Substance Abuse: The Scope of the Problem

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Drug-related convictions place a substantial burden on the criminal justice system and on society. The MD Magazine Peer Exchange “Medication-Assisted Treatment in Drug Abuse Cases: A Path to Success” features a panel of experts in the criminal justice field who provide insight on medication-assisted re-entry programs.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Phillip Barbour, master trainer with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jac Charlier, director for consulting and training, also with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jonathan Grand, MSW, LICSW, senior program associate at the Advocates for Human Potential in Sudbury, MA
• Joshua Lee, MD, MSc, associate professor in the Department of Population Health, and a research clinician at Bellevue Hospital Center, NYU Langone Medical Center, and the New York City jails

Peter L. Salgo, MD: Hello, and thank you for joining us for this MD Magazine Peer Exchange entitled “Medication-Assisted Treatment in Drug Abuse Cases: A Path to Success.” Drug-related convictions place a substantial burden on the criminal justice system in this country and on our society. Reentry programs are designed to help individuals to once again become contributing members of society. However, there are many barriers to success, including continued substance abuse. Today’s panel of experts is going to focus on addressing those barriers and provide insight on the best ways to structure a medication-assisted treatment program, including the necessary referral patterns in the physician community.

I’m Dr. Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and an associate director of surgical intensive care at New York-Presbyterian Hospital in New York City. Joining us today are: Phillip Barbour, master trainer with the Treatment Alternatives for Safe Communities, or TASC, in Chicago; Jac Charlier, director for consulting and training, also with TASC in Chicago; Jonathan Grand, senior program associate at the Advocates for Human Potential in Sudbury, Massachusetts; and Dr. Joshua Lee, associate professor in the Department of Population Health and Research. He’s a research clinician at Bellevue Hospital Center, NYU Langone Medical Center, and the New York City jails.

We’re going to start by understanding addiction in the criminal justice system because it’s prevalent in the criminal justice system. I don’t think we’re telling any tales out of school here. What is the burden of nonviolent, drug-related convictions on the criminal justice system right now? Who wants to jump in on that?

Jac A. Charlier, MPA: When we first think about the criminal justice system, we have to think about the 7.2 million people in the justice system. And the vast majority of them, over 5 million, are in our communities, not in our prisons and jails. That’s the first thing people need to know.

Peter L. Salgo, MD: What do you mean by that? Because I think our viewers are saying, “Wait, if they’re in the criminal justice system but they’re not in jail, where are they?”

Jac A. Charlier, MPA: Exactly, and that’s why I wanted to open up with that statistic, because most people think of jails and prisons. But of those 7.2 million, approximately 5.2 million are in the community. They’re in our neighborhoods; they’re under probation and parole supervision, with probation being the largest chunk. So, when we talk about substance abuse disorders or drug use in the criminal justice population, we should think about our communities, our neighbors, our family members, our coworkers, and people living right around us, not in Orange Is the New Black, where they are away in prison, or in jail.

Peter L. Salgo, MD: I get those strange emails inviting me to join some website that says these criminal people are living down the block from you or upstairs in your apartment building. I suspect the apps are crazy, but the numbers are not.

Jac A. Charlier, MPA: That’s correct. That’s why we start off often with the numbers to kind of scope out the size of it. The numbers vary depending on what you’re looking at in terms of the individuals. But within that population, for example, 55% to 80%—and again, the numbers vary depending on what subset of that population you look at—have a substance use disorder, have something to do with drugs and drug use. Whereas the United States’ general population is only at 9%. The difference is massive.

Peter L. Salgo, MD: It’s startling actually. And is it causation? Are so many of these people in the criminal justice system because of an offense related to drugs, or did they get involved in drugs as part of the criminal justice system?

Phillip Barbour: My first role at TASC, I’ve been there for what will be 26 years coming up in October, was as a case manager, and I did assessments. I probably assessed several hundred clients in the first 7 years of my career there. One of the things that we were charged to do was to look at that nexus between criminal behavior and the addiction. And I’d have to say that the majority of the clients that I interviewed were involved with the criminal justice system as a result of their drug addiction problem.

Of the majority of those that I interviewed, heroin addiction was the prevalent drug of choice. And the demographics have changed in the last 5 to 10 years. We’re seeing younger and younger addicts who are experimenting in using heavier and heavier drugs such as heroin and crack cocaine. So, in answer to your question, I think there is some causation behind the addiction leading them into criminal behavior.