in-prison treatment address both the trauma of the incarceration itself and the prison culture that conflicts with treatment goals. Since prisons can be violent, harsh, and psychologically damaging, incarcerated people live in an environment that is both depersonalizing and dehumanizing. When added to the social stigma associated with incarceration, this may result in a sense of hopelessness and powerlessness, as well as deeply internalized shame and guilt -- highlighting the need to concurrently treat for both substance use and mental health.

• NIDA has published a research-based guide titled "Principles of Drug Abuse Treatment for Criminal Justice Populations." NIDA reports that over 80% of prisoners who would benefit from treatment while incarcerated do not receive it -- despite the overwhelming evidence that drug treatment is more effective than incarceration.

• GAO Report on Overcrowding of Jails and Prisons. One of the major barriers to treatment and recovery support during incarceration is the availability of effective treatment. Overcrowding is a leading factor as to why inmates with drug dependency problems are not enrolled in these programs. This report indicates that over 50,000 inmates were on waiting lists to enter drug treatment programs. In addition to overcrowding, staff shortages and limited resources are part of the enrollment issues in drug treatment programs.

• The National Drug Intelligence Center (NDIC) estimated the cost of illicit drug use to society was $193 billion. This is in addition to the $249 billion, estimated by the Office of the Surgeon General, in costs associated with alcohol misuse. The NDIC estimated the cost to treat drug use at $14 billion -- including healthcare costs, hospitalizations, and government specialty treatment.

• This article is titled "Treating Drug Abuse and Addiction in the Criminal Justice System: Improving Public Health and Safety." It summarizes relevant findings in neuroscience and evidence-based principles of addiction treatment that could help improve public heath and reduce criminal behavior. The authors report that individuals who participated in prison-based drug treatment programs paired with community programs after release were 7 times more likely to continue to abstain from substances and 3 times less likely to re-offend when compared to those who did not receive treatment.

• This article documents the benefits of treatment for the incarcerated in terms of both increased recovery rates and decreased recidivism.

Impactful Federal, State, and Local Policies

• The Residential Substance Use Disorder Treatment Act of 2021 expanded access to substance use treatment in jails and prisons within the United States. This bill also expanded access to treatment within the communities after offenders were released. This was a step in the right direction for providing treatment in place of incarceration. One major advance was the government’s acknowledgment of how important it is to stop the "revolving door" pattern associated with substance use and incarceration through the use of treatment and medication.

• Medicaid now allows those leaving incarceration to have Medicaid coverage, expanding their access to treatment options upon release from jail or prison.

• The Adult Drug Court Grant Program is managed by the Department of Justice. It provides financial assistance to states, local courts and government, and federally recognized Indian tribal governments to integrate substance abuse treatment, drug testing, incentives, and sanctions in judicially supervised settings with the intent to reduce recidivism and substance use among offenders.

• Many states are revising their drug penalties and focusing on prevention, treatment, and recovery to integrate evidenced-based practices for treatment. For example:
  • Connecticut enacted sentencing and drug-free zoning reform based on two models promoted by the American Legislative Exchange Council (ALEC). In its 2021 Report, ALEC has a policy section titled "Criminal Justice Reform" which references ALEC resolutions, supporting drug free zones and a minimum age of 10 for delinquency adjudication.
  • Oregon passed a groundbreaking drug law in 2020 which was reversed in 2024. The 2020 legislation, “Measure 110,” decriminalized the possession of small amounts of illegal substances and expanded funding and access to substance use treatment. Previously, access to treatment for substance use treatment was a common result of being arrested or coming into contact with the criminal justice system, having detrimental impacts on an individual’s life and ability to hold employment. Measure 110 offered another pathway by treating possession like a traffic ticket and opening the door to treatment instead of incarceration. During its four years of implementation, Measure 110 used tax revenue from savings from reduced arrests and incarceration. One downside to this new approach was the impact it had on the medical community, stressing resources to handle and increase in overdose patients. One critique raised in the campaign to reverse Measure 110 was that it was poorly implemented, normalizing and amplifying a crisis of drug use by a growing unhoused population. In the wake of 110, there has been a change in the way some law enforcement agencies address substance use possession. Likewise, there has been increased support for alternatives to incarceration, such as diversion programs. However, this is highly variable from county to county.

Available Tools and Resources

SAFE Project:

• Treatment and Family Support Locator is a resource created with the University of Maryland which is designed to allow users seeking substance use/mental health treatment to search the SAMHSA Treatment Locator database using more specific criteria to help find the best options available.
• SAFE Connections. This SAFE Project subprogram of the SAFE Choices portfolio provides an opportunity to impact youth recidivism and redirect young lives toward reaching their full potential.
• See the wiki titled "Expand Law Enforcement Assisted Diversion and Deflection Programs" for more detailed information on diversion and deflection programs that aim to redirect individuals away from the justice system, particularly those with behavioral health needs, to reduce recidivism, address personal needs, and optimize justice system resources.

The US Department of Justice has published "Criminal Conduct & Substance Abuse Treatment: Strategies for Self-Improvement and Change Pathways to Responsible Living."

BJA manages the Residential Substance Abuse Treatment Program (RSAT) which offers training and technical assistance to county and states BJA runs the Comprehensive Opioid, Stimulant, and Substance Use Program (COSSUP) which hosts a website which offers peer-to-peer learning opportunities, profiles of COSSUP sites across the nation, information on demonstration projects, and access to technical assistance. COSSUP has published "Guidelines for Managing Substance Withdrawal in Jails: A Tool for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals."

The American Academy of Addiction Psychiatry Published "Cultivating Law and Medicine Partnerships to Support Justice-Involved Individuals With Substance Use Disorders – Digital Guide."

The National Institute of Corrections provides training for correctional professionals. One of these is Residential Substance Abuse Training (RSAT).

The Opioid Response Network provides "Community Supervision and MOUD Toolkit," a free online learning series to help probation officers and treatment providers enhance client recovery during supervision.

Promising Practices

Massachusetts. This video titled "Reforming Criminal Justice to Help Inmates Live a Life of Dignity, not Dependency" highlights a positive case study associated with fostering musical talent in a Worcester prison.

New York. An innovative triage approach called Buffalo Opioid Court, reduced the risk of overdose deaths and substance use by providing funding for court staff and treatment programs such as substance use counseling and medical interventions. The court staff has the ability to deploy a Rapid Integration Team that connects individuals with immediate treatment, assessment, and access to a licensed professional counselor.