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Balancing Health and Criminal Justice Goals for Substance Abusing Offenders

— Elizabeth A. Peyton, Bruce Fry, and the Honorable Richard S. Gebelein. Beth Peyton is a private consultant and former Director of Delaware's Treatment Access Center, a TASC program that supports a drug court. Bruce Fry is the Project Director of the CSAT Criminal Justice Treatment Networks Program, Johnson, Bassin & Shaw, Inc. Judge Gebelein is an Associate Judge of Delaware's Superior Court and former Attorney General. As chairman of the Delaware Sentencing Accountability Commission and Treatment Access Committee, he led the development of Delaware's statewide Drug Court and the effort to expand substance abuse treatment for offenders.

A significant percentage of public clients in any community are offenders with substance abuse problems. The growing acceptance of managed care raises a number of important issues concerning the treatment and control of offenders in the community. These issues need to be seen within the context of the very different outcome goals of the criminal justice and health care systems.

Managed care in the private and public health sectors has achieved prominence because of the Nation's skyrocketing health care costs. Simultaneously, crime and violence in our society have put the public increasingly at risk. The costs of crime for the Nation are staggering. We have responded with dramatic increases in jail and prison expenditures that threaten to impoverish our State and local governments. Yet we have not seriously examined how to obtain public safety in a cost-effective way.

Advantages of a

Collaborative Approach

The high costs of public safety and crime are issues as important for our Nation as the quality and cost of health care. With substance-abusing offenders, these two high-cost, high-profile issues come together. Pairing health care and public safety offers a tremendous opportunity to address collaboratively the health and criminal justice issues of offenders in innovative ways. Such collaboration could create dramatic savings in public safety, crime, and health expenditures, while at the same time improving public health and safety outcomes.

This collaborative approach is necessary for success because a high percentage of substance-abusing public clients are involved with the criminal justice system. Consequently, any effective managed care program for public clients must work with the criminal justice system. Over the last 20 years, we have learned how to treat offenders more effectively by combining accountability and treatment in a completely new approach, which currently bears very little relationship to the medical model of treatment. Research has documented that the new approaches are cost effective in reducing substance abuse, crime, and recidivism. For example, a study of publicly funded clients in Oregon showed that every tax dollar spent on treatment produced $5.60 in avoided costs to the taxpayer (see Societal Outcomes and Cost Savings from AOD Treatment, in this issue). Most of the savings in Oregon resulted from impressive reductions in criminal activity and criminal justice costs. During the 3 years following treatment, offenders who completed residential treatment were incarcerated at a rate 70 percent lower than the matched group.

Successfully Treating Addicted Offenders

Experience suggests that the only practical, cost-effective way to treat offenders is to combine the outcome goals of the criminal justice and health care systems. This will require a substantial change in the approach and operation of both systems. It is our view that combining these outcome goals will result in significant improvements over all current approaches for offender treatment and public safety. In several States, criminal justice and health care professionals are beginning to collaborate to address these issues.

Any new model of collaboration needs to build on current knowledge about how best to treat criminal offenders with substance abuse problems. Over the last 20 years, thoughtful legislators and criminal justice policy makers have developed a variety of approaches that integrate a comprehensive continuum of strict accountability options with a comprehensive continuum of AOD treatment options. These programs work because they use sanctions to compel offenders to participate in treatment and hold offenders accountable for their progress. This strategy works best when it occurs within a continuum of effective, often intensive, treatment services.

Study after study has shown that this integrated approach reduces drug use, crime, and recidivism at much lower cost than traditional sanctions or treatment alone. Hundreds of programs using this approach exist around the country in a variety of forms. Such programs include drug courts, Treatment Alternatives for Safer Communities (TASC), criminal justice programs that offer intensive supervision combined with treatment, and modified treatment programs in many settings — residential, day treatment, and outpatient — that focus on offenders and stress accountability combined with treatment.

Costs of Crime to U.S. Society

In 1996, annual victim losses due to crime were $450 billion, according to a report by the National Institute of Justice.1 $105 billion of this total is attributed to tangible costs. $345 billion is attributed to reduced quality of life. These estimates do not include: $40 billion per year to run the Nation's prisons, jails, and parole and probation systems.2 The costs of prosecutors and the courts. Substance abuse is pervasive among people involved in the criminal justice system. Two-thirds of arrestees in 1994 — male and female — tested positive for at least one drug.3

Outcome Goals of the Criminal Justice System

Public safety is now, and must remain, the top priority of judges and other criminal justice professionals. In making decisions related to offenders' sentencing, judges choose among sometimes conflicting policies, including retribution, rehabilitation, deterrence, and incapacitation. Their foremost concern, however, is whether the sentence contributes to public safety.

Some substance-abusing offenders must be placed in prison for long periods of time because of the nature of their criminal acts and their continued threat to public safety. However, a great many substance-abusing offenders can be managed safely in the community, so long as their addiction is being addressed and they are tightly supervised. For these offenders, judges perceive treatment as one part of a network of supervision, in which all components seek to ensure the offenders' recovery and end their criminal activity.

Judges will usually opt to support those treatment recommendations that are most likely to ensure public safety. The criminal justice system, when required to choose, must subordinate cost savings and cost effectiveness to the primary goal of public safety. Judges, for example, may mandate a seriously addicted offender to a residential treatment program, counting on the level of supervision to both support the offender's recovery and the public's safety.

Outcome Goals of

Managed Care

As more public AOD clients are brought into managed care plans, both treatment and criminal justice professionals are concerned that we preserve and expand the existing relationships between the treatment and criminal justice systems. Outcome goals for managed care providers must be examined and adapted to meet the needs of both these systems. McGuirk and colleagues have defined managed care as "various strategies that seek to optimize the value of provided services by controlling their cost and utilization, promoting their quality, and measuring performance to ensure cost-effective outcomes.⁴

This definition is not inconsistent with the criminal justice system's primary outcome goal of public safety. At first glance, the most troubling issue may be the need for "cost-effective outcomes." However, we can redefine cost effectiveness to include criminal justice as well as health outcomes. This would make possible a dramatic shift in how we view the treatment of offenders.

Connecting Court and

Managed Care Goals

The ability to reach satisfactory agreements between the courts and managed care providers is critical in any collaborative approach. Judges can choose to release offenders to community treatment programs in lieu of jail, a decision that saves considerable money. Keeping offenders in jail costs roughly $25,000 per year, versus about $15,000 for residential treatment. To meet the goal of public safety with many offenders, a judge is likely to choose treatment only when it can be combined with reliable, ongoing supervision. The requisite level of supervision may only be possible in a residential treatment program.

The judge's perspective and responsibility is in potential conflict with managed care goals. In the interest of cost-effectiveness, a managed care provider is likely to assign any client to the least intrusive treatment that might work from a medical perspective. This "medical necessity" criterion needs to be modified for criminal justice offenders. The factors that the managed care provider will need to consider include: