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By Dennis Miller, BHC Senior Writer

The National Center on Addiction and Substance Abuse at Columbia University (CASA) today released a comprehensive report on the cost and consequences of untreated substance abuse disorders in the nation’s correctional system, entitled Behind Bars II: Substance Abuse and America’s Prison Population. CASA describes the 144-page report as “the most exhaustive analysis ever undertaken to identify the extent to which alcohol and other drugs are implicated in the crimes and incarceration of America’s prison population.” The report is a follow-up to CASA’s first analysis of the issue, Behind Bars, released over a decade ago.

The situation remains grim. “A key finding is that 65 percent of inmates behind bars in America today meet medical criteria for a substance use disorder,” says Susan Foster, CASA’s Vice President and Director of Policy Research and Analysis. “So there is a profound public health problem here and only 11 percent of them are getting any kind of treatment.”

The study found that 1.5 million of the nation’s 2.3 million inmates meet the DSM-IV criteria for substance abuse or addiction, and that an additional 458,000 prisoners either have histories of substance abuse or their crimes were related to drug or alcohol use in some way. Combined, the two groups represent 85 percent of the U.S. prison population.

The impact, both financial and social, is tremendous. “Our failure to prevent and to treat addiction in the justice system both increases crime and dramatically increases cost to government and taxpayers,” says Foster, who led the study. “So this is really a call to action to address these addiction needs in the inmate population.”

Arming policymakers with data

The good news is that the report provides policymakers with solid, empirical data on how much money the nation could save if it adequately treated substance-use disorders among its offender populations. CASA hopes that, armed with this information, policymakers will begin changing correctional policies that focus on punitive measures over treatment. “In every cost/benefit analysis that we examined, the benefits of investing in treatment outweighed the cost,” explains Foster. “In fact, a large study done by the National Institute on Drug Abuse showed that the return on investing in treatment for this population may be more than $12 for every dollar spent on treatment.”

CASA’s own research confirms this meta-analysis. “Our own analysis found that if we provided the most intensive evidence-based services — that’s prison-based treatment and aftercare — to all inmates who met these medical criteria who weren’t now receiving treatment, and if only 11 percent of them (a very conservative estimate) recover and remain substance- and crime-free and employed, intervention would pay for itself in one year,” Foster says. “And then, for each additional year an inmate stayed substance- and crime-free and employed, there would be economic benefits to society of over $90,000 [per inmate]. So that’s a significant return.”

The report’s authors say its conclusions should be particularly relevant now as states and municipalities face intense budgetary pressures to cut spending. Many are now eliminating such programs in a misguided attempt to reduce costs — a trend the study suggests will ultimately be counterproductive and increase costs over the long term. “The issue is convincing public policy makers to make the investment in prevention and treatment,” says Foster. “And I think it’s very important to think about this over the long term. I mean, it makes no sense to be spending, as we found in a report we did called Shoveling Up last year, $74 billion dollars every year in our criminal justice system coping with the consequences of our failure to prevent and treat addiction. That’s billions of dollars that we could save if only we would make an investment in providing prevention and treatment for them.”

Hidden long-term costs

Another, more hidden, long-term social and financial cost of untreated substance abuse in prisons is the devastating effect it can have on families, as young children essentially lose a parent during their most formative years and as a result, face a much higher risk of becoming substance abusers themselves later in life. “It’s really very sad to see that there are about 2.2 million minor children affected by the incarceration of their parents,” says Foster. “About 75 percent of the children are age 12 or younger. We found that these parents, for the most part, are not connected to their children after their incarceration. Many state prisoners — most of them — report that they have not seen their children since incarceration. We know that these children who come from substance-involved families have a much higher risk of walking in the footsteps of their parents without intervention.”

The study found few bright spots in the nation’s correctional system where states and municipalities are doing a good job treating substance use disorders in prisons, but where it did, it found substantial savings and lower recidivism rates. “There are examples in states of alternatives to incarceration or prison-based treatment and aftercare that have shown some great results,” Foster explains. “We have examples from Delaware, California and Illinois where they did controlled studies of inmates who participated in treatment and aftercare and those who didn’t, and we found much better success rates in terms of re-arrest rates and re-incarceration rates in those groups that received the treatment. We also have evidence from diversion programs, such as the drug treatment alternatives program (DTAP) in Brooklyn, which is a prosecutorial based diversion program. Graduates from that program at two years were 87-percent less likely to return to prison than a matched group. And they did that at half the cost of incarceration.”

Drug courts as well are also proving beneficial in those communities and states where they are used to divert substance-abuse related offenders to treatment instead of prisons. “There’s been a lot of attention to drug courts, and all that track cost and savings have shown positive net benefits,” Foster says. “There are also DUI courts. And there are other approaches springing up. In Hawaii, for example, they target offenders at high risk of probation revocation, and when they provide treatment-based alternatives and intensive assistance with that group, they find the re-arrest rate was three times lower than the comparison group.”

Foster says the data are unimpeachable. Where these programs are employed and done so in accordance with evidence-based guidelines and best practices, communities save money on prison costs, offenders are less likely to return to prison, and families and lives are restored. “We have standards of practice. We have examples of cost-effective alternatives. So we know that these alternatives can work,” she says “And we have a lot of information on the overall cost and benefits of these investments. I think what we’re looking for is the public will on public policy makers to make these changes that really are long overdue.”

Countering 'soft on crime' charges

One nagging obstacle to the wider adoption of such policies is the fear of many politicians that if they push for treatment over incarceration, they may be perceived as ‘soft on crime,’ a wedge issue that may be used against them when they come up for reelection. Foster says public education is the key to neutralizing such rhetoric. “We don’t deny healthcare for people who have other chronic diseases like diabetes or hypertension. Why should we deny healthcare for inmates who happen to suffer from addictive disorders?” she argues. “These concepts of providing medical services and holding offenders accountable for their crime aren’t mutually exclusive. They are complementary. It just depends on how you think of this. It doesn’t seem to me to be tough on crime to deny someone the right to medical care. I don’t quite get that. I think you can hold an offender accountable for crimes, but treat the disease, and that’s a benefit to society as well as to the individual.”

CASA hopes the release of the report goes a long way toward giving policymakers the ammunition they need to make that case, and changing public attitudes toward how our justice system deals with drug and alcohol-related crime. “We just want to underscore the fact that addiction is a disease, that risky substance use is a public health problem, addiction is a treatable medical problem, and we know that these things can be treated effectively in the context of the justice system,” says Foster. “It’s time to change.”

Read a statement from CASA Chairman and President and former Secretary of Health, Education and Welfare Joseph A. Califano, Jr. on the report.

Below is a three-part presentation from CASA summarizing the findings of the Behind Bars II: Substance Abuse and America’s Prison Population report:

Part I

Part II

Part III

To listen to our complete interview with Susan Foster, click on the audio icon at the top of the page. The following is a complete written transcript.

BHC: Tell us a little more about this report and what it found.

Susan Foster: This is the second report that CASA has done on the topic of substance abuse in America’s prison population and this is probably the most extensive analysis that’s been done so far. What we did this year was to try and identify what percentage of the population today is, as we call it, “substance-involved,” and I’ll define that in a minute.

But a key finding is that 65 percent of inmates behind bars in America today meet medical criteria for a substance use disorder. So there is a profound public health problem here and only 11 percent of them are getting any kind of treatment. And what we know is that our failure to prevent and to treat addiction in the justice system both increases crime and dramatically increases cost to government and taxpayers. So this is really a call to action to address these addiction needs in the inmate population.

BHC: How did CASA go about compiling this report?

SF: Our methodology involved several things. One, we did an extensive analysis of 11 national data sets with information on this problem. And we have a data analysis center here at CASA that is uniquely capable of combining information from these multiple sources and presenting a comprehensive picture that we may not have otherwise have had. We reviewed extensively the existing literature on the topic, so we have more than 650 articles and publications we looked at. We examined practices in prevention, intervention and treatment for substance-involved offenders. We reviewed accreditation standards to see if there were any available or required for providing treatment to this population, and then the absence of such standards — any voluntary guidelines. And we looked at existing cost/benefit studies and conducted our own analysis of the potential return on investment for treatment.

So it was a multi-year project that was pretty comprehensive. The interesting thing is that since we released our last report, over a decade ago, the science of addiction has grown showing that it is clearly a public health problem that can be prevented and treated within the context of the justice system and there are also more detailed data available now about the inmate population enabling us to take a look at what percentage of them actually need treatment.

BHC: Has the situation gotten better or worse since CASA first issued its report ten years ago?

SF: It certainly has not improved at all and it looks as if it’s gotten a little worse. We still have, right now, 85 percent of the inmates in America’s prisons and jails are what we call substance-involved. That means they either met those clinical criteria for substance use disorder or they had one of the following criteria: They had a history of using illicit drugs regularly or of alcohol treatment; they were under the influence of alcohol or other drugs at the time of their crime; they may have committed their crime to get money to buy drugs; or they were incarcerated for an alcohol or a drug law violation, and that would be, for example, possession, sale, distribution or driving under the influence.

So, it’s about 85 percent now. If you look back, our original work showed that somewhere between 79 and 80 percent of the population in ’96 met those criteria. So we have not made any improvement at all.

Now, that is not to say there aren’t examples of effective interventions. There are many, and those are in operation in some states across the country. They just haven’t taken them to scale. We aren’t employing those alternatives in a way that can make a significant impact on this problem.

BHC: Were you able to get data on how many prisoners with addictive disorders are now receiving the treatment they need?

SF: It looks like about 11 percent of those who meet clinical criteria get something called treatment. But we have reason to be concerned about the quality of the treatment that they do receive, because other research has shown that very few receive what we call evidence-based practice —that is, receive intervention such as comprehensive assessments, evidence-based treatment, treatment for co-occurring disorders, comprehensive treatment plans, aftercare planning and aftercare services. Very few inmates receive that.

And then we know that others receive some type of support services, and those support services may be very important. These could be things like participating in Alcoholics Anonymous or Narcotics Anonymous meetings or receiving drug education, but those are not sufficient in themselves to meet the needs of offenders who have substance use disorders.

BHC: How has the trend toward increasing privatization prisons affected them?

SF: There are not a lot of good data on it, but it appears that there is a prison industry there, which may sort of argue against reducing the prison population. I mean, if you have people who are making good salaries and benefits working in prison facilities, it becomes more difficult to close them, particularly in this time of economic crisis. Although, on the other hand, the cost of providing incarceration for offenders can range up to $65,000 a year in some states — the average is a little over $25,000. So you have a tension there, and it may be in fact a barrier to meeting the addiction-related needs of offenders, and I think it’s something that public policy officials need to take a close look at.

What we see is that public policy in this case really has not caught up with either the science or with public attitudes, because in most public opinion surveys, we see the public is generally very supportive of providing treatment for offenders, either as alternatives to incarceration or prison-based treatment and aftercare.

BHC: You talked a little bit about some of the pressure right now and, I guess, always on local, state and federal budgets. Did your report get into at all how more treatment could actually ease that pressure?

SF: Absolutely. In every cost benefit analysis that we examined, the benefits of investing in treatment outweighed the cost. In fact, a large study done by the National Institute on Drug Abuse showed that the return on investing in treatment for this population may be more than $12 for every dollar spent on treatment. And that is as a result of reduced substance-related crime and criminal justice and healthcare costs.

Our own analysis found that if we provided the most intensive evidence-based services — that’s prison-based treatment and aftercare — to all inmates who met these medical criteria who weren’t now receiving treatment and if only 11 percent of them — a very conservative estimate — recover and remain substance- and crime-free and employed, that intervention would pay for itself in one year if only 11 percent recovered. And then, for each additional year that an inmate stayed substance- and crime-free and employed, there would be economic benefits to society of over $90,000.

So that’s a significant return. The issue is convincing public policy makers to make the investment in prevention and treatment. And I think it’s very important to think about this over the long term. I mean, it makes no sense to be spending — as we found in a report we did called Shoveling Up last year — $74 billion dollars every year in our criminal justice system coping with the consequences of our failure to prevent and treat addiction. That’s billions of dollars that we could save if only we would make an investment in providing prevention and treatment for them.

There would be added costs for providing prison-based treatment and aftercare, of somewhere, we think, around $9,000 but as I said, that would pay for itself in a year and then you begin to reap close to $100,000 in economic benefits every year as a result. It’s very important. And you can also save more money by employing more treatment-based alternatives to incarceration, because the additional court costs and treatment costs are generally lower than the cost of incarceration itself.

So it’s a good deal for policy makers and, again, it’s very important for taxpayers too. What we have to understand is that addiction is a disease that can and must be treated, and that the concepts of accountability for crime and treatment for disease are mutually supportive, and that doing both just makes good policy and good economic sense.

BHC: Susan, did you look at all at how other countries handle this issue and if you did, how does the United States rate in comparison to other countries?

SF: Well, we didn’t do an examination of treatment and incarceration practices in other countries, but one notable fact is that the United States has less than five percent of the world’s population and we have almost 25 percent of the world’s prisoners. We have the highest incarceration rate in the world.

So that is something we know is an enormous problem, particularly as state governments try to face these rising costs. It makes no sense to incarcerate people without treating their addiction, which drives much of the crime in the first place. So what we’re hoping is that the public and policy makers can begin to see that the public is supportive of the actions necessary to treat these addictive disorders, which can reduce their costs and reduce crime in the long term.

BHC: I understand that your report looked as well at the impact on families and children of those people who are imprisoned with substance abuse disorders. Can you talk about that a little bit?

SF: Yes. It’s really very sad to see that there are about 2.2 million minor children affected by the incarceration of their parents. So these inmates are parents to these children, and about 75 percent of the children are age 12 or younger. We found that these parents, for the most part, are not connected to their children after their incarceration. In fact, most live more than 100 miles away from them. And many state prisoners — most of them — report that they have not seen their children since incarceration.

We know that these children who come from substance-involved families have a much higher risk of walking in the footsteps of their parents without intervention. So this is a high-risk group and it really does deserve some attention of prevention and early intervention, in order to make sure these kids avoid the problems that their parents faced.

BHC: We’ve talked a lot here about areas that we are not doing well in. Are there parts of the country — districts or states — that are doing a better job than others at handling drug-related offenses, and saving money by ordering treatment instead of or along with incarceration?

SF: We don’t have state-by-state data in that regard. In our study of the cost of addiction to government that I referenced earlier, our Shoveling-Up Report, most states were spending far, far more on incarceration than they were on treatment in enormous orders of magnitude. There really isn’t one state we can hold up.

There are examples in states of either alternatives to incarceration, or prison-based treatment and aftercare that have shown some great results. I mean, we have examples from Delaware and California and Illinois where they did controlled studies of inmates who participated in treatment and aftercare and those who didn’t, and we found much better success rates in terms of re-arrest rates and re-incarceration rates in those groups that received the treatment. We also have evidence from diversion programs, such as the drug treatment alternatives program — the DTAP program — in Brooklyn, which is a prosecutorial based diversion program. Graduates from that program at two years were 87-percent less likely to return to prison than a matched group. And they did that at half the cost of incarceration.

There’s been a lot of attention to drug courts, and many of those programs that track cost and savings — in fact, all that track cost and savings — have shown positive net benefits. There are also DUI courts. And there are other approaches springing up. In Hawaii, for example, they target offenders at high risk of probation revocation, and when they provide treatment-based alternatives and intensive assistance with that group, they find the re-arrest rate was three times lower than the comparison group.

So we do have a lot of examples. We also have a large body of professional standards that would be guidance to states and localities for how they can provide treatment in correctional facilities. The American Correctional Association has produced such standards, as have four federal agencies. And some of those standards date back 20 years. Unfortunately only one of those set of standards is mandatory and that is a federally mandated accreditation standard for facilities that choose to provide opioid treatment in prisons and jails. But that doesn’t mean they have to do it, it means if you choose to do it you have to meet these standards.

So we have standards of practice. We have examples of cost-effective alternatives. So we know that these alternatives can work. And we have a lot of information on the overall cost and benefits of these investments. I think what we’re looking for is the public will on public policy makers to make these changes that really are long overdue.

BHC: That’s kind of the subject of my next question. We live in an era when no politician wants to been seen as “soft on crime.” How do you sell the message that it isn’t coddling criminals to treat them for their problems in an environment where no one wants to be seen that way?

SF: Well, I think that that is a polarization that makes no sense. We don’t deny healthcare for people who have other chronic diseases like diabetes or hypertension. Why should we deny healthcare for inmates who happen to suffer from addictive disorders? Particularly when there’s such a return to be realized in terms of reduced crime and reduced spending by investing in that treatment.

Those concepts of providing medical services and holding offenders accountable for their crime aren’t mutually exclusive. They are complementary. It just depends on how you think of this. It doesn’t seem to me to be tough on crime to deny someone the right to medical care. I don’t quite get that. I think you can hold an offender accountable for crimes, but treat the disease, and that’s a benefit to society as well as to the individual.

BHC: What does CASA hope the impact of this report will be?

SF: We hope that it resonates with policy makers who may have been feeling that they didn’t quite know if there was public support for this, or they didn’t quite know if there was evidence for it. And we hope to generate public discussion that might influence or encourage policy makers to make better investments in treatment for this group of people.

I know that it’s very hard. Particularly in these budget times, when there is lots of competition for resources, people may have offenders last on their list. But that is insane public policy in terms of its long-term cost. It simply visits enormous burden on American taxpayers and that’s what we need, that’s the message we need to get across.

BHC: Susan, I really want to thank you for talking with us today. Anything in closing that we haven’t touched on here that’s important about the report?

SF: I think we just want to underscore the fact that addiction is a disease, that risky substance use is a public health problem, addiction is a treatable medical problem, and we know that these things can be treated effectively in the context of the justice system. It’s time to change.

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