The substantial prison population in the United States is strongly connected to drug-related offenses. While the exact rates of inmates with substance use disorders (SUDs) is difficult to measure, some research shows that an estimated 65% percent of the United States prison population has an active SUD. Another 20% percent did not meet the official criteria for an SUD, but were under the influence of drugs or alcohol at the time of their crime.1
Decades of science shows that providing comprehensive substance use treatment to criminal offenders while incarcerated works, reducing both drug use and crime after an inmate returns to the community. Treatment while in jail or prison is critical to reducing overall crime and other drug-related societal burdens—such as lost job productivity, family disintegration and a continual return to jail or prison, known as recidivism. Inadequate treatment while incarcerated also contributes to overdoses and deaths when inmates leave the prison system.
What are the challenges in addressing substance use disorders in this population?
To be effective for this population, treatment must begin in prison and be sustained after release through participation in community treatment programs. By engaging in a continuing therapeutic process, people can learn how to avoid relapse and withdraw from a life of crime. However, only a small percentage of those who need treatment while behind bars actually receive it, and often the treatment provided is inadequate.
Inmates with opioid use disorders particularly pose a challenge. During their time in prison, many untreated inmates will experience a reduced tolerance to opioids because they have stopped using drugs while incarcerated. Upon release, many will return to levels of use similar to what they used before incarceration, not realizing their bodies can no longer tolerate the same doses, increasing their risk of overdose and death.2 One study found that 14.8 percent of all former prisoner deaths from 1999 to 2009 were related to opioids.3 Insufficient pre-release counseling and/or post release follow-up are partially responsible for this alarming increase in mortality.4
Why is treatment so critical in this population?
Scientific research since the mid-1970s shows that treatment of those with SUDs in the criminal justice system can change their attitudes, beliefs, and behaviors toward drug use; avoid relapse; and successfully remove themselves from a life of substance use and crime.5-7 For example, studies suggest that using medications for opioid use disorder treatment in the criminal justice system decreases opioid use, criminal activity post-incarceration, and infectious disease transmission.8-10 Studies have also found that overdose deaths following incarceration were lower when inmates received medications for their addiction.11-12
How are substance use disorders treated in the criminal justice system?
The recent National Academy of Sciences report on Medications for Opioid Use Disorder stated that only 5% of people with opioid use disorder in jail and prison settings receive medication treatment.13 A survey of prison medical directors suggested that most are not aware of the benefits of using medications with treatment, and when treatment is offered, it usually consists of only behavioral counseling, and/or detoxification without follow-up treatment.13
Effective treatment of substance use disorders for incarcerated people requires a comprehensive approach including the following:
- Behavioral therapies, including:
- cognitive-behavioral therapy, which helps modify the patient’s drug-use expectations and behaviors, and helps effective manage triggers and stress
- contingency management therapy, which provides motivational incentives in the forms of vouchers or cash rewards for positive behaviors
- Medications including methadone, buprenorphine, and naltrexone
- Wrap-around services after release from the criminal justice system, including employment and housing assistance
- Overdose education and distribution of the opioid reversal medication naloxone while in justice diversion treatment programs or upon release.15
What about the cost of treatment?
Failure to treat substance use disorder in the criminal justice system not only has negative societal implications, but also proves to be expensive. One study of people involved in the criminal justice system in California showed that engagement in treatment was associated with lower costs of crime in their communities in the 6 months following treatment. In addition, the economic benefits were far greater for individuals receiving time-unlimited treatment.
A report from the National Drug Intelligence Center14 estimated that the cost to society for drug use was $193 billion in 2007, a substantial portion of which—$113 billion—was associated with drug related crime, including criminal justice system costs and costs borne by victims of crime. The same report showed that the cost of treating drug use (including health costs, hospitalizations, and government specialty treatment) was estimated to be $14.6 billion, a fraction of these overall societal costs.14 It is estimated that the cost to society has increased significantly since the 2007 report, given the growing costs of prescription drug misuse.
Science suggests that even those who are not motivated to change at first can eventually become engaged in a continuing treatment process, suggesting it is a myth that treatment has to be voluntary to work. More information can be found in the Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide.
NIDA funded scientists are actively seeking solutions through the NIH HEAL (Helping to End Addiction Long-Term) initiative. In addition, to support those who work with juveniles and adults within the court system, including judges, counselors, social workers, case workers, and others, NIDA has created materials and has identified other helpful resources that can be used in educating offenders and those who work with them about the science related to drug use, misuse, and addiction.
- The Science of Drug Use - Discussion Points
- NIDA Research Dissemination Center
- NIDA Justice System Research Initiatives
- Family Resource Center
Points to Remember
- There are high rates of substance use within the criminal justice system.
- 85% of the prison population has an active substance use disorder or were incarcerated for a crime involving drugs or drug use.
- Inmates with opioid use disorder are at a higher risk for overdose following release from incarceration.
- Treatment during and after incarceration is effective and should include comprehensive care (including medication, behavioral therapy, job and housing opportunities, etc.)
- Despite the cost, treatment in the criminal justice system saves money in the long run.
- Research is underway to find better solutions.
- Center on Addiction, Behind Bars II: Substance Abuse and America’s Prison Population, February 2010. https://www.centeronaddiction.org/addiction-research/reports/behind-bars-ii-substance-abuse-and-america’s-prison-population
- Krinsky, C. S., Lathrop, S. L., Brown, P., & Nolte, K. B. (2009). Drugs, detention, and death: A study of the mortality of recently released prisoners. The American Journal of Forensic Medicine and Pathology, 30(1), 6-9.
- Binswanger, I. A., Blatchford, P. J., Mueller, S. R., & Stern, M. F. (2013). Mortality after prison release: Opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009. Annals of Internal Medicine, 159(9), 592-600.
- Møller, L. F., Matic, S., van Den Bergh, B. J., Moloney, K., Hayton, P., & Gatherer, A. (2010). Acute drug-related mortality of people recently released from prisons. Public Health, 124(11), 637- 639.
- Gordon, M. S., Kinlock, T. W., Schwartz, R. P., & O’Grady, K. E. (2008). A randomized clinical trial of methadone maintenance for prisoners: Findings at 6 months post‐release. Addiction, 103(8), 1333-1342.
- Wakeman, S. E., & Rich, J. D. (2015). Addiction treatment within U.S. Correctional facilities: Bridging the gap between current practice and evidence-based care. Journal of Addictive Diseases, 34(2-3), 220-225.
- Lee, J. D., Friedmann, P. D., Kinlock, T. W., Nunes, E. V., Boney, T. Y., Hoskinson, R. A. J., . . . O’Brien, C. P. (2016). Extended-release naltrexone to prevent opioid relapse in criminal justice offenders. New England Journal of Medicine, 374(13), 1232-1242.
- Mattick RP, Breen C, Kimber J, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence (review). Cochrane Database of Systematic Reviews. 2009; 3: Art. No CD002209. doi: 10.1002/14651858.CD002209.pub2
- Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews. 2014; 2: Art. No CD002207. doi: 10.1002/14651858.CD002207.pub4.
- Schwartz RP, Gryczynski J, O’Grady KE, et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. Am J Public Health. 2013; 103(5):917-922. doi: 10.2105/AJPH.2012.301049
- Green TC, Clarke J, Brinkley-Rubinstein L, et al. Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System. JAMA Psychiatry. February 2018. doi:10.1001/jamapsychiatry.2017.4614
- Marsden J, Stillwell G, Jones H, et al. Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England. Society for the Study of Addiction. 2017; 112(8): 1408-1418. doi: https://doi.org/10.1111/add.13779
- National Academies of Sciences, Engineering, and Medicine. 2019. Medications for Opioid Use Disorder Save Lives. Washington, DC: The National Academies Press. https://doi.org/10.17226/25310
- National Drug Intelligence Center, The Economic Impact of Illicit Drug Use on American Society. Washington D.C.: United States Department of Justice, 2011. https://www.hsdl.org/?abstract&did=4814
- Gicquelais RE, Mezuk B, Foxman B, Thomas L, Bohnert ASB. Justice involvement patterns, overdose experiences, and naloxone knowledge among men and women in criminal justice diversion addiction treatment. Harm Reduct J. 2019;16(1):46. Published 2019 Jul 16. doi:10.1186/s12954-019-0317-3
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