Treatment Options and Reducing Relapse-Related Recidivism

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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: But, the people who come out, unless something awful has been happening in the prison, they’re off drugs. They’ve been off drugs while incarcerated, unless they’ve gotten them through some extra legal means.

Jac A. Charlier, MPA: From prisons, it’s a good assumption. From jails, I’ll be more hesitant to say that that’s the case. From prison, yes, I say that is.

Peter L. Salgo, MD: Out you come, and you’re going back to the world in which you got into trouble in the first place.

Jac A. Charlier, MPA: People, places, and things, Peter.

Peter L. Salgo, MD: What are the options you’ve got? What kind of treatment options? A psychosocial treatment? Are there medications? What do you do?

Phillip Barbour: Well, again, it has to be individualized. That’s the other concept over the last 20 years or so that’s really gotten a lot of attention. One treatment approach doesn’t work for everybody. When you’re talking about re-entry management and the question of where do they go, what do they get, it’s got to be individualized for that offender to address their criminogenic needs. To give you an example, in Illinois, we have two prisons that are solely dedicated to substance use treatment. There are small, general population offenders in there, but that’s only for prison operation. The majority of the populations in both prisons are going through treatment, cognitive behavioral therapy models. And in their re-entry effort, the parole agent is an intricate part of that team.

They actually go out and look at the environment where that person’s supposed to be released at. And they do an assessment of that. They do what’s called the whole site investigation. If the parole agent doesn’t think that environment is conducive to recovery, they will deny that whole site. So, then we have the options of possibly placing them in a half-way house or a recovery home that is conducive to the recovery process. That’s just one small example how re-entry works. It needs to be tailored, and it needs to work along the entire continuum from the enter treatment in the jail, or prison, until the time they get released, and where they’re going.

Peter L. Salgo, MD: Out in the community, are there resources? Are there psychologic support resources? Are there medication-based resources out there?

Joshua D. Lee, MD, PhD: Yes. So, then we’re really now describing what is drug treatment in the community.

Peter L. Salgo, MD: Right.

Joshua D. Lee, MD, PhD: Many of whom, the clients, or patients there, are criminal justice involved, just got out of prison or jail, or that happens to them frequently. So, what is basic community drug treatment? It’s typically outpatient. It can be residential. We have detoxes, we have 28-day rehabs, we have long-term therapeutic communities. We have the sober house, three-quarter house. But, the bulk of counselors, doctors, psychiatrists, psychologists, and care managers are in some kind of outpatient setting. So, it could be a day program that’s probably open 5 or 6 days a week, and does a lot of therapy typically; talk therapy, group therapy, much of which can be based on the 12-Step Model. Or some kind of approach like CBT, or cognitive behavioral therapy, and is probably licensed by the state, although there’s a lot of variation across what state you’re talking about.

Phillip Barbour: Sure.

Joshua D. Lee, MD, PhD: It’s probably funded by federal and state block monies, or is billing Medicaid or another commercial insurance. It’s, in essence, part of the health system.

Peter L. Salgo, MD: You’re talking about talking. You’re talking about engaging, if you will, the interactive cortex. And the drug problem certainly with narcotics is at deep-brain level. It’s at receptor levels. So, my question is, are there medication programs out there to supplement what you’re doing? Clearly, you need both. But, what about the medications?

Joshua D. Lee, MD, PhD: So, within those outpatient settings, some of which may be…

Peter L. Salgo, MD: Why are we laughing at this?

Joshua D. Lee, MD, PhD: Some of those might be classic opiate treatment programs or methadone clinics.

Peter L. Salgo, MD: Okay.

Joshua D. Lee, MD, PhD: Those are treating, for the most part, only opiate dependence with methadone, although it’s opening up where they could use other medications that are approved for opiate dependence. And, then, in a non-methadone program, outpatient drug clinic, you could also prescribe medications for psychiatric disorders, or for addicted disorders. You couldn’t prescribe methadone, that’s got to be in a methadone clinic per federal regulations and how we regulate methadone. But, you could get other stuff. Like buprenorphine is something we’re using very commonly for opiate addiction. Naltrexone is for opiate and alcoholic addition. But, much like when you’re in prison, you’re likely not to get much quality treatment even though you clearly have a disorder. When you’re in outpatient drug treatment in the United States, even though it’s indicated, you’re unlikely to get a medication, which is a problem.

Peter L. Salgo, MD: Which raises the obvious question, right? What are the barriers here? If we all know that these things probably work, they’re better than not getting them. And that society, if you don’t get these treatments, is looking at a whole bunch of recidivism. Is that the right word?

Phillip Barbour: Yes.

Joshua D. Lee, MD, PhD: Recidivism, yes.

Peter L. Salgo, MD: Then, what are the barriers here? Why can’t we do it?

Phillip Barbour: Well, perceptions are one big barrier. I’ve worked with a number of judges and probation officers over the years. They look at things like methadone and buprenorphine as just substituting one drug for another. There’s a lot of stigma behind that treatment approach. Methadone has been around for over 50 years. It’s an effective medication if it’s used correctly along with talk therapy, psychotherapy. But, the public perception of using medication to treat addiction has got to come a long way. It’s gotten better probably in the last 10 years than the previous 10 years. But, public perception is one huge barrier, and regulations. As Josh mentioned, you can only do certain things in certain places, and it becomes very difficult to get those certifications.

Jonathan Grand: And one of the barriers, obviously, is that we’re taking people and putting them back pretty much in the same milieu, the same atmosphere where they came. And their neighbors, or their friends, or the people they hang out with are the ones who they were drinking and drugging with to begin with. So, then the question is, if you’re putting them back there, how do they stay clean? And one of the things that is happening now, which is really exciting, is that a number of the jails and prisons are doing things for aftercare, such as we now have people who do, we call it a warm handoff. There are now people who are assigned to the inmates 30 to 90 days before they’re discharged. And they’re the people who work with them on their discharge planning. Then when the inmate leaves, that person picks them up and sees that they complete their aftercare plan in terms of behavioral counseling, individual-group-family counseling, and case management. They make sure that they go for housing assistance, employment assistance, transportation, healthcare, and, of course, medical-assistance.

Peter L. Salgo, MD: Does it work statistically? Does it work?

Jonathan Grand: It’s something new that is starting out, and we’re getting very good results. We’re seeing huge reductions in recidivism. We’re seeing huge results in reduction in deaths, mortality, reduction in HIV, all the things that we’re concerned about. It’s really helping.