Treating Drug Abuse and Addiction in the Criminal Justice System Improving Public Health and Safety

SPECIAL COMMUNICATION

Redonna K. Chandler, PhD Despite increasing evidence that addiction is a treatable disease of the brain, Bennett W. Fletcher, PhD most individuals do not receive treatment. Involvement in the criminal jus- Nora D. Volkow, MD tice system often results from illegal drug-seeking behavior and participa- HE PAST 20 YEARS HAVE SEEN tion in illegal activities that reflect, in part, disrupted behavior ensuing from significant increases in the brain changes triggered by repeated drug use. Treating drug-involved of- numbers of individuals incar- fenders provides a unique opportunity to decrease substance abuse and re- cerated or under other forms of duce associated criminal behavior. Emerging neuroscience has the potential Tcriminal justice supervision in the United States. These numbers are stag- to transform traditional sanction-oriented public safety approaches by pro- gering—approximately 7.1 million viding new therapeutic strategies against addiction that could be used in adults in the United States are under the criminal justice system. We summarize relevant neuroscientific findings some form of criminal justice supervi- and evidence-based principles of addiction treatment that, if implemented sion.1 The large increase in the crimi- in the criminal justice system, could help improve public heath and reduce nal justice population reflects in part criminal behavior. tougher laws and penalties for drug of- JAMA. 2009;301(2):183-190 www.jama.com fenses.2 An estimated one-half of all prisoners (including some sentenced for other than drug offenses) meet the cri- and hepatitis C5 and frequently have co- leased returned to prison within 3 years teria for diagnosis of drug abuse or de- morbid psychiatric disorders,6,7 which for technical violations that included, pendence (TABLE 1).3,4 further highlights the dire treatment among other things, testing positive for During the past 20 years, fundamen- needs of this population. drug use.9 Illicit drugs are used in jails tal advances in the neurobiology of ad- Not treating a drug-abusing offender and prisons despite their highly struc- diction have been made. Molecular and is a missed opportunity to simulta- tured, controlled environments,10 but imaging studies have revealed addic- neously improve both public health and even enforced abstinence can mislead tion as a brain disorder with a strong safety. Integrating treatment into the criminal justice professionals as well as genetic component, and this has gal- criminal justice system would provide addicted persons to underestimate the vanized research on new pharmaco- treatment to individuals who other- vulnerability to relapse postincarcera- logical treatments. However, a large dis- wise would not receive it, improving tion. On release from prison or jail, ad- connect remains between addiction their medical outcomes and decreas- dicted persons will experience chal- research and the treatment of addic- ing their rates of reincarceration.8 lenges to their sobriety through multiple tion in general, particularly within the stressors that increase their risk of re- criminal justice system. This is evi- Recidivism in the Drug-Abusing Offender denced in that most prisoners (80%- Author Affiliations: Services Research Branch, Na- 85%) who could benefit from drug The inadequacy of incarceration by it- tional Institute on Drug Abuse (Drs Chandler and 3,4 Fletcher); and National Institute on Drug Abuse (Dr abuse treatment do not receive it. In self in addressing drug abuse or addic- Volkow), Bethesda, Maryland. addition, drug-using offenders are at tion is evident in the statistics. A re- Corresponding Author: Nora D. Volkow, MD, Na- tional Institute on Drug Abuse, 6001 Executive Blvd, high risk for infectious diseases such as view of recidivism in 15 states found Room 5274, Bethesda, MD 20892 (nvolkow@nida human immunodeficiency virus (HIV) that one-quarter of individuals re- .nih.gov).

Downloaded from www.jama.com at University Of New Mexico on January 16, 2009 TREATING DRUG ABUSE AND ADDICTION IN THE CRIMINAL JUSTICE SYSTEM

Table 1. Inmate Drug Use, Abuse/Dependence, and Treatment No. (%)

Drug Use Drug Abuse or Dependence

At Time of In Month Prior Received Treatment Inmate Type Offense to Offense Met Criteria While Incarcerated Local jail inmatesa,b 128 030 (29) 242 720 (55) 245 830 (55) 16 520 (7) State inmatesc 393 610 (32) 686 670 (56) 642 500 (53) 95 090 (15) Federal inmatesc 34 140 (26) 64 910 (50) 57 200 (46) 9950 (17) a Convicted jail inmates only. If all jail inmates are included, 50% were under the influence of drugs at the time of the offense, and about two-thirds were regular users. b Weighted estimates derived from the US Bureau of Justice Statistics Survey of Inmates in Local Jails, 2002.3 A stratified sample of 6982 inmates were interviewed (9.9% refusal rate) in 417 jails (of 465 selected). Survey methodology is described in Karberg and James.3 c Weighted estimates derived from the US Bureau of Justice Statistics Survey of Inmates in State and Federal Correctional Facilities, 2004.4 In the state prison sample, a total of 14 499 inmates were interviewed (10.2% refusal rate) in 287 state prisons (of 301 selected). In the federal prison sample, a total of 3686 inmates were interviewed (13.3% refusal rate) in 39 federal prisons (of 40 selected). Survey methodology is described in Mumola and Karberg.4 lapsing to drug use. These include the courts, prison- and jail-based treat- better in reducing drug use than the stigma associated with being labeled an ments, and reentry programs in- usual alternatives.20 In a meta-analysis ex-offender, the need for housing and tended to help offenders transition from of 66 incarceration-based treatment legitimate employment, stresses in reincarceration back into the commu- evaluations, therapeutic community unifying with family, and multiple re- nity.8,18 Through monitoring, supervi- and counseling approaches were requirements for criminal justice super- sion, and threat of legal sanctions, the spectively 1.4 and 1.5 times more likely vision.11,12 justice system can provide leverage to to reduce reoffending.27 Drug courts Returning to neighborhoods associ- encourage drug abusers to enter and re- combine judicial supervision with drug ated with preincarceration drug use main in treatment. treatment as an alternative to incar- places the addicted individual in an en- Behavioral treatments are the most ceration; their graduates have rearrest vironment rich in drug cues. As dis- commonly used interventions for ad- rates about half those of matched com- cussed below, these conditioned cues dressing substance use disorders. Evi- parison samples and much lower than automatically activate the reward/ dence-based behavioral interventions those of drug court dropouts.28 Indi- motivational neurocircuitry and can include cognitive therapies that teach viduals who participated in prison- trigger an intense desire to consume coping and decision-making skills, con- based treatment followed by a commu- drugs (craving).13 The molecular and tingency management therapies that re- nity-based program postincarceration neurobiological adaptations resulting inforce behavioral changes associated were 7 times more likely to be drug free from chronic drug use persist for with abstinence, and motivational and 3 times less likely to be arrested for months after drug discontinuation,14 therapies that enhance the motivation criminal behavior than those not re- and evidence exists that compulsive to participate in treatment and in non– ceiving treatment.29,30 seeking of drugs when addicted indi- drug-related activities.19,20 Many resi- The benefits of medications for drug viduals are reexposed to drug cues pro- dential treatment programs rely on the treatment were shown in a recent ran- gressively increases after drug with- creation of a “therapeutic commu- domized trial in which heroin- drawal.15 This could explain why many nity” based on a social learning model.21 dependent inmates began methadone drug-addicted individuals rapidly re- Medications such as methadone, bu- treatment in prison prior to release and turn to drug use following long peri- prenorphine, and naltrexone are ben- continued in the community postre- ods of abstinence during incarcera- eficial for the treatment of heroin ad- lease. At 1-, 3-, and 6-month follow- tion and highlights the need for ongoing diction and naltrexone and topiramate up, patients who received methadone treatment following release. for the treatment of alcoholism.22-24 Self- plus counseling were significantly less help programs such as Alcoholics likely to use heroin or engage in crimi- Drug Abuse Treatment Anonymous or SMART Recovery can nal activity than those who received Effectiveness in the Criminal be valuable adjuncts to formal drug only counseling.31-33 The potential ex- Justice System treatment.25 ists for immediate adoption of metha- Research over the last 2 decades has Research has consistently shown that done maintenance for incarcerated per- consistently reported the beneficial ef- community-based drug abuse treat- sons with opioid addictions, but most fects of treatment for the drug abuser ment can reduce drug use and drug- prison systems have not been recep- in the criminal justice system.16,17 These related criminal behavior.26 A meta- tive to this approach.34 interventions include therapeutic al- analysis of 78 comparison-group Economic analyses highlight the ternatives to incarceration, treatment community-based drug treatment stud- cost-effectiveness of treating drug- merged with judicial oversight in drug ies found treatment to be up to 1.8 times involved offenders.35 On average, in-

Downloaded from www.jama.com at University Of New Mexico on January 16, 2009 TREATING DRUG ABUSE AND ADDICTION IN THE CRIMINAL JUSTICE SYSTEM carceration in the United States costs Access to Treatment cerationtocommunitysupervision.43 Fail- approximately $22 000 per month,36 Drug education—not drug treatment— ure to receive treatment on release and there is little evidence that this strat- is the most common service provided to increases the risk not only of relapse but egy reduces drug use or drug-related re- prisoners with drug abuse or addiction also of mortality from drug overdose and incarceration rates for nonviolent drug problems.4,42 More than one-quarter of other causes.44 offenders. By contrast, the average cost state inmates and 1 in 5 federal inmates Infectious diseases such as HIV and of methadone is $4000 per month,37 and meeting abuse/dependence criteria par- hepatitis C are associated with illicit drug treatment with methadone has dem- ticipate in self-help groups such as Alco- use and occur at higher rates in correc- onstrated effectiveness in reducing drug holicsAnonymouswhileinprison.4 How- tional populations than in the general use and criminal activity following re- ever, though treatment during and after population,5 but treatment for these con- lease.31 Alternatives to incarceration can incarceration has been shown to signifi- ditions appears to fall short of need.45,46 also defray job productivity losses and cantly reduce drug use and drug-related It is feasible to implement screening and the separation from family and social crime, less than 20% of inmates with drug treatment in correctional settings for support systems. abuse or dependence receive formal treat- HIV47,48 and hepatitis C.49,50 Continuity The cost of integrating volunteer- ment (Table 1).3,4 of treatment for released offenders with led self-help organizations such as Al- In a recent survey of correctional pro- infectious disease is crucial not only for coholics Anonymous and Narcotics gramsandorganizationsacrosstheUnited the individual’s health51,52 but also for the Anonymous into criminal justice set- States,42 most correctional agencies re- health of the community.45,53 tings is nominal and could provide supported providing some type of drug abuse There are many barriers to treat- port to the recovery efforts of addicted treatment services; however, the median ment for the drug-involved offender, in- persons in the criminal justice system. percentage of offenders who had access cluding lack of the resources, infra- One dollar spent on drug courts is es- tothoseservicesatanygiventimewaslow, structure, and treatment staff (including timated to save approximately $4 in usually less than 10% (TABLE 2).42 Even physicians knowledgeable about ad- avoided costs of incarceration and if a correctional institution does provide diction medicine) required to meet the health care,38 and prison-based treat- treatment, the continuity of treatment drug treatment needs of individuals un- ment saves between $2 to $6.39 These postincarceration,whichisessentialtore- der their supervision. Addiction re- economic benefits in part reflect reduc- covery,16 is often lacking when the drug- mains a stigmatized disease not often tions in criminal behavior.40,41 involved offender transitions from incar- regarded by the criminal justice sys-

Table 2. Access to Health, Mental Health, and Substance Abuse Treatment Services in Correctional Facilitiesa Prisons Jails Community Corrections (n = 98) (n = 57) (n = 134)

Access to Access to Access to Offer Services, Offer Services, Offer Services, Service Type Services, %b Median %c Services, %b Median %c Services, %b Median %c Physical/mental health services HIV testing 89.1 68.7 73.4 22.0 42.0 12.1 HIV/AIDS counseling 80.5 50.1 80.3 27.6 45.2 12.9 Hepatitis C testing 98.2 79.6 74.1 23.3 39.0 11.5 Mental health assessment 99.8 86.5 94.6 39.8 63.6 19.7 Mental health counseling 96.3 58.9 94.5 31.1 63.9 18.6 Pharmacological treatment Methadone 8.9 Ͻ1.0 54.5 1.7 1.7 Ͻ1.0 Other medications for 12.4 NA 36.8 NA 2.4 NA substance use disorder Medication for mental illness 80.3 NA 85.4 NA 7.8 NA Substance abuse services Detoxification 12.2 Ͻ1.0 26.0 1.5 3.2 Ͻ1.0 Alcohol/drug education 74.1 8.3 61.3 4.5 53.1 8.8 Outpatient counseling Յ4 h/wk 54.6 3.4 59.8 7.4 47.1 10.0 Ն5 h/wk 47.1 2.7 22.5 10.8 21.6 8.8 Therapeutic community 26.9 6.6 26.3 3.0 5.7 11.1 Abbreviations: HIV, human immunodeficiency virus; NA, not applicable. a Data provided from analyses of the National Criminal Justice Treatment Practices Survey of the Criminal Justice Drug Abuse Treatment Studies (F.S. Taxman, PhD, and M. Per- doni, MS, George Mason University, written communication, November 2008).42 b Percentage of facilities that indicated that the service or treatment was available. c Median percentage of facility’s average daily population who were provided the service or treatment.

Downloaded from www.jama.com at University Of New Mexico on January 16, 2009 TREATING DRUG ABUSE AND ADDICTION IN THE CRIMINAL JUSTICE SYSTEM tem as a medical condition; as a con- Among the genes identified to contrib- tically, this suggests that an addicted sequence, treatment is not constitu- ute to the vulnerability for addiction are individual may experience less motiva- tionally guaranteed as is the treatment those that participate in the neuroplas- tion to pursue activities likely to result of other medical conditions. tic changes associated with learning.56 in beneficial outcomes and to avoid those Imaging studies have identified mul- that could result in punishment. One can Neurobiology of Addiction tiple brain circuits that are disrupted in also predict that dysfunction in this neu- Addiction is a chronic brain disease for addicted persons57; these include cir- rocircuitry would reduce an addicted which genetic factors are believed to con- cuits involved in reward and motiva- person’s motivation to abstain from drug tribute 40% to 60% of the vulnerabil- tion, learning and memory, cognitive use because alternative reinforcers (natu- ity.54 Repeated drug exposure in indi- control, mood, and interoception (aware- ral stimuli) are comparatively weaker and viduals who are vulnerable (because of ness of physiological body signals) negative consequences (eg, incarcera- genetics, or developmental or environ- (FIGURE). Disruption of these circuits tion) are less salient.62 mental factors) trigger neuroadapta- impairs the addicted person’s ability to In parallel, the repeated use of drugs tions in the brain that result in the com- inhibit intentional actions or to con- leads to the formation of new linked pulsive drug use and loss of control over trol strong emotions and desires and memories that condition the addicted drug-related behaviors that character- also increases the likelihood that the in- individual to expect pleasurable izes addiction. Molecular and neuroim- dividual will have difficulties making responses—not only when exposed to a aging studies have helped illuminate how adaptive decisions.60,61 drug but also when exposed to stimuli genes may affect vulnerability to addic- Addiction also decreases sensitivity in associated with the drug. These stimuli tion and how repeated use of addictive the reward and the motivational cir- trigger automatic responses that fre- drugs causes long-lasting disruptions to cuits, which modulate response to posi- quently drive relapse, even in individu- the structure and function of the brain.55 tive as well as negative reinforcers. Prac- als motivated to stop taking drugs.63 The

Figure. Proposed Network of Brain Circuits Involved With Addiction57

A B Nonaddicted individual Addicted individual Unidirectional regulation Inhibitory Inhibitory Bidirectional regulation control control Disrupted regulation

Interoception Interoception

Reward Reward

Mood Mood

Memory Motivation Memory Motivation

Inhibition of Drug use drug use

Circuits work together and change with experience. Each is linked to an important concept: reward (saliency), motivation (drive), memory (learning associations), inhibitory control (conflict resolution), mood (well-being),58 and interoception (internal awareness).59 Size of circuit ovals indicates influence in determining behavioral outcomes. Thicker line weights indicate greater influence on regulation of the circuit. A, In a nonaddicted person the decision to consume a drug (same process pertains for natural rewards) is a function of the balance between the expected pleasure (based on past experience or memory), alternative stimuli (this includes internal states such as mood and interoception but also alternative external rewards), and potential negative outcomes that oppose the motivation to take the drug (inhibitory control exerted by prefrontal cortex) and stop the drug use. B, During addiction, the enhanced value of the drug in the reward, motivation, and memory circuits overcomes the inhibitory control exerted by the prefrontal cortex, thereby favoring a positive feedback loop initiated by the consumption of the drug and perpetuated by enhanced activation of the motivation/drive and memory circuits. Decreased sensitivity to rewards also raises the hedonic threshold, disrupting mood and increasing the saliency values of drugs and behaviors temporarily associated with relief from the dysphoria. Learning and conditioning result in an enhanced interoceptive awareness of discomfort and the associated desire for the drug (craving). Absence of lines from inhibitory control circuit to reward and motivation circuits indicates loss of regulation.

Downloaded from www.jama.com at University Of New Mexico on January 16, 2009 TREATING DRUG ABUSE AND ADDICTION IN THE CRIMINAL JUSTICE SYSTEM enhanced sensitivity to drugs as rewards and the conditioning to associated drug Box. NIDA Principles of Drug Abuse Treatment for Criminal Justice cues increase the interoceptive aware- Populations ness of discomfort (anxiety and ten- Drug addiction is a chronic brain disease that affects behavior sion) that occurs when the individual is Recovery from drug addiction requires effective treatment, followed by contin- exposed to drug cues and increase the ued care desire to consume the drug.64 Addition- Duration of treatment should be sufficiently long to produce stable behavioral ally, repeated drug use also affects brain changes regions implicated in mood and anxiety, which could explain the high rate of Assessment is the first step in treatment addiction comorbid with dysphoria, Tailoring services to fit the needs of the individual is an important part of effective depression, or both and the vulnerabil- drug abuse treatment for criminal justice populations ity of the addicted person to relapse when Drug use during treatment should be carefully monitored exposed to social stressors.65,66 Treatment should target factors associated with criminal behavior Impairment of the neural substrates af- Criminal justice supervision should incorporate treatment planning for drug- fected by addiction—particularly those abusing offenders, and treatment providers should be aware of correctional su- concerned with behavioral inhibition, pervision requirements control of emotions and desires, and de- Continuity of care is essential for drug abusers reentering the community cision-making—increase the likeli- A balance of rewards and sanctions encourages prosocial behavior and treatment hood that addicted individuals will make participation choices that appear impulsive.67,68 This Offenders with co-occurring drug abuse and mental health problems often re- idea is supported by research in the quire an integrated treatment approach emerging area of behavioral econom- ics, which has found that addicted indi- Medications are an important part of treatment for many drug-abusing offenders viduals differ from those who do not use Treatment planning for drug-abusing offenders living in or reentering the com- drugs in how they make decisions. Ad- munity should include strategies to prevent and treat serious, chronic medical dicted individuals tend to have higher conditions such as human immunodeficiency virus/AIDS, hepatitis B and C, and tuberculosis levels of temporal discounting than those who do not use drugs; ie, they tend to NIDA indicates National Institute on Drug Abuse. Principles adapted from Fletcher and Chandler.75 choose immediate, smaller rewards over future, larger rewards.69 High temporal discounting is also associated with im- pulsivity—the inability to delay imme- of the human brain provides new tar- criminal behavior, but understanding diate gratification and to recognize the gets for medication development and be- how addictive drugs affect behavior potential for negative consequences.70 havioral interventions in addiction. Al- through brain mechanisms can in- Many of the neurobiological changes though many of the neurobiological form decisions to provide treatment to associated with repeated drug use per- changes associated with repeated drug addicted individuals. For example, sist for long periods after drug discon- use persist for long periods after drug dis- mandated treatment may be useful for tinuation.71 This helps explain why ad- continuation,71 research suggests that the drug-involved offenders who would dicted individuals who have ceased impaired brain can regain some of the otherwise not engage in the treatment drug use are at high risk of relapse and functions damaged by use of illicit drugs process or make progress toward re- provides neurobiological support for over time.73 covery. The persistence of neurologic the recognition of addiction as a chronic Second, neuroscience establishes a deficits provides support for the rec- relapsing disease.72 biological framework for understand- ognition of addiction as a chronic dis- What are the implications of neuro- ing aspects of addictive behavior that ease and highlights the need for the science research for how society and cli- otherwise seem to defy rational expla- same continuity of care so important in nicians might regard the addicted of- nation. In the absence of known bio- treatment of other chronic diseases (eg, fender? There are at least 3 implications logical determinants, these behaviors of- asthma, hypertension).72 It also sug- for how this emerging knowledge about ten have been attributed to “moral gests that agonist medications such as the neurologic basis of addictive be- weakness.”74 Identifying the neuro- methadone are important treatments for havior is important. logic factors underlying addictive be- addiction, even for individuals who First, of most importance, neurosci- havior can place these moral argu- have been under enforced abstinence ence’s uncovering of new molecular tar- ments into a more reasoned context. during incarceration. gets implicated in the responses to drugs Addiction does not absolve one of re- Third, neuroscience may help ad- and of new knowledge on the function sponsibility for use of illicit drugs or for dicted individuals to better under-

Downloaded from www.jama.com at University Of New Mexico on January 16, 2009 TREATING DRUG ABUSE AND ADDICTION IN THE CRIMINAL JUSTICE SYSTEM stand their own addiction. Such indi- the individual over time to sustain re- nated response between criminal jus- viduals may become frustrated when covery. tice agencies, drug abuse treatment their efforts to control their own drug Principles of Drug Abuse Treat- providers, mental health and physical use are unsuccessful, and even with ment for Offenders. Principles of Drug health care organizations, and social treatment many become frustrated with Abuse Treatment for Criminal Justice service agencies. Each type of crimi- what is often a slow and tenuous re- Populations,75 published by the Na- nal justice agency (eg, jail, drug court, covery process. The neurobiology of the tional Institute on Drug Abuse, synthe- probation, prison) has its own role in brain can help the addicted individual sizes research on drug abuse treat- sanctioning and supervision and lends put this disease into a more under- ment for drug abusers in the criminal itself to specific intervention opportu- standable context and thereby facili- justice system. It is intended as a re- nities. TABLE 3 provides a simplified tate effective treatment. Little re- source for criminal justice profession- overview of the criminal justice sys- search has been conducted in the field als and the treatment community work- tem and identifies the points at which of addiction on whether knowing more ing with drug abusers involved with the intervention is possible. about the substance use disorder is use- system. The publication summarizes 20 Effective integration of drug treat- ful in helping to sustain recovery, and years of research to provide guidance ment interventions into criminal jus- more research is needed. However, the on evidence-based practices and iden- tice settings requires matching the in- concept of the “expert patient” who tifies general principles on how to ef- tervention to the organization. For serves as his or her own best health ad- fectively address the drug abuse prob- example, since jail stays are usually brief, vocate in a recovery management para- lems of populations involved with the the interventions best suited to jails may digm has been promoted for chronic criminal justice system (BOX).75 be screening for drug and alcohol abuse, disorders. As with these other ill- Implementing the Principles. Effec- other mental illnesses, and medical con- nesses, addiction must be managed by tive interventions depend on a coordi- ditions (eg, HIV, hepatitis B or C), with referral to community-based treatment providers. Implementing these prin- Table 3. Intervention Opportunities in Criminal Justice Systems ciples throughout the criminal justice Offender Intervention Stage Event Participants Opportunities and drug abuse treatment systems also Entry Arrest Crime victim Screening or referral requires that these systems work to- Police gether to address the addicted individu- FBI al’s drug use, comorbid mental disor- Prosecution Court Crime victim Diversion programs Pretrial release Police Drug courts ders and medical conditions, if present, Jail FBI Community-based and criminal behavior. Treatment pro- Judge treatment fessionals should understand the crimi- TASCa nal justice process and the supervision Adjudication Trial Prosecutor NA Defense attorney requirements of their patients. In addi- Defendant tion to addressing drug use behaviors, Jury Judge treatment outcomes improve when an- Sentencing Fines Jury Drug court tisocial and criminal behaviors are tar- Community Judge Terms of incarceration gets of clinical intervention.76 Criminal supervision Release conditions Incarceration justice professionals must develop an un- Corrections Probation Probation officers Screening and treatment derstanding of addiction—signs and Jail Correctional for substance use symptoms, treatment, and relapse— Prison personnel disorders Screening and treatment and their role in facilitating recovery. for other mental Substance Abuse Treatment Re- illnesses search in Criminal Justice Settings. Screening and treatment for other medical Prison environments are inherently co- disorders ercive,77 and special safeguards have Community Probation Probation or Drug treatment been developed to ensure that prison- reentry Parole parole officer Aftercare Release Family Housing ers can choose freely whether to par- Community-based Employment ticipate in biomedical research with- providers Mental health Medical care out fear of consequence. Beyond mere Halfway house equipoise, clinical trials must be de- TASC signed so the research is of benefit to Abbreviations: FBI, Federal Bureau of Investigation; NA, not applicable; TASC, Treatment Accountability for Safer Com- munities. the prisoner participant regardless of the a Interventions of the TASC organization are based on a case management model for integrating criminal justice and assigned study group. Within these con- drug abuse treatment services. straints, it is important to conduct re-

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Kingston, NJ: Civic Re- development of vaccines against co- treatment for drug addiction seek help search Institute; 2004:33-1–33-9. caine, methamphetamine, or heroin. voluntarily; in light of this, the crimi- 12. Shivy VA, Wu JJ, Moon AE, Mann SC, Holland JG, Eacho C. Ex-offenders reentering the workforce. Several avenues currently exist for nal justice system provides a unique op- J Couns Psychol. 2007;54(4):466-473. providing drug abuse treatment as an portunity to intervene and disrupt the 13. Volkow ND, Wang GJ, Telang F, et al. Cocaine cues and dopamine in dorsal striatum: mechanism of alternative to incarceration. Drug courts cycle of drug use and crime in a cost- craving in cocaine addiction. J Neurosci. 2006; were intended to provide a bridge be- effective manner. 26(24):6583-6588. 14. Nestler EJ. Review: transcriptional mechanisms of tween drug treatment and adjudica- addiction: role of Delta FosB. Philos Trans R Soc Lond tion; from the first drug court estab- Author Contributions: Study concept and design: B Biol Sci. 2008;363(1507):3245-3255. Chandler, Fletcher, Volkow. 15. Grimm JW, Hope BT, Wise RA, Shaham Y. Neu- lished in Miami in 1989, drug courts Analysis and interpretation of data: Fletcher. roadaptation: incubation of cocaine craving after have increased in number to nearly Drafting of the manuscript: Chandler, Fletcher. withdrawal. Nature. 2001;412(6843):141-142. Critical revision of the manuscript for important in- 16. Inciardi JA, Martin SS, Butzin CA, Hooper RM, 2000 today. States such as Arizona, tellectual content: Chandler, Fletcher, Volkow. Harrison LD. An effective model of prison-based treat- California, and New York have cre- Administrative, technical, or material support: ment for drug-involved offenders. J Drug Issues. 1997; Chandler, Fletcher, Volkow. 27(2):261-278. ated treatment alternatives to incar- Financial Disclosures: None reported. 17. Pearson FS, Lipton DS. A meta-analytic review of ceration for first-time drug offenders, Funding/Support: This article was written by staff from the effectiveness of corrections-based treatments for juvenile offenders, and others. Many the National Institute on Drug Abuse and there was drug abuse. Prison J. 1999;79(4):384-410. no external funding for this work. 18. Leukefeld CG, Tims F, Farabee D, eds. Treat- states are coming under political pres- Disclaimer: The statements in this article are those of ment of Drug Offenders: Policies and Issues. New York, sure to reduce the costs associated with the authors and not necessarily those of the National NY: Springer; 2002. Institute on Drug Abuse. 19. Wormith JS, Althouse R, Simpson M, Reitzel LR, incarceration by diverting nonviolent Additional Contributions: We thank Faye S. Tax- Fagan TJ, Morgan RD. The rehabilitation and reinte- drug offenders to treatment. man, PhD, and Matthew Perdoni, MS, both of George gration of offenders—the current landscape and some Mason University, for data on physical/medical, men- future directions for correctional psychology. Crim Jus- tal health, and substance use services (Table 2) from tice Behav. 2007;34(7):879-892. Conclusions the NIDA National Criminal Justice Drug Abuse Treat- 20. Prendergast ML, Podus D, Chang E, Urada D. The ment Studies (CJ-DATS) National Criminal Justice Treat- effectiveness of drug abuse treatment: a meta- Punishment alone is a futile and inef- ment Practices Survey. Neither of these individuals re- analysis of comparison group studies. Drug Alcohol fective response to drug abuse,2 fail- ceived compensation for their contributions. Depend. 2002;67(1):53-72.

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