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Speech to National Corrections Conference on Substance Abuse Testing, Sanctions and Treatment

National Corrections Conference on Substance Abuse Testing, Sanctions and Treatment, New Orleans

Framing the National Agenda: a Research and Policy Perspective

I am very pleased and honored to be with you this morning. In fact, I am in awe of the level of expertise and commitment that is represented in this audience. Larry Meachum and his colleagues at the Corrections Program Office are to be commended for gathering together the right people, with the right expertise, at the right time to talk about an issue of overarching importance to the Nation -- how to leverage the resources, both old and new, of the corrections and treatment professions to move our country's thinking and practice forward to yield a safer and healthier society.

Many of the people here this morning have been my teachers and exemplars -- nearly ten years ago, Doug Lipton demonstrated to me and then to the Criminal Justice subcommittee of the House Judiciary Committee the wisdom and efficacy of prison-based treatment. In many ways, his testimony before that Committee resulted in the inclusion of the Residential Substance Abuse Treatment Program in the Crime Act. Jim Inciardi provided me and my colleagues at the Department of Justice the excitement of his research findings on the positive impact of the Key Crest experiment in Delaware. David Mactas has been a steady advocate for treatment within the federal policy circles. Pat Seitz is a powerhouse working closely with that other powerhouse, Gen. McCaffrey, to advocate for sensible drug control policies throughout the Nation. And the correctional administrators I am getting to know as NIJ is developing our new partnership with corrections -- Chase Riveland, Harold Clarke, Dora Schriro, Martin Horn, Morris Thigpen and others -- are continuing sources of inspiration about the value of leadership. I am honored to be addressing all of you this morning.

This is an enormously important conference -- for you have been given the assignment of developing and expanding our Nation's efforts to reduce drug abuse and to enhance public safety by intervening in the lives of offenders in your custody. You know -- better than anyone else -- the difficulty of this assignment. By the time they have reached your institutions and organizations, these offenders have proven themselves resistant to most efforts to redirect them toward law-abiding, safe and healthy behavior. This is particularly true for offenders with a history of drug abuse -- they have often been in and out of treatment programs, often have tried to kick their habits by themselves only to return to old patterns of drug abuse, and too often seem to accept their addiction as their fate. In short, your assignment would appear to be a "mission impossible."

Yet there is a sense of optimism in the air -- a sense that our country is moving toward a drug control policy that recognizes the enormous contributions that the criminal justice system -- particularly the corrections field working with treatment providers -- can make in reducing drug abuse and enhancing public safety -- a sense that we now know enough to invest our scarce resources wisely in approaches that work and that the end result will be a safer society.

My task this morning is to lay out for you the research findings that provide the anchors for this emerging new emphasis within our national drug control policy. I ask you to focus on two questions -- first, Why should we look to the criminal justice system, and particularly the corrections systems, as a point of intervention to reduce drug abuse? And second, Why should we think that these interventions might be effective?

I. Rationale for Criminal Justice Intervention.

One could imagine any number of ways to spend a taxpayer's dollar to reduce drug use in this country. One could invest in interdiction efforts to keep drugs from coming into this country in the first place. At the other end of the spectrum, one could invest in educational programs to prevent young people from using drugs in the first place. Between these polar extremes, there are many other worthy contenders for the tax dollar -- public education campaigns, police crackdowns, communication systems to alert law enforcement to the movement of drug shipments, research to develop ways to block the effects of illegal substances, treatment for youthful drug users.

For the last four years, the National Drug Control Strategy of the Clinton Administration has recommended increased investments in reducing drug use among hard core drug users; the central strategy has been using the criminal justice system as the point of intervention. Allow me to read from the Office of National Drug Control Policy's 1997 National Drug Control Strategy. I ask you to note carefully the forcefulness of this language:

"The fastest and most cost-effective way to reduce the demand for illicit drugs is to treat chronic, hardcore drug users. They consume the most drugs, commit the most crimes, and burden the health care system to the greatest extent. Without treatment, chronic hardcore users continue to use drugs and engage in criminal activity, and when arrested, they too frequently continue their addiction upon release. The cycle of dependency must be broken and the revolving door of criminal justice brought to a halt." This policy emphasis on treating chronic, hardcore drug users has not been universally applauded. Why, some ask, should we invest our scarce tax dollars in programs that serve frequent drug users and drug addicts who have committed serious, sometimes violent crimes, and have demonstrated resistance to rehabilitation efforts? Why, some would ask, should we provide any rehabilitation or treatment services to this group of undeserving individuals, when those same dollars could be spent on more deserving causes?

I think there are two answers to this question. The first answer is hard to fathom, but is essential to understanding the critical importance of the assignment you have been given: quite simply, the people under your supervision consume a staggering volume of illegal drugs, and any reduction in their drug use represents a significant reduction in the nation's aggregate demand for illegal drugs. According to one estimate, about 60% of the cocaine and heroin consumed by the entire nation over a year is consumed by individuals arrested in that year. Without considering any other factors such as any impact upon levels of crime committed by hard core drug users, a policy that focuses on individuals under criminal justice supervision has the potential for significantly reducing our national demand for drugs, which in turn will impact upon the forces that supply that demand.

The second answer is, for most people, also hard to believe, but we are making progress by sharing research based knowledge to turn public skepticism into open minds. Simply stated, we now know that we can effectively reduce drug use in the offender population -- in other words, treatment works -- with the important corollary result that we can reduce the number of new crimes they commit. As Gen. McCaffrey succinctly summarizes this argument, "If you hate crime, you will love treatment."

In short, there is an emerging policy consensus, based on solid research, that an investment of scarce taxpayer dollars in the work that you do is a high yield investment -- with dividends in reduced demand for drugs and less crime.

About a year ago, I traveled to Princeton New Jersey to meet with the staff and board of the Robert Wood Johnson Foundation, one of the nation's preeminent foundations supporting research and demonstration projects in the medical and public health fields. They have a longstanding interest in drug abuse, but from a medical perspective, not a criminal justice perspective. Over the past few years, they have gingerly begun to invest in criminal justice programs as a way to reach and treat drug addicts. I asked the program officer why they had made this shift in their funding strategy, and he said that for years they had been looking to find ways to reach drug addicts and then came to the startling realization that they were in the criminal justice system. Following Willie Sutton's observation that he robs banks because that's where the money is, this foundation -- reflecting a broader, emerging policy consensus -- has discovered that WE -- YOU -- have the drug abusers and the drug addicts in our system and that the criminal justice system can be a place for effective interventions.

Research published by the National Institute of Justice supports the proposition that there is a strong nexus between drug abuse and the criminal justice population. According to our Drug Use Forecasting program, which interviews arrestees in police lockups in 23 cities on a quarterly basis and takes urine samples from them, between half and three quarters of arrestees test positive for drugs. I hasten to add that there is significant regional variation in the specific findings regarding drug abuse. For example, in San Diego more arrestees test positive for methamphetamine than cocaine; in the eastern cities such as New York and Washington, methamphetamine barely registers on the scale. There is also significant variation within smaller regions. For example, in Baltimore, the drug problem is a heroin problem; in Washington, the drug problem is crack cocaine. The Drug Use Forecasting data also show some variation between men and women, and between adults and juveniles. The most recent data (from the 1996 DUF report about to be published) show that women generally continue to test positive for cocaine and methamphetamines at higher rates than men, and that juveniles test positive for marijuana at significantly higher rates than adults. Yet even 54% of juvenile males arrested and charged with crimes test positive for drugs. But I think the important larger point is not the differences in drug use patterns, but the central observation that overall, the incidence of drug abuse in our population is remarkably high and remarkably constant. So when we arrest someone for violating the law, we are most likely bringing into out custody someone who has a drug problem.

And the absolute numbers are as staggering as the percentages. According to a five year old estimate, the number of drug-using arrestees who are probably in need of treatment exceeds two million a year -- including about a million for cocaine use, a quarter million for opiates, three quarters of a million for injection drugs, and about 27,000 nationally for amphetamines, a figure certainly much higher now in the frightening era of the methamphetamine crisis.

To further complicate the picture, we also know that drug users who come into the criminal justice system are likely to use more than one drug and to abuse other substances such as alcohol. According to recent data, 22% of the arrestees test positive for more than one drug. A prior study showed that 45% of arrestees charged with violent crimes or income generating crimes such as robbery, burglary or theft tested positive for more than one drug when arrested. Illegal drugs are not the only substances being abused. Earlier DUF data -- from a study conducted between 1986 and 90 -- showed that almost 60% of males and 50% of females reported recent alcohol use, which means that actual use is probably higher.

Furthermore, we are starting to understand, through research funded by the National Institute of Drug Abuse and conducted in Baltimore, that the drug users coming through the criminal justice system are highly dependent upon illegal substances. Casual use is not the phenomenon we encounter in the criminal justice context. Nor is this a population that has frequently sought treatment in the past. Only a quarter of drug users in prison were previously in treatment and, according to a study of New York City addicts, 70 percent have neither been in treatment nor intend to seek treatment. The final piece of this complex puzzle is provided by research showing that the process of arrest, detention, adjudication and imprisonment -- which sometimes serves as a de facto detoxification and abstinence program -- has only a short term effect on drug use. Between 60 and 75 percent of untreated parolees who have histories of heroin and/or cocaine use are reported to return to those drugs within three months after release.

So the picture painted by these research findings is of a criminal justice system heavily populated by frequent drug users, often drug users with complex drug problems involving more than one illegal substance and often complicated further by a history of alcohol abuse -- and drug users who have not been amenable to treatment in the past and show few signs of stopping drug use even after long periods of incarceration. Given this client profile, why should we be at all optimistic that any interventions are likely to be successful? Aren't the skeptics right when they say that investing in this group is a waste of taxpayers money?

II. The Promise of Criminal Justice Intervention.

The good news that we are sharing this morning is that treatment works, and more specifically that treatment under criminal justice coercion works with this most difficult of client groups. I do not mean to imply that it always works -- treatment is not a vaccine -- not that it works across the board. But treatment does result in overall reductions in crime and drug use within the criminal justice population.

A number of solid research studies have been published to support these twin conclusions. The most recent is the Drug Treatment Outcomes Study, or DATOS, sponsored by the National Institute on Drug Abuse. DATOS is a major longitudinal study of clients in four types of community-based drug treatment -- outpatient methadone, long-term residential facilities, out-patient drug free programs and short-term inpatient programs, principally detoxification programs. About 35% of those in the long-term and outpatient programs were criminal justice referrals. The study examined about 8,000 subjects in eleven cities. The final analysis was performed on about 3,000 subjects who were reassessed 12 months after leaving treatment.

The initial results of this study are very encouraging and confirm similar findings in other studies. The researchers found that both long-term residential and outpatient drug free programs led to significant decreases in illegal activity. Drug use after treatment also decreased in both types of programs, especially for those who were treated for at least 90 days.

A key factor in successful outcomes was the length of stay in the treatment programs -- those who stayed at least 90 days were more likely to succeed. Interestingly, the study also shows that the presence of criminal justice supervision increased the likelihood that the individual would stay beyond the 90 day mark.

But what about cost-effectiveness, you might ask? Another body of research demonstrates that treatment interventions not only work, they are also cost-effective. In 1994, the RAND corporation reported that drug treatment is the most cost-effective drug control intervention. Another 1994 study examined CALDATA, a comprehensive drug and alcohol treatment program in California, and concluded that for every dollar invested in drug treatment, taxpayers saved $7. These savings are attributable to decreased use of drugs and alcohol and the resulting reduction in costs related to crime and health care.

So, if these studies show that treatment is generally effective, how about those treatment-resistant, poly-drug using, hardened offenders we just described who come through the criminal justice system? Again, we have early results of some very promising initiatives that demonstrate the potential for a policy of criminal justice intervention.

Most of you are familiar with drug courts. Beginning several years ago in Dade County Florida, judges, prosecutors, defense counsel and treatment providers have collaborated on the development of a highly innovative approach to the drug abuse problem. For selected defendants, usually facing low level charges, judges agree to an extended period of supervision over the case with a promise of leniency (often a dismissal of the charges) if the defendant agrees to participate in treatment, and returns to the court frequently for status reports, including urine tests. The early research on drug courts is very promising. According to an evaluation of the Dade County program, drug court defendants had far lower rates of offending that a comparison group and had longer periods between arrests. A more rigorous evaluation of the District of Columbia Drug Court is finding declines in drug use within the defendants participating in the drug treatment court and those participating in a parallel graduated sanctions court. Here in New Orleans, the District Attorney is administering a diversion program for first time felony drug users that combines treatment with testing, using both urine and hair analysis. Preliminary analysis shows that those who participate in the program are showing significant decreases in cocaine consumption and rearrest rates, and increases in employment rates.

But the findings with the greatest policy significance come from the correctional context. Researchers have now examined the results of highly rigorous evaluations of a number of prison-based therapeutic communities around the country, many of them administered by people in this room -- Stay'n Out and KEEP in New York, Cornerstone in Oregon, Amity Prison TC in California, Key-Crest in Delaware, the Texas Initiative, the Florida comprehensive drug treatment program and TASC. All of them are showing that they have positive impact. All have been shown to reduce drug use after the offender is released from prison; all have been shown to reduce criminal behavior after the offender is released.

These studies contain another very important finding: when we combine prison-based therapeutic community-style treatment with post-release supervision, then the reductions in drug use and criminal behavior are even greater. Graduates of Delaware's Key-Crest program who participated in the transitional work-release program after in-prison drug treatment were more than twice as likely to remain drug-free (76% versus 30% for in-prison TC alone and 45% for work-release program alone and 19% for the control group). Participants of in-prison drug treatment and transitional, residential work-release were one third more likely to remain arrest-free than those participating only in the in-prison drug treatment (71% from Key-Crest, 48% from Key alone, 65% Crest alone, 30% control group). Earlier studies were based on self-report -- that is, reports by offenders themselves on their levels of drug use and criminal involvement -- but Prof. Jim Inciardi, who will be addressing this conference later, has now gathered data using urinalysis surveillance and these data show much the same results: strong evidence of that these offenders who participate in both components of the program -- in-prison treatment and post release supervision -- are highly more likely to remain drug-free and arrest-free 18 months after their release from prison.

I hope that you begin to sense the power of these research findings when they are put together to support a comprehensive policy initiative leveraging the potential of the criminal justice system. First, a significant portion of our national drug consumption is attributable to individuals arrested and placed under the custody of the criminal justice system. Second, over half of those arrested are drug users and therefore candidates for some sort of intervention. Third, interventions under criminal justice coercion and control have the effect of significantly reducing drug use and criminal behavior. Put together, these are the building blocks of an emerging policy initiative.

Remember back to the period in our Nation's history when it was accepted wisdom that "nothing works" -- that the only rational crime policy was one of just desserts and retribution -- and that recidivism could never be considered as an appropriate measure of the social value of incarceration because criminals could not be changed? These new findings that we are discussing at this conference show that something does work -- and work extremely well -- and now the burden has shifted to the professionals represented in this room to deliver on the promise that recidivism can be reduced.

III. Components of the National Initiative.

We should not rush to the conclusion that new policy directions have been established overnight, or that new programs are in place on a broad scale that reflect this emphasis upon the criminal justice system as a point for intervention. We should recognize that the programs that are producing results can trace their lineage to pioneering work of others. We stand on the shoulders of giants. We should recognize the contributions of the Bureau of Justice Assistance and its Project REFORM -- which assisted 22 states in developing prison-based treatment programs -- and follow-on work of Project RECOVERY of the Center for Substance Abuse Treatment and the ongoing work of the National Institute for Corrections helping states implement effective programs. Notwithstanding all of this valuable work laying the foundation, the more sobering assessment is that there is a long way to go before we begin to realize the potential of this focus on the criminal justice population.

Yet we can now see the components beginning to take shape -- and I would like to sketch out for you consideration the pieces that I see from the NIJ perspective -- readily acknowledging that you can add to this list from the experience within your state.

A. Understanding the Local Dimensions of the Drug Problem

The first, and in some ways most important, piece of the puzzle is the development of a better understanding of the drug problem. If knowledge is power, then one reason we have been so ill-equipped to deal with the problem of drug abuse is that we have had so little knowledge. There are now two major research efforts underway that will provide local policy makers with powerful knowledge about the drug problems facing their communities. The first is the Arrestee Drug Abuse Monitoring program of the National Institute of Justice, called ADAM for short. As part of the President's budget now being considered by Congress, and with strong support from Attorney General Reno and Gen. McCaffrey, NIJ is proposing to expand its Drug Use Forecasting program -- with its quarterly interviews with arrestees and urinalysis to determine levels of drug use -- and expand it with the new name ADAM to all 75 cities over 200,000 population by the year 2000. Each ADAM site will also be expected to conduct an annual outreach survey in a neighboring rural or suburban jurisdiction so that we can learn the extent of drug abuse in these parts of America that for too long have been under-represented in our research profiles. The second research effort is SANTA [Substance Abuse and Need for Treatment Among Arrestees] being conducted by the Center for Substance Abuse Treatment or CSAT. SANTA, which focuses on a state level assessment, emphasizes the treatment dimensions of the profile of drug users within the arrestee population.

Taken together, ADAM and SANTA will accentuate the truth that you know too well, namely that America does not have "a" drug problem, it has a wide variety of drug problems -- drug problems that change over time, that reflect associated changes in crime patterns or gang migration, that affect men differently from women, adults differently from young people, poor differently from well-off, ethnic, racial and immigrant communities differently from each other. We need to develop measures other than those national surveys that tell us drug use is up or down a few percentage points. We need local drug use profiles that are sensitive to local phenomena in order to develop local policy. It is very good news for all of us that, by the time the century turns in three years, with ADAM and SANTA in place, we will have at our disposal up to date, reliable, localized research findings that will help local policy makers determine enforcement, intervention, treatment and prevention strategies that are tailored to local drug problems.

B. Mixing Interventions and Supervision.

We are seeing an exciting spirit of innovation in the criminal justice system, particularly in the willingness of criminal justice practitioners to use their authority to leverage behavioral changes in drug abusing defendants. Most prominent are the drug courts -- now well over a hundred around the country. Starting at the local level, the drug court movement has now received significant federal support -- $30 million in FY97 under the drug court program, and interestingly, of the $450 million allocated by Congress for the Local Law Enforcement Block Grant program, approximately 19% has been allocated by local jurisdictions to support or expand drug courts.

Equally important are the innovative programs of probation and parole departments mixing treatment with ongoing supervision, including graduated sanctions. Clearly, the drug court movement has yet to reach its full potential. We are even seeing applications beyond traditional criminal justice system. Last week, Chief Judge Kaye in the State of New York announced that parents appearing before the Family Court on abuse and neglect proceeding would also be tested for drugs and referred to treatment under judicial supervision.

C. Adopting a System Approach to Drug Use.

There are three important experiments underway that take the lessons learned from drug courts and apply them to the entire criminal justice system. A little over a year ago, President Clinton signed a memorandum asking the Attorney General to design and implement a comprehensive system of drug testing, sanctions, and treatment in the federal court system. Working closely with the Administrative Office of the United States Courts, the Department of Justice has now completed development of universal drug testing and intervention programs in 23 of the 74 federal districts, one of which is here in New Orleans. Called Operation DrugTEST -- TEST standing for Testing, Effective Sanctions and Treatment -- this new initiative represents the leading edge of system-wide reform in the federal courts.

The Center for Substance Abuse Treatment is also funding a number of five year demonstration projects, called Criminal Justice Treatment Networks, that are seeking to provide treatment services on a system-wide basis to under-served populations such as female and juvenile offenders.

Finally, the National Institute of Justice, with funding from the Office of National Drug Control Policy, is implementing a research demonstration project in Birmingham, Alabama called Breaking the Cycle. Under this project, everyone arrested in Birmingham will be tested for drug use, and every component of the criminal justice system -- including the jails and prisons, the pretrial and probation departments, the judges, prosecutors and defense counsel, with leadership provided by the Birmingham TASC program, will work together with a common goal: to reduce the level of drug use in the population that moves from arrest to final disposition. This project will begin operation in June, and we hope to fund additional Breaking the Cycle demonstration projects in both adult and juvenile jurisdictions within the next year.

D. Prison as Point of Intervention.

Of particular importance in the emerging consensus that our prisons represent an important point of intervention in the cycle of drug use within the offender population. I do not mean to imply that this is a new concept - certainly prisons have been drug treatment sites for the better part of a generation. Yet, I believe that the level of commitment to this approach is much higher than in the past. At the federal level, Congress has appropriated $36 million this year, and authorized up to $72 million in coming years to fund the Residential Substance Abuse Treatment -- or RSAT -- program that many of you participate in. The federal Bureau of Prisons is embarked on perhaps the most ambitious treatment initiative in a prison setting. At the state level, new resources are being made available for treatment -- over the decade of the 80's, the percentage of inmates receiving some sort of treatment tripled.

Two recent developments show the next opportunities for innovation. A recent issue of the New York Times reported that the State of Connecticut is considering a major overhaul of its sentencing policy for drug users, with an emphasis on mandated treatment.

This linkage between sentencing policy and drug policy represents an important new frontier for our states that are struggling with the twin concerns of growing prison budgets and intractable drug problems. Interestingly, the State of Pennsylvania Department of Corrections, under the leadership of Martin Horn, and in partnership with the National Institute of Justice, recently undertook an ADAM-like survey to determine the levels of drug use within the prison population itself. On the reasonable theory that neither safety nor successful treatment is possible in institutions suffering drug use in the inmate population, the Pennsylvania officials, using both urinalysis and hair testing, have been able to isolate patterns of drug use within the population.

The data from random drug tests have evolved then to identify not only prevalence leads, but usage by cellblock, by day of week, and time of day. This is a powerful management tool. Undoubtedly, many in this room could add to this list of drug policy innovations within the prison population, but the important point should not be lost: in prison treatment is effective at reducing drug use and crime.

E. Post-release Supervision Matters.

In any case, the next most important challenge for the criminal justice system is to manage the process of reintegration of the drug involved offender into the community following a period of treatment during incarceration. As the Key-Crest findings underscore, as much as in prison treatment is effective, when combined with treatment under post-release supervision, it is significantly much more effective. These research findings provide the basis for the Presidential initiative, now enacted into law by Congress, that requires each state to develop, by March 1998, a plan for testing and treatment of inmates before and after release. These research findings provide the rationale for the decision by Congress to add $25 million to the Byrne formula funds that can be made available -- but only if you ensure that your state spends the money this way -- for these purposes.

Yet it is an understatement to say that the gulf between research findings, statutory language and the reality of operating programs is wide and intimidating. Suffice it to say that we desperately need your guidance and ideas on how to translate these research findings and this statutory directive into sound correctional policy and practice. I find it ironic that, at a time when so many states are eliminating or restricting parole, we have such strong research findings that supervision can be effective at reducing recidivism. In the not too distant past, when researchers and practitioners alike were caught up with the notion that "nothing worked," the temptation to eliminate parole was somewhat more understandable. Yet we now know the value of that system of phased and supervised reintegration. We now know that the public is safer if inmates are released back into their communities with a support system that increases the likelihood that they will remain crime and drug free. So, as you are working together over the remainder of this conference to devise ways to meet the requirements of the statute, we are counting on you to tap your creativity and your powers of advocacy to devise new approaches that can yield best results.

I would like to conclude my remarks with some observations about the relationship between research and policy. Too often, researchers carry out their work in isolation, publishing reports that are read only within a small circle. Too often, practitioners work in isolation from the knowledge built within the research community, developing ideas and debating issues within a separate small circle. Our role at NIJ is to create overlapping circles -- to find the power of knowledge that can influence policy. I am proud to say that many of the initiatives I mentioned this morning have a research component -- certainly ADAM is an NIJ project, NIDA has supported evaluations of the prison programs I mentioned -- and NIJ is also supporting evaluations of the drug court program, the federal Operation Drug TEST, Breaking the Cycle, and, most directly relevant to this conference, we are supporting several evaluations connected to RSAT, evaluations funded by the Corrections Program Office through a wonderful collaborative between that office and NIJ. Larry Meachum and I sincerely believe that we are building the foundation of knowledge upon which the next generation of innovation can be built. Yet much more remains to be done to learn from your experiences -- to share both the ecstasy of victory and the agony of defeat so that others may benefit from your efforts. We have a number of initiatives that seek to link correctional agencies with researchers on a variety of topics and I want to encourage you to seek out representatives of NIJ or write to me if you are interested in participating in these efforts.

I thank you for your attention -- and extend again my admiration for the important work you do and the new challenges you have assumed -- and wish you a most successful conference.