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.

What treatment and other health services should be provided to drug abusers involved with 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.

7. What treatment and other health services should be provided to drug abusers involved with the criminal justice system?

One of the goals of treatment planning is to match evidence-based interventions to individual needs at each stage of drug treatment. Over time, various combinations of treatment services may be required.

Evidence-based interventions include cognitive-behavioral therapy to help participants learn positive social and coping skills, contingency management approaches to reinforce positive behavioral change, and motivational enhancement to increase treatment engagement and retention.

In those addicted to opioid drugs, agonist/partial agonist medications can also help normalize brain function, and antagonist medications can facilitate abstinence. For juvenile offenders, treatments that involve the family and other aspects of the drug abuser’s environment have established efficacy.

Drug abuse treatment plans for incarcerated offenders can facilitate successful re-entry into the community by incorporating relevant transition plans and services. Drug abusers often have mental and physical health, family counseling, parenting, educational, and vocational needs, so medical, psychological, and social services are often crucial components of successful treatment. Case management approaches can be used to provide assistance in obtaining and integrating drug abuse treatment with community services.

Are relapse risk factors different in offender populations? How should drug abuse treatment deal with these risk factors?

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.  
6. Are relapse risk factors different in offender populations? How should drug abuse treatment deal with these risk  factors?
Often, drug abusing offenders have problems in other areas. Examples include family difficulties, limited social skills, educational and employment problems, mental health disorders, infectious diseases, and other medical issues. Treatment should take these problems into account, because they can increase the risk of drug relapse and criminal recidivism if left unaddressed.
Stress is often a contributing factor to relapse, and offenders who are re-entering society face many challenges and stressors, including reuniting with family members, securing housing, and complying with criminal justice supervision requirements. Even the many daily decisions that most
people face can be stressful for those recently released from a highly controlled prison environment.
Other threats to recovery include a loss of support from family or friends, which incarcerated people may experience. Drug abusers returning to the community may also encounter people from their lives who are still involved in drugs or crime and be enticed to resume a criminal and drug using lifestyle. 
Returning to environments or activities associated with prior drug use may trigger strong cravings and cause a relapse. A coordinated approach by treatment and criminal justice staff provides the best way to detect and intervene with these and other threats to recovery. In any case, treatment is needed to provide the skills necessary to avoid or cope with situations that could lead to relapse.
Treatment staff should identify the offender’s unique relapse risk factors and periodically re-assess and modify the treatment plan as needed. Generally, continuing or re-emerging drug use during treatment requires a clinical response—either increasing the amount or level of treatment, or changing the treatment intervention.

Is legally mandated treatment effective?

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.

5. Is legally mandated treatment effective?

Often, the criminal justice system can apply legal pressure to encourage offenders to participate in drug abuse treatment; or treatment can be mandated through a drug court or as a condition of pretrial release, probation, or parole. A large percentage of those admitted to drug abuse treatment cite legal pressure as an important reason for seeking treatment.

Most studies suggest that outcomes for those who are legally pressured to enter treatment are as good as or better than outcomes for those who entered treatment without legal pressure. Individuals under legal pressure also tend to have higher attendance rates and remain in treatment for longer periods, which can also have a positive impact on treatment outcomes.

Are all drug abusers in the criminal justice system good candidates for 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.

4. Are all drug abusers in the criminal justice system good candidates for treatment?

A history of drug use does not in itself indicate the need for drug abuse treatment. Offenders who meet drug dependence criteria should be given higher priority for treatment than those who do not. Less intensive interventions, such as drug abuse education or self-help group participation, may be appropriate for those not meeting criteria for drug dependence. Services such as family- based interventions for juveniles, psychiatric treatment, or cognitive- behavioral interventions for changing “criminal thinking” may be a higher priority for some offenders, and individuals with mental health problems may require specialized services.

Low motivation to participate in treatment or to end drug abuse should not preclude access to treatment if other criteria are met. Motivational enhancement interventions may be useful in these  cases. Examples include motivational interviewing and contingency management techniques, which often provide tangible rewards in exchange for meeting program goals. Legal pressure that encourages abstinence and treatment participation may also help these individuals by improving retention and prompting longer treatment stays.

Drug abuse treatment is also effective for offenders who have a history of serious and violent crime, particularly if they receive intensive, targeted services. The economic benefits in avoided crime costs and those of crime victims (e.g., medical costs, lost earnings, and loss in quality of life) may be substantial for these high-risk offenders. Treating them requires a high degree of coordination between drug abuse treatment providers and criminal justice personnel to ensure that the prisoners receive needed treatment and other services that will help prevent criminal recidivism.

The Roles of Culture, the Justice System and Support Groups in Adolescent Drug Treatment , Part 8.

The Roles of Culture, the Justice System and Support Groups in Adolescent Drug Treatment, Part 8

Reprinted from the National Institute of Drug Abuse by Tom Wilson Counseling Center offering online substance abuse education for adults and adolescents.

15. What are the unique treatment needs of adolescents from different racial/ethnic backgrounds?

Treatment providers are urged to consider the unique social and environmental characteristics that may influence drug abuse and treatment for racial/ethnic minority adolescents, such as stigma, discrimination, and sparse community resources.

With the growing number of immigrant children living in the United States, issues of culture of origin, language, and acculturation are important considerations for treatment. The demand for bilingual treatment providers to work with adolescents and their families will also be increasing as the diversity of the U.S. population increases.

16. What role can the juvenile justice system play in addressing adolescent drug abuse?

Involvement in the juvenile justice system is unfortunately a reality for many substance-abusing adolescents, but it presents a valuable opportunity for intervention. Substance use treatment can be incorporated into the juvenile justice system in several ways.

These include:
• screening and assessment for drug abuse upon arrest
• initiation of treatment while awaiting trial
• access to treatment programs in the community in lieu of incarceration (e.g., juvenile treatment drug courts)
• treatment during incarceration followed by community-based treatment after release

17. What role do 12-step groups or other recovery support services play in addiction treatment for adolescents?

Adolescents may benefit from participation in self- or mutual-help groups like 12-step programs or other recovery support services, which can reinforce abstinence from drug use and other changes made during treatment, as well as support progress made toward important goals like succeeding in school and reuniting with family. Peer recovery support services and recovery high schools provide a community setting where fellow recovering adolescents can share their experiences and support each other in living a drug-free life.

It is important to note that recovery support services are not a substitute for drug abuse treatment. Also, there is sometimes a risk in support-group settings that conversation among adolescents can turn to talk extolling drug use; group leaders need to be aware of such a possibility and be ready to direct the discussion in more positive directions if necessary.

Questions about Medications to Treat Adolescent Drug Use

Questions about Medications to Treat  Adolescent Drug Use

Reprinted from the National Institute of Drug Abuse by Tom Wilson Counseling Center offering online substance abuse education for adults and adolescents.

13. Are there medications to treat adolescent substance abuse?

Several medications are approved by the FDA to treat addiction to opioids, alcohol, and nicotine in individuals 18 and older. In most cases, little research has been conducted to evaluate the safety and efficacy of these medications for adolescents; however, some health care providers do use these medications “off-label,” especially in older adolescents.

14. Do girls and boys have different treatment needs?

Adolescent girls and boys may have different developmental and social issues that may call for different treatment strategies or emphases.

For example, girls with substance use disorders may be more likely to also have mood disorders such as depression or to have experienced physical or sexual abuse.

Boys with substance use disorders are more likely to also have conduct, behavioral, and learning problems, which may be very disruptive to their school, family, or community. Treatments should take into account the higher rate of internalizing and traumatic stress disorders among adolescent girls, the higher rate of externalizing disruptive disorders and juvenile justice problems among adolescent boys, and other gender differences that may play into adolescent substance use disorders.

How effective is drug abuse treatment for criminal justice-involved individuals?

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.

3. How effective is drug abuse treatment for criminal justice-involved individuals?

Treatment is an effective intervention for drug abusers, including those who are involved with the criminal justice system. However, the effectiveness of drug treatment depends on both the individual and the program, and on whether interventions and treatment services are available and appropriate for the individual’s needs.

To alter attitudes, beliefs, and behaviors that support drug use, the drug abuser must engage in a therapeutic change process, which may include medications to help prevent relapse. Longitudinal outcome studies find that those who participate in community-based drug abuse treatment programs commit fewer crimes than those who do not participate.