Ricky is Right: Breaking the Drug Abuse/Criminal Justice Cycle

Ricky may have been on the edge of losing control, but he was still teaching me some health policy lessons.

Word was out among his friends that Ricky was drinking again, and my cousin, who has been friends with him for 35 years, had flown in to see what was going on and how she could help. He had driven into town, and they had been hanging out all day. Now we were all out for an evening stroll.  We ended up sitting on some park steps downtown—and talking.

Ricky and I are acquaintances, but not close. He knew he was being checked in on—and he knew that I knew. Our conversation wandered stiffly from our current jobs to the challenges of finding satisfying work. Then before I realized it, we were speaking about substance abuse, how the court and prison systems were serving as holding centers for substance abusers, and the poor treatment options available for the justice-involved who want to treat their addiction. It was a conversation bounded by social constraints—he did not volunteer where he had gotten his information and I did not want to ask.

“It’s bad,” he said. “There are people—especially in the rural parts of the state—who are really hurting themselves.  And the courts—they don’t do anything, really. And when people do get into treatment, it’s too short and no good.”

I was struck by his intensity and his empathy—it was obvious he was walking this road.

For states and local municipalities that agree, and want to change how people with substance abuse and mental health conditions are treated as they leave the justice system, there is a new reference. An issue brief released this month by the Milbank Memorial Fund, Coordinating Access to Services for Justice-Involved Populations, documents how corrections agencies, Medicaid programs, and providers can work together to help the justice-involved seek effective treatment and reduce the “drug use/criminal justice cycle” that costs money and wastes lives.

Ricky, it turns out, knew what he was talking about. The issue brief states that two-thirds of people in jails have documentable substance abuse disorders and over a quarter have a mental health condition. Access to effective treatment for the justice-involved is poor and results in re-entry into the prison system.  At any time, over half of the current inmates with a substance abuse condition have been previously incarcerated at least once.

The average cost per year of incarceration in 2010 was over $31,000 per inmate, according to the Vera Institute of Justice. That makes recidivism expensive. Treatment is cheap by comparison. A study by the Washington State Institute for Public Policy calculates that for every dollar spent on community drug treatment programs, there are $18 in societal benefits, including reduced medical and incarceration costs and increased income tax revenues.

So how can we do better for Ricky, for those in the criminal justice system with substance abuse and mental health conditions, and for burdened corrections programs? The issue brief outlines key steps:

• Expand Medicaid access as made available under the ACA and enroll the justice-involved in Medicaid as they end incarceration.
• Design special Medicaid benefits—using waivers and state plan amendments—for populations that need access to evidence-based services that work.
• Pay for providers who have experience with justice-involved populations to actively coordinate care for these services, using information technology to help that care coordination.

The issue brief details promising practices in Minnesota, Miami, Texas, and San Diego, and summarizes evidence-based practices and programs for justice-involved adults with behavioral health disorders. It is a comprehensive primer for communities that want to work on this complex and costly issue.

You would think an 18 to 1 return on investment would be a sure bet, but breaking the drug abuse/criminal justice cycle remains a tough issue. Substance abusers have neither political power nor public sympathy. Public sentiment ignores the science behind the effects of addiction and mental health on brain functioning, and there remain deeply engrained societal calls for the afflicted merely to exercise more personal responsibility. “Just say no,” those with substance abuse problems are told.

Recent state and federal actions to address the toll of opioid abuse indicates that some of these cultural attitudes may be changing. These societal changes must be matched by skillful policy development and implementation. This requires committed multi-agency coordination across state and local jurisdictions, informed by the evidence and experience captured in issue briefs like ours.

Ricky is right. Incarceration should not pass for treatment.