Pubdate: Sun, 19 Sep 1999
Source: Houston Chronicle (TX)
Copyright: 1999 Houston Chronicle
Author: Lonnie Bristow, M.D. and David Lewis, M.D.


For a drug abuser, is the answer jail or treatment?

For America the answer is critical. When added up, health-care costs,
lost work productivity, accidents, crime and related prison time cost
the nation more than $100 billion a year.

Stereotypes and stigma drive the debate. While impoverished minorities
are the drug-user image, the reality is that about 70 percent of drug
abusers work full time and most are not minorities. The drug struggle
occurs in the streets, in the suburbs and workplaces, and in Congress.
Now police, the courts, legislators and doctors are collaborating to
come up with new, more effective answers.

Fortunately, there is good news. While the best answer is to turn
people from substance abuse before they start and before they break
the law, for too many it won't happen because of the powerfully
addictive nature and availability of many drugs. On the positive side,
major research now shows that treating addiction greatly reduces
crime. And now there are effective new alternatives emerging within
the criminal justice system. They include drug courts, professional
addiction treatment in more and more prisons and treatment
availability once prisoners are back in their communities, though this
is still too rarely available.

Most challenging, but perhaps most important, are newly evolving
programs to treat troubled teen-agers. For many reasons, adolescents
can tumble into substance abuse when parents or supportive families
are missing from their lives or they suffer abuse. A new nonprofit
group called Physician Leadership on National Drug Policy recently
commissioned reviews of these criminal justice approaches and found
important successes. PLNDP includes 37 of the nation's best-known
physicians, and is principally funded by The John D. and Catherine T.
MacArthur Foundation and The Robert Wood Johnson Foundation.

Here are the outcomes:

For adults arrested for drug problems, the nationwide expansion of
"drug courts" provides great hope for personal renewal. The best
designed courts offer treatment, health care, job counseling and, if
necessary, treatment for contributing psychological problems. The drug
courts also provide enforcement to keep abusers in treatment, though
that pressure is often not necessary once the program starts turning
the person's life around. The courts, which now number some 300 across
the country and continue to grow rapidly, are a positive mechanism
whereby the community's own treatment, health-care and job services
can be thoughtfully marshaled to help those most in need. The best
courts provide a positive signal to the arrestee that they want to
help, not punish, the person.

For some substance abusers, this is society's first positive message
to them. The successful drug courts' bottom line is that they send
those in their care back to their families and to full employment and
ready to make positive contributions to their communities. In our
nation's overloaded prisons, more than 60 percent of those behind bars
have had serious drug or alcohol problems that are often directly
connected to their crimes. Once released from jail, and never having
benefited from drug treatment, recidivism often reaches 80 percent.
However, for inmates who take serious substance abuse treatment in
prison, the recidivism rate drops remarkably, and the percentage
returning to full employment and positive lifestyles rises
dramatically. The PLNDP study found that about 50 percent of those
having in-prison treatment would even be willing to stay behind bars
an extra three months because of the treatment's value to them.

One huge barrier is a much greater demand for in-prison treatment than
there are professionals able to provide it. Research shows that 10
percent or less of prisoners in need of treatment receive the care
they need. That people are jailed for addiction-related offenses and
then not treated for their addiction is a truly powerful combination
of irrational realities.

A second serious shortcoming is the very limited availability of
treatment after prison. Once released, the job search can be difficult
and depressing for an ex-prisoner, which can threaten a relapse that
treatment or support groups can thwart. However for those with
in-prison treatment, and treatment available after release, new
research shows that recidivism can drop from about 80 percent to 25

The third, very promising area is juvenile treatment. While some new
teen projects show good results, a great deal more research is needed
on how to best design and implement effective programs. A critical new
finding is that teen-age conduct problems typically precede substance
abuse. Thus dealing substantively with delinquency can greatly reduce
the later onset of drug abuse, violence and other threatening behaviors.

The PLNDP-sponsored research found important steps that are not yet
being taken to save our troubled children. These include targeting
high risk youth; increased involvement and mentorship by an adult; a
program reaching across a person's early years and through high-risk
periods of puberty; and skill-enhancing programs for youth, rather
than those based on punishment. Without building on these efforts,
delinquency, drug abuse, criminal activity, suicide, risky sexual
behaviors and psychiatric and health problems will continue to rise.
By comparison, the recent rise in the number of juvenile arrests
appears to have had little impact on substance abuse.

One teen-age answer that shows good outcomes, in the few places where
it has been tried, is a variation on adult drug courts, but designed
for adolescents to provide them close but supportive supervision. In
short, these several PLNDP- sponsored studies show remarkable new
opportunities for lowering drug abuse in America through the use of
adult and adolescent drug courts, prison treatment, parolee treatment
and youth drug-prevention programs.

If we fail to foster these new initiatives, the national trend is
likely to continue: imprisoning low-level street dealers, harsher
penalties for drug sales and possession and proliferating mandatory
sentences for drug-related crimes. In so many instances, straight
prison time is the pathway to a failed life.

That is not the answer that America seeks. The outcome will be
overcrowding of our prisons, huge new law-enforcement costs and little
impact on drug use, crime rates, health and social problems in that
part of our population that is often in greatest need of our help.

Note: Bristow is vice chair of Physician Leadership on National Drug Policy
and a past president of the American Medical Association. Lewis is
project director of PLNDP and also director of the Center for Alcohol
and Addiction Studies at Brown University, Providence, R.I.
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