Monthly Archives: August 2016

What works for offenders with co-occurring substance abuse and mental disorders?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center.
What works for offenders with co-occurring substance abuse and mental disorders?

It is important to adequately assess mental disorders and to address them as part of effective drug abuse treatment. Many types of co-occurring mental health problems can be successfully addressed in standard drug abuse treatment programs. However, individuals with serious mental disorders may require an integrated treatment approach designed for treating patients with co-occurring mental and substance use disorders.

Much progress has been made in developing effective medications for treating mental disorders, including a number of antidepressants, anti-anxiety agents, mood stabilizers, and anti-psychotics. These medications may be critical for treatment success with offenders who have co-occurring mental disorders such as depression, anxiety disorders, bipolar disorder, or schizophrenia. Cognitive-behavioral therapy can be effective for treating some mental health problems, particularly when combined with medications.

Contingency management can improve adherence to medications, and intensive case management may be useful for linking severely mentally ill individuals with drug abuse treatment, mental health care, and community services. A specialized type of treatment—Modified Therapeutic Communities (MTCs)—incorporates features of traditional Therapeutic Communities with a special focus on addressing co-occurring mental health conditions.

How can the criminal justice and drug abuse treatment systems reduce the spread of HIV/AIDS, hepatitis, and other infectious diseases among drug abusing offenders?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center.
How can the criminal justice and drug abuse treatment systems reduce the spread of HIV/AIDS, hepatitis, and other infectious diseases among drug abusing offenders?
Individuals involved in the criminal justice system have disproportionately high rates of substance use disorders and infectious diseases, including HIV/AIDS. In fact, 14 percent of HIV-infected individuals in this country pass through the criminal justice system each year (Spaulding et al. 2009). Other infectious diseases, such as hepatitis B, hepatitis C, and tuberculosis, also are pervasive in the criminal justice system.
This overrepresentation also provides an opportunity to integrate treatment and improve outcomes for both substance use disorders and infectious diseases. Research shows that treatment for drug abuse can lessen the spread of infectious diseases by reducing high-risk behaviors like needle-sharing and unprotected sex (Metzger et al. 2010). Identifying those who are HIV+ and starting them on HAART treatment could not only improve their health outcomes but also decrease HIV spread (Montaner et al. 2010).
It is imperative that offenders with infectious diseases be linked with community-based medical care prior to release. Offenders often have difficulty negotiating access to health services and adhering to complex treatment protocols following release from prison and jail. One study found that simply helping HIV-infected inmates complete the paperwork required to get their prescriptions filled upon release significantly diminished treatment interruption, although improvement was still needed, since fewer than half had filled their prescriptions within 2 months of release (Baillargeon et al. 2009).
Community health, drug treatment, and criminal justice agencies should work together to offer education, screening, counseling, prevention, and treatment programs for HIV/AIDS, hepatitis, and other infectious diseases to offenders returning to the community.

What is the role of medications in treating substance abusing offenders?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center

10. What is the role of medications in treating substance abusing offenders?

Medications can be an important component of effective drug abuse treatment for offenders. By allowing the brain to function more normally, they enable the addicted person to leave behind a life of crime and drug abuse. Although some jurisdictions have found ways to successfully implement medication therapy, addiction medications are underused in the treatment of drug abusers within the criminal justice system, despite evidence of their effectiveness. Effective medications have been developed for treating addiction to opiates/heroin and alcohol:

Opiates/Heroin Treatment  Medications
Long-term opiate abuse results in a desensitization of the brain’s opiate receptors to endorphins, the body’s natural opioids. Opioid agonist/partial agonist medications, which act at the same receptors as heroin, morphine, and endorphins, tend to be well tolerated and can help an individual remain in treatment. For example, methadone, an opiate agonist, reduces the craving that otherwise results in compulsive use of heroin or other illicit opiates.

  • Methadone treatment has been shown to be effective in decreasing opiate use, drug-related criminal behavior, and HIV risk behavior. 
  • Buprenorphine is a partial agonist and acts on the same receptors as morphine (a full agonist), but without producing the same level of dependence or withdrawal symptoms. 
  • Suboxone is a unique formulation of buprenorphine that contains naloxone, an opioid antagonist that limits diversion by causing severe withdrawal symptoms in addicted users who inject it to get “high.” It has no adverse effects when taken orally, as prescribed.

An alternative approach, in previously detoxified opiate users, is to use an antagonist medication that blocks the effects of opiates. 

  • Naltrexone has been available for more than 2 decades, but poor compliance in the face of severe cravings and addiction has undermined its benefits. An extended-release injectable formulation of naltrexone (Vivitrol) was recently approved by the U.S. Food and Drug Administration (FDA) for treating opioid addiction. 
  • Vivitrol requires dosing every few months rather than daily, which stands to improve treatment adherence.
Alcohol Dependence Treatment Medications
  • Disulfiram (also known as Antabuse) is an aversion therapy that induces nausea if alcohol is consumed. 
  • Acamprosate, a medication that helps reduce alcohol craving, works by restoring normal balance to the brain’s glutamate neurotransmitter system. 
  • Naltrexone (and now Vivitrol), which blocks some of alcohol’s pleasurable effects and alcohol craving, is also approved by the FDA for treatment of alcohol abuse.

How can rewards and sanctions be used effectively with drug-involved offenders in treatment?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center

9. How can rewards and sanctions be used effectively with drug-involved offenders in treatment?

The systematic application of behavioral management principles underlying reward and punishment can help individuals reduce their drug use and criminal behavior. Rewards and sanctions are most likely to change behavior when they are certain to follow the targeted behavior, when they follow swiftly, and when they are perceived as fair. It is important to recognize and reinforce progress toward responsible, abstinent behavior.

Rewarding positive behavior is more effective in producing long-term positive change than punishing negative behavior. Indeed, punishment alone is an ineffective public health and safety intervention for offenders whose crime is directly related to drug use (Leukefeld et al. 2002). Non-monetary rewards such as social recognition can be as effective as monetary ones. A graduated range of rewards given for meeting predetermined goals can be an effective strategy.

Contingency management strategies, proven effective in community settings, use voucher-based incentives or rewards, such as bus tokens, to reinforce abstinence (measured by negative drug tests) or to shape progress toward other treatment goals, such as program session attendance or compliance with medication regimens. Contingency management is most effective when the contingent reward closely follows the behavior being monitored.

An intervention tested by CJ-DATS researchers, called “Step’n Out,” used a contingency management approach whereby criminal justice staff monitored specific behaviors (e.g., abstinence, employment searches, and counseling attendance) and rewarded individuals who met agreed-upon goals with social acknowledgement (e.g., congratulatory letter from parole supervisor) and small material incentives (e.g., partial payment for clothes for job interviews). This approach improved parolees’ attendance at integrated community parole and addiction treatment sessions, as well as increased use of treatment and individual counseling services (Friedmann et al. 2009).

Graduated sanctions, which invoke less punitive responses for early and less serious noncompliance and increasingly severe sanctions for more serious or continuing problems, can be an effective tool in conjunction with drug testing. The effective use of graduated sanctions involves consistent, predictable, and clear responses to noncompliant behavior.

Drug testing can determine when an individual is having difficulties with recovery. The first response to drug use detected through urinalysis should be a clinical one—for example, increasing treatment intensity or switching to an alternative treatment. This often requires coordination between the criminal justice staff and the treatment provider. (Note that more intensive treatment should not be considered a sanction, but rather a routine progression in health care practice when a treatment appears less effective than expected.)

Behavioral contracting can employ both rewards and sanctions. A behavioral contract is an explicit agreement between the participant and the treatment provider or criminal justice monitor (or among all three) that specifies proscribed behaviors and associated sanctions, as well as positive goals and rewards for success. Behavioral contracting can instill a sense of procedural justice because both the necessary steps toward progress and the sanctions for violating the contract are specified and understood in advance.

How long should drug abuse treatment last for individuals involved in the criminal justice system?

FREQUENTLY ASKED QUESTIONS (FAQS) About Drug Abuse Treatment for People Involved with the Criminal Justice System.

Reprinted from “Principles of Drug Abuse Treatment for Criminal Justice Populations” by the National Institute on Drug Abuse (in the Public Domain) by Thomas A. Wilson, MA, LCPC & CEO of Tom Wilson Counseling and Telehealth Center.  
8. How long should drug abuse treatment last for individuals involved in the criminal justice system?
While individuals progress through drug abuse treatment at different rates, one of the most reliable findings in treatment research is that lasting reductions in criminal activity and drug abuse are related to length of treatment. Generally, better outcomes are associated with treatment that lasts longer than 90 days, with treatment completers achieving the greatest reductions in drug abuse and criminal behavior. Again, legal pressure can improve retention rates.
A longer continuum of treatment may be indicated for individuals with severe or multiple problems. Research has shown that  treatment provided in prison and continued in the community after release can reduce the risk of recidivism to criminal behavior as well as relapse to drug use.
Early phases of treatment help the participant stop using drugs and begin a therapeutic process of change. Later stages address other problems related to drug abuse and, importantly, help the individual learn how to self-manage the drug problem. Because addiction is a chronic disease, drug relapse and return to treatment are common features of recovery. Thus, treatment may need to extend over a long period across multiple episodes of care.