Substance Use Treatment in Jails: Current Issues and Recommendations

The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that, in 2014, 21.5 million people in the United States age twelve and older had at least one substance use disorder (SUD), as cited by the Center for Behavioral Health Statistics and Quality (CBHSQ; 2015). Approximately 2.6 million of those (12.1 percent) had both an alcohol and illicit drug use disorder (SAMSHA, 2014). Among adults age eighteen and older, 7.9 million had both a SUD and a mental illness, the coexistence of which is referred to as a “co-occurring disorder” (CBHSQ, 2015).
SUDs occur when individuals’ substance use significantly interferes with their regular functioning, such as causing health problems or disability, social dysfunction, and/or failure to fulfill major responsibilities. SUD is an umbrella term describing alcohol use disorder, tobacco use disorder, and illicit drug use disorders, the latter of which includes several subgroups such as opioid use disorder and cannabis use disorder (CBHSQ, 2015).
The financial and social burdens of SUDs in the United States are exorbitant. The cost in dollars of alcohol, illicit drug, and tobacco use is estimated to top $740 billion annually, with the crime, health care costs, and lost productivity resulting from SUDs responsible for this stunning economic toll (NIDA, 2015a). Aside from aggregate financial costs, SUDs can have devastating effects on individuals, families, and communities (Chandler, Fletcher, & Volkow, 2009; Stuart van Wormer & Bartollas, 2014).

Magnitude and Scope of SUDs in  the Criminal Justice System
Although SUDs can result in criminal behavior with significant financial and social costs, there is an increasing awareness that the criminal justice system, as it currently operates, cannot adequately address these illnesses (Clay, 2006; AAAP, 2015). The 1980s ushered in an era of harsh sentencing laws and a dearth of treatment facilities, funneling more individuals with SUDs and co-occurring disorders into the criminal justice system (SAMHSA, 2005). Rather than receive the help they desperately need, these individuals have been subjected to an overwhelmingly punitive system intent on controlling inmates, probationers, and parolees rather than facilitating their rehabilitation.
A punitive approach has not functioned to “fix” the incarcerated or deter criminal activity or behaviors; recidivism of released inmates is astonishingly high, with as many as three out of four ex-offenders experiencing rearrest within five years of release (James & Glaze, 2006). Substance-use-involved ex-offenders have a higher likelihood of reincarceration than those who are not substance use involved (CASA Columbia, 2010). Only recently has the all-time high of those incarcerated across the country taken a slight downturn, with just over two million held on any given day in local jails, youth detention centers, state prisons, federal prisons, immigration detention facilities, Indian country facilities, and military detention facilities (Wagner & Rabuy, 2017). A total of 7.1 million people are under varying forms of supervision, including incarceration, probation, and parole (Chandler et al., 2009). Meanwhile, use of illicit drugs has been rising and plateauing since the early 2000s, depending on the substance (NIDA, 2015b).
It is difficult to ascertain precisely how many of those incarcerated across the United States meet the criteria for SUDs, although the number appears to have grown over time. A 2005 survey by the Bureau of Justice Statistics estimated that 56 percent of those incarcerated in state prisons and 53 percent of those incarcerated in local jails experienced substance dependence or abuse based on the diagnostic criteria used at time of assessment (James & Glaze, 2006; SAMHSA, 2015). A Columbia University report estimated that 65 percent of all inmates in the country met The Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) criteria for abuse or dependence (CASA  Columbia, 2010).

Treatment in the Criminal Justice System
Despite the fact that many individuals entering the criminal justice system could benefit from treatment for their SUD, most do not receive it—approximately 80 to 85 percent, by one estimate (Chandler et al., 2009). Other researchers found the situation even grimmer, with only 11 percent of inmates who meet DSM-IV substance abuse or dependence criteria in jails and prisons receiving treatment (CASA Columbia, 2010). Admittedly, providing treatment in certain criminal justice contexts can be difficult, despite the proven success of interventions such as therapeutic communities, counseling, and psychoeducation (Chandler et al., 2009).
There are over eleven million jail admissions in the United States per year (Wagner & Rabuy, 2017). Prisons are often the focus when discussing the difficulties of providing substance abuse treatment in criminal justice institutions, as they hold incarcerated individuals longer than local jails and typically offer more robust programming. Jails, however, are overwhelmingly reserved for individuals awaiting trial and not yet sentenced (Ortiz, 2015). The remainder of the jail population is comprised of those who have been convicted and sentenced to short amounts of time, typically less than one year (Wagner & Rabuy, 2017).
A strong case for providing substance abuse treatment and continuity of care through jails still remains; inmates reporting substance abuse issues are as high as 75 percent (Washington University in St. Louis, 2015). Going to jail, even for a short time, could prompt at the very least a referral and connection to treatment on the outside. For others, the pretrial phase can last for months or even years with many released and never sent to prison, constituting a missed opportunity to intervene (Wagner & Rabuy, 2017; Wilson, 2000). Further, inmates reporting histories of SUDs tend to have more extensive criminal justice involvement, reporting three or more prior incarcerations compared to inmates without SUDs (Washington University in St. Louis, 2015).

Barriers to Treatment in Jails
Conflicting Perspectives    
The conceptualization of a problem is a precursor to specific treatment approaches. According to SAMHSA (2005), jails are arguably designed to promote public safety and deliver short-term punishments to those who have committed low-level crimes, while also housing those who are awaiting trials for sometimes more serious crimes. Even though many jail detainees have not been convicted, and others are low-level, nonviolent offenders, most people in society frown on those who go to jail (SAMHSA, 2005). Some may consider jailed populations as an “out of sight, out of mind” problem. What may be surprising to some professionals outside of the social work and public health professions is that most inmates in jails are there because of their substance abuse and/or mental health issues (SAMHSA, 2005; Marlowe, 2003).
Incarceration can be a critical intervention point for inmates reporting substance abuse histories, benefiting both individuals and the communities they return to (NIDA, 2014). Because jails have a high level of interaction with people who abuse drugs and those with mental health issues, they have a unique opportunity to develop strong connections with community resources that can help low-level drug offenders improve their chance for recovery and benefit the whole community (Smith & Strashny, 2016; SAMHSA, 2005; Marlowe, 2003). Furthermore, inmates struggling with substance abuse issues will be released into their communities and may not have received any treatment, putting them at further risk of relapse (NIDA, 2014), which increases their chances of recidivism (Tangney et al., 2016). With a shift in public perception and more inclusion in coordinated care, jails could become key providers in community networks of care.

Jail Population, Structure,  and Resources
A significant barrier to delivering treatment to inmates in jail settings is the very limited timeframe some individuals are incarcerated (Leukefeld & Tims, 1992). There are many inmates in a pretrial phase of incarceration who remain incarcerated for a very short time; while in 2014, the average length of stay in jail was approximately twenty-three days (Subramanian, Delaney, Roberts, Fishman, & McGarry, 2015), with the median stay approximately only a few days (Turner, 2016). Both measures account for the inmates who stay for longer periods as well as those who are in and out of jail within hours, but the much smaller median reveals that far more inmates have shorter jail stays (Turner, 2016).
Jails structurally run on schedules including inmate counts, meals, work, recreation, and educational and other activity times, which can further hinder treatment access as those seeking treatment in jail often must choose between the aforementioned activities and treatment programming (SAMHSA, 2005). Length of stay in jail is important to consider because duration of treatment research indicates that optimum outcomes occur, on average, when clients can participate in at least ninety days of treatment (McGovern & Carroll, 2003; Swartz, Lurigio, & Slomka, 1996). Because of the variation in length of stay and the average amount of time needed to achieve positive outcomes from treatment, jails should also be equipped with adequate referral sources.
Jail housing assignments and space are also significant barriers to treatment. Most jails house inmates based on categorization techniques that consider security risks and availability of space, but the housing assignments do not necessarily consider individuals’ treatment needs. This provides for a wide variety of mixed populations within a given jail environment, which creates a problem when trying to administer substance abuse treatment (SAMHSA, 2005). Additionally, many of the smaller or less urban jails do not have adequate space for providing treatment services, with many experiencing limited funding for substance abuse treatment (SAMHSA, 2005). Without designated space for groups, one-on-one counseling, assessments, and screenings, among other items, it is extremely difficult to provide inmates with adequate, treatment-related programming.

Cultural Competence
Given the diversity, subgroups, and cliques that are a part of incarcerated populations, special care should be taken by providers within criminal justice institutions to expand their knowledge of diverse backgrounds to deliver culturally competent treatment to heterogeneous and diverse populations. Treatment providers in jail settings must be familiar with jails’ policies and procedures involving gangs; a competence should be developed for identifying secretive, gang-related behaviors to disrupt the prevalence of these behaviors, increase benefit from treatment, and promote safety within the jail (SAMHSA, 2005).
Additionally, treatment providers must be aware of best practices used when delivering treatment to mixed target populations—those with mental health disorders, sex offenders, gang members, and violent offenders—while providing them with services (Parent & Barnett, 2004). Counselors need to also be aware of the stresses offenders face when reintegrating into the community, such as employment, family reunification, and limited social service availability, and how best to mitigate these with treatment and/or referral while considering the risk of recidivism (Visher & Travis, 2003).

Continuity of Care
Continuity of care has been shown to be extremely effective in reducing rates of recidivism and relapse for inmates, specifically for those involved in some form of substance abuse treatment while incarcerated (Inciardi, 1996; Wexler, 1996). However, there are many problems with streamlining a continuity of care process after release from jails. One problem is the fragmented and uncoordinated nature of the criminal justice system, in which many agencies have different responsibilities, are funded by different sources, and have difficulty collaborating (Field, 1998). While there are similarities in treatment needs of individuals involved with the criminal justice system and of those seeking substance abuse treatment, there can be different treatment goals, which can cause a lack of coordination in the system (SAMHSA, 2005).
Additionally, there is a lack of adequate services in many communities to assist offenders during their period of transition; this problem causes many offenders to disregard treatment center options entirely due to not having more fundamental needs met such as housing, transportation, and medication (Field, 1998). Lastly, the time between many inmates’ release and when they can meet with treatment providers is often too long and results in unsuccessful outcomes postrelease (S. Doherty, personal communication, March 6, 2017), namely relapse and recidivism (NIDA, 2014). Because of the risk of drug overdoses for those exiting the criminal justice system with substance abuse issues, coordinated efforts should be made prior to release (Binswanger et al., 2007), particularly among criminal justice staff, inmates, and community providers.  

Current Treatment Practices  in Jails and Evidence-Based Practices
One of the greatest benefits of receiving treatment while incarcerated is breaking the cycle of drug relapse and recidivism (NIDA, 2014). Despite this benefit to individuals and to general public health and safety, two-thirds of jails do not offer substance-abuse-specific treatments to inmates (SAMHSA, 2005). Some jails in the United States do offer services to inmates with histories of SUDs requesting treatment. These include, but are not limited to, motivational interviewing (MI), cognitive behavioral therapy (CBT), assessments, and substance abuse psychoeducation (SAMHSA, 2005). Although treatment is offered in some jails, not all interventions are evidence-based or demonstrate any long-term success, as recidivism rates have not seen significant decreases (Chandler et al., 2009). Research on prison-based substance abuse treatment is more widely available than jail-based treatment, perhaps because jail treatment is less widespread and has a more transient population. While these counseling interventions vary by institution, client, funding, and treatment provider, a review of the literature revealed only a few promising modalities which will be the focus of this article.

Therapeutic Communities
Therapeutic communities (TCs) are recovery-oriented systems and have been used by many prisons and some jails for substance abuse treatment (Wexler & Prendergast, 2010). While inmates may have other responsibilities during their jail stays (e.g., work), they are often able to participate in four to five hours of treatment per week (Sacks, Sacks, McKendrick, Banks, & Stommel, 2004). TCs in the jail setting focus on helping inmates learn how to live honestly and with integrity (i.e., being accountable for their actions), practicing self-reliance, and emotion regulation, among other skills (Wexler & Prendergast, 2010). Often these communities are facilitated by former participants in the communities and these former “clients” serve as bridges to inmates, often helping to form therapeutic alliances more readily (NIDA, 2015c). TCs are usually separated from the rest of the incarcerated population, are recovery oriented, and utilize a holistic perspective (i.e., viewing overall people and their lifestyles) rather than focusing solely on abstinence from drug use (NIDA, 2015c). TCs promote prosocial living of the participants by having participants follow a set of recovery principles (NIDA, 2015c). Participants in TCs go through different stages of recovery and, as they transcend, can assume more responsibilities and thus improve their self-efficacy (NIDA, 2015c). Using community as a modality, there is a heavy focus on mutual self-help and engaging in altruistic behaviors with others in the community to change oneself (De Leon, 2015). TCs respect the need for continued support upon completion of their program and engage in relapse prevention techniques such as developing coping mechanisms and connecting clients to sustainable supports in their home communities (NIDA, 2015c).
A recent meta-analysis of drug treatment programs in prisons and jails by Mitchell, Wilson, and MacKenzie (2012) examined TCs, counseling programs, narcotic maintenance, and boot camp models. Their research showed that TCs and counseling interventions had a statistically significant effect on recidivism (Mitchell, Wilson, & MacKenzie, 2012). The results also suggest that TCs were effective across populations including juveniles, adults, different races, and violent/nonviolent offenders, and across type of facility (Mitchell et al., 2012). In other words, TCs were effective in both a jail and a prison setting, even with the specific barriers experienced in jails discussed previously. Counseling programs were similarly effective at reducing recidivism among the incarcerated populations. However, neither type of program had a significant effect on postrelease measures of relapse. The researchers note that this may be in large part because of the low number of studies that included postrelease relapse as an outcome. Narcotic maintenance programs were the only types to achieve statistical significance with relapse, but they had little effect on recidivism (Mitchell et al., 2012).
The evidence for TCs makes sense in context of the evidence supporting lengthier treatment duration. Research indicates that that for better recidivism outcomes, the optimal duration for jail substance abuse treatment is at least three months (SAMHSA, 2005; Marlowe, 2003). Aftercare treatment in the community is also associated with lower recidivism rates (Smith & Strashny, 2016; SAMHSA, 2005). Unfortunately, not all jail inmates remain for this length of time or have access to TCs and continuity of care. The time immediately after release can be a life-threatening period for individuals with certain addictions who are released detoxified, without support, and experiencing the same cravings (SAMHSA, 2005). Recent research shows that relapse is most likely to occur within ninety days after release (Tangney et al., 2016).

Medication-Assisted Treatment
Medication-assisted treatment (MAT) includes the use of specific medications—methadone, buprenorphine, naltrexone, naloxone, disulfiram, and acamprosate—coupled with counseling to effectively address SUDs by focusing, like TCs, on the whole person (SAMHSA, 2015). While this approach is often used for opioid addiction, it can also be used for alcohol dependency (SAMHSA, 2015). MAT medications alter brain chemistry to block the effects brought on by drugs or alcohol, while also providing relief from physical cravings (SAMHSA, 2015). Opioid treatment programs utilize and practice MAT with individuals who have a diagnosis of opioid use disorder (OUD), which is a common diagnosis for inmates residing in America’s jails (SAMHSA, 2015; Karberg & James, 2002; BJS, 2000).
A less complicated intervention bridging the gap between treatment in jail and treatment in the community has emerged in the form of a long-acting injectable naltrexone, or Vivitrol. Vivitrol is an opioid antagonist and blocks the effects of heroin and other opioids (McDonald et al., 2016). One feasibility study examining its effectiveness with a jail population outlined its obvious utility in the context of brief stays and high turnover in many jails (McDonald et al., 2016). Another small, randomized pilot study found the acceptance of the treatment was high among the experimental group and one-month relapse rates significantly lower than the comparison group (Lee et al., 2015). Recidivism rates, however, were no different between groups. An observational study offering Vivitrol to forty-seven inmates prerelease and twenty more postrelease resulted in a statistically significant, much higher treatment retention rate (55 percent versus 25 percent) one-month postrelease (Lincoln, Johnson, McCarthy, & Alexander, 2018). Fifty state prisons in seven states now offer this medication to inmates, and thirty jails in twelve states provide it to releasing inmates (Vestal, 2016). One of these jails, the Barnstable County Correctional Facility in Massachusetts, has seen a recidivism rate of just 9 percent for its Vivitrol-supplied inmates compared to the national rearrest rate of 77 percent (Vestal, 2016).
Studies of MAT are limited, especially in the jail setting. Due to social and economic constraints, MAT is not being used as often as it could be. More research is needed to see if other forms of MAT work outside of Vivitrol and OTPs. Furthermore, opioid treatment programs should be studied and documented more rigorously to best provide these treatments to the growing opioid-addicted populations filtering through jails.

Recommendations
Make Jails an Epicenter for Resource Referrals
With such large numbers of people cycling in and out, many of them with either psychological issues or SUDs, jails stand to be an epicenter for providing services that may slow recidivism, criminal behaviors, and substance abuse in general. If jails could adequately provide substance abuse assessments for their populations at entry, they could serve as a primary intervention point for referring clients to services and provide treatments that could assist inmates in living sustainable lives.
Provide Substance Abuse Treatment to All Inmates:  A Modular Approach
Due to the transient populations in jails and limited funding sources, building optimum and sustainable programs can be a tricky endeavor, but with careful conceptualization and planning this can be addressed with a modular structure as suggested by SAMHSA (2005). According to Figure 1, brief, short-, and long-term treatment objectives can be addressed and be based on the length of stay for many inmates. This would include all inmates whose stay is over one week long and could begin immediately.   

Providing Spatial Units Specifically Devoted to Treatment
Keeping isolated and specific treatment center units within jails separated from the rest of the population would be beneficial to clients and improve outcomes. These units would provide insulation that promotes privacy and are in line with best practices for treatment efficacy (SAMHSA, 2005).

Continuity of Care
Continuity of care for inmates releasing from jail is of paramount importance for many inmates receiving substance abuse treatment in jail. Individuals releasing from jail have significant risk for treatment dropout rates, which increases risk of relapse, recidivism, and even suicide. Meeting inmates prior to their release to coordinate and support transitional services is an important first step to increase the chance of a successful continuity of care. For example, Gateway Corrections in St. Louis, Missouri has begun to send recovering and formerly incarcerated staff members to meet inmates in Missouri the day of their release, which has shown to be an effective remedy to providing continuity (S. Doherty, personal communication, March 6, 2017).

Drug Courts
Many drug court studies have shown significant positive results in recidivism rates (SAMHSA, 2005; Marlowe, 2003). For example, in Clark County, Nevada, there was at least a 12 to 14 percent difference for those who participated in drug courts compared to those who did not over a three-year period (Goldkamp, White, & Robinson, 2001). The actual recidivism percentages of individuals participating in drug courts were significantly less than the 80 percent recidivism rate for other inmates who were released from jails or prisons (SAMHSA, 2005). Diverting inmates away from jails and/or prisons, especially those with drug crimes, is and will continue to be an incredibly sustainable endeavor. As such, building capacity to divert more drug users into drug courts could have positive outcomes on individuals, their families, and society.
Summary and Conclusion
Jails are filled with many individuals struggling with SUDs and less pathological but still serious substance abuse issues. Criminalizing illicit substances and those in possession of them incites a punitive response to what is really an issue of mental and public health. Currently, most inmates are not receiving the kind of care that can promote lower rates of recidivism and relapse. There is limited funding for substance abuse treatment in jails for reasons such as community perception, conflict between criminal justice and public health perspectives, and an overall lack of public knowledge when it comes to how substance abuse treatment mitigates criminal behaviors. There is also an absence of public knowledge related to the high turnover rates that occur in jails, problems that those in custody have (e.g., substance abuse and mental health disorders), and the high social and financial cost of not treating these issues (SAMHSA, 2005).
An alternative approach to nonviolent drug offenders could be framed from a public health perspective. This perspective often sees individuals with SUDs abusing substances as a way of self-medication or maladaptive coping. An appropriate treatment response would be to provide adequate rehabilitative opportunities such as psychoeducation to those utilizing harmful coping strategies while incarcerated. As such, getting these inmates the treatment they need to live free of the cyclical criminal justice system begins by reframing the substance abuse problem. Continued research on the impact of substance abuse treatment in criminal justice institutions and educating the general public and policymakers may accelerate systemic change in how we can provide substance abuse treatment to offenders. Because jails can serve as an optimum intervention point (e.g., referral services, direct services) for people struggling with substance abuse issues, finding coordinated and streamlined ways to implement care is of extreme importance to individuals and society.

About the Authors
Sarah Phillips, MSW, MPH, graduated in 2017 from the Brown School of Social Work at Washington University in St. Louis. Prior to graduate school, she taught high school math in Jackson, Mississippi. While at the Brown School, she completed social work and public health fieldwork with the Missouri State Public Defender, ArchCity Defenders, and the Federal Public Defender of the Eastern District of Missouri. She is currently the diversion coordinator at the St. Louis Circuit Attorney’s Office.
Jacob Eikenberry, MSW, graduated May 2018 from the Brown School of Social Work at Washington University in St. Louis with a concentration in criminal-justice-involved populations while specializing in system dynamics. He is currently working at the Clark-Fox Family Foundation designing, recruiting, training, and facilitating presentations to leaders across the State of Missouri about the impact of mass incarceration on individuals, families, and communities.
Sara Beeler-Stinn, LCSW, MPA, is a NIDA TranSTAR predoctoral fellow at the Brown School of Social Work at Washington University in St. Louis. She has direct practice experience in community engagement, case management, behavioral health counseling, grant management, and quality improvement. Her research interests focus on women at the intersection of substance abuse, trauma, and the criminal justice system.
David A. Patterson Silver Wolf, PhD, is an assistant professor at the Brown School of Social Work at Washington University in St Louis. He is faculty scholar with Washington University’s Institute for Public Health and director of the Community-Academic Partnership in Addictions (CAPA).

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