Improve Recovery Support for People in the Criminal Justice System

 

Introductory Paragraph

Substance use is common among justice-involved individuals. More than half of those in US prisons and jails meet the criteria for substance use disorders (SUDs). As the opioid epidemic unfolds, correctional institutions are looking for best practices that they can use to help handle the increased demand for substance abuse and addiction treatment, including diversion, treatment/drug courts, treatment while incarcerated, and re-entry services and resources. Ongoing research has suggested that substance use can be associated with poorer outcomes among individuals who have been incarcerated, including those under supervision in the community. A study by Pew Trusts study shows that more imprisonment does not reduce drug related issues. This study reinforces a large body of prior research that cast doubt on the theory that tough prison terms deter drug misuse, distribution, and other drug-law violations. The evidence strongly suggests that policymakers should pursue alternative strategies - that research shows work better. Many states are revising their drug penalties and focusing on prevention, treatment, and recovery to integrate evidenced-based practices for treatment and recovery. Implementation of evidenced-based practices allows criminal justice agencies and communities to work together to save lives and decrease costs associated with criminal justice system and healthcare system involvement. Many individuals return to communities, social networks and families and require mental and/or physical healthcare services. Community-based behavioral health systems have an essential role in serving individuals with mental and substance use disorders who are currently or formerly involved with the criminal justice system. These individuals are a part of every community and providing resources to a person with a SUD can help lead to a life in recovery as opposed to a life in long-term incarceration.

Key Information

Community-based behavioral health providers play a key role in ensuring that every individual they serve has the treatment, support, skills, and opportunity for recovery and that they live productively with dignity and respect. People who simply need access to quality community-based care may be arrested instead. In many communities, people with behavioral health disorders cannot access adequate community-based services and find themselves channeled into the justice system. This may happen when a person is arrested for behaviors related to their untreated mental illness or when a law enforcement officer believes that a person could benefit from healthcare services that are provided in the jail. Arrest and even brief incarceration can destabilize an individual’s life in many ways, including housing, health care, employment, and disruptions in family life and social connections. Once in the criminal justice system, individuals with mental and substance use disorders stay in jails longer, have an increased risk for self-harm, and receive more frequent punitive responses to infractions. Due to funding and staffing limitations, many people with mental illnesses do not receive the services that they need, and their conditions often worsen inside jail settings. For individuals already receiving medications and treatment in the community, these services may be interrupted during incarceration, creating lapses in treatment and difficulties in resuming treatment upon reentry to the community. Without continuous coordinated care throughout and following incarceration, these individuals are at risk for re-incarceration. Programs to improve outcomes of those in recovery within the criminal justice system includes community-based diversion programs, drug/treatment courts, treatment while incarcerated, and re-entry resources and services. For more detailed information on re-entry, please see the SAFE wiki titled "Improve Reentry After Incarceration."

SAMHSA's 8 Principles

The Substance Abuse and Mental Health Services Administration (SAMHSA) identified eight principles to assist community-based behavioral health providers and criminal justice professionals to collaborate most effectively. These principles provide a strong foundation for understanding re-entry programs, evidence-based practices, the risk of recidivism, pre-arrest and diversion programs, and medication assisted therapy:

• Community providers are knowledgeable about the criminal justice system. This includes the sequence of events, terminology, and processes of the criminal justice system, as well as the practices of criminal justice professionals.
• Community providers collaborate with criminal justice professionals to improve public health, public safety, and individual behavioral health outcomes.
• Evidence-based and promising programs and practices in behavioral health treatment services are used to provide high quality clinical care for justice-involved individuals.
• Community providers understand and address criminogenic risk and need factors as part of a comprehensive treatment plan for justice-involved individuals.
• Integrated physical and behavioral health care is part of a comprehensive treatment plan for justice-involved individuals.
• Services and workplaces are trauma-informed to support the health and safety of both justice-involved individuals and community providers.
• Case management for justice-involved individuals incorporates treatment, social services, and social supports that address prior and current involvement with the criminal justice system and reduce the likelihood of recidivism .
• Community providers recognize and address issues that may contribute to disparities in both behavioral health care and the criminal justice system.

Drug Treatment & Specialty Courts

In the late 1980s, justice-system professionals began to recognize the importance of treating substance use and mental health to prevent relapse and recidivism. Innovative approaches, such as drug courts, began to emerge. Drug courts aim to reduce drug use relapse and criminal recidivism through a variety of services. These services include risk and needs assessment, judicial interaction, monitoring and supervision, graduated sanctions and incentives, treatment, and various rehabilitation services. As of today, there are more than 3,000 drug courts across the United States. Drug courts consist of juvenile, adult, and family treatment (aimed at family parenting and reunification of families). Overall, the drug court approach intends to reduce time in the criminal just system and provide treatment to individuals instead of punishment.

There are also Veteran Treatment Courts that are specifically aimed at working with veterans. These are served by judges who understand veteran behavioral health challenges and are familiar with the Veterans Health Administration. Veteran Treatment Courts are one type of what is referred to as a specialty court. These include Family Drug Treatment Courts, DUI/DWI, Mental Health, Juvenile, Tribal, Opioid and Re-entry Courts. Additional information on specialty courts may be found at the SAFE wiki titled "Expand and Enhance Specialty Courts."

Pre-Arrest Diversion & Deflection Programs

These two types of program are related, but distinct. Deflection is the practice by which law enforcement or other first responders, such as fire and EMS, connect individuals to community-based treatment and/or services when arrest would not have been necessary or permitted. This is done in lieu of inaction when issues of addiction, mental health, and/or other needs are present. Deflection is performed without fear by the individual that if they do not “accept the deflection” they will subsequently be arrested. Pre-arrest diversion is the practice by which law enforcement officers connect individuals who otherwise would have been eligible for criminal charges to community-based treatment and/or services, in lieu of arrest. This diverts them from the justice system into the community. Some pre-arrest diversion programs have policies that mandate holding charges in abeyance until treatment or other requirements, such as restitution or community service, are completed, at which time the charges are dropped. Although pre-arrest diversion is facilitated by justice system stakeholders (usually police and sheriffs), clients are diverted to community-based services. Pre-arrest diversion programs should not be confused with prosecutorial diversion, which occurs after individuals have already been arrested and become involved in the justice system. In contrast, pre-arrest diversion occurs before the filing of charges.

Pre-arrest diversion programs are designed to reduce the number of persons who are arrested and placed in jail because of a mental health problem, these programs shift responsibility for rehabilitation from the criminal justice system to the mental health system. Early diversion programs provide an alternative to arrest for individuals with substance use and/or mental health disorders, as well as for low-risk offenders. They allow these individuals to avoid the collateral consequences that result from arrest and contact with the criminal justice system. The movement for early diversion is data-driven and is grounded in the belief that public safety and public health approaches must work in tandem to support vulnerable individuals with substance use disorder and/or mental illness. Instead of shifting responsibility or cost from one system actor to another, this collaborative approach creates additional tools and supports for those on the front line. It provides appropriate treatment for eligible individuals. It opens up community opportunities for systemic change by leadership looking for creative solutions to complicated problems. Thus, these programs serve the best interest of the individuals involved, the community, and taxpayers. A variety of case studies provide documentation of the following beneficial outcomes of pre-arrest diversion and deflection programs:

• Break the costly cycle of justice system involvement for eligible individuals.
• Increase cross-sector collaboration to create new pathways to community-based behavioral health services.
• Enhance relations between community members and law enforcement.
• Decrease crime, incarceration, and recidivism rates.
• Lessen the burden on justice systems.
• Improve public health and safety.
• Reduce the burden on individuals who commit non-violent, low-level offenses.
• Ensure equal access to pre-arrest diversion regardless of race, income, or geography; and
• Save taxpayer dollars

Additional information on early diversion can be found at the SAFE wiki titled "Expand Law Enforcement Assisted Diversion and Deflection Programs."

The Sequential Intercept Model (SIM)

SIM helps communities identify resources and gaps in services at each of six "interception points." The SIM mapping process brings together leaders and different agencies and systems to work together to identify local strategies and action plans to divert people with mental and substance use disorders away from the justice system into treatment. The six SIM intercepts are described below:

• Community Services. This involves opportunities to divert people into local crisis care services. Resources are available without requiring people in crisis to call 911, but sometimes 911 and law enforcement are the only resources available. The emphasis is on connecting people with treatment or services instead of arresting or charging them with a crime.
• Law Enforcement. At this point diversion performed by law enforcement and other emergency service providers who respond to people with mental and substance use disorders. It allows people to be diverted to treatment instead of being arrested or booked into jail.
• Initial Court Hearings/Initial Detention. This involves diversion to community-based treatment by jail clinicians, social workers, or court officials during jail intake, booking, or initial hearing.
• Jails/Courts. This interception involves diversion to community-based services through jail or court processes and programs after a person has been booked into jail. It includes services that prevent the worsening of a person’s illness during their stay in jail or prison.
• Reentry supports reentry back into the community after jail or prison to reduce further justice involvement of people with mental and substance use disorders. It includes reentry coordinators, peer support staff, or community in-reach to link people with proper mental health and substance use treatment services.
• Community Corrections. This involves community-based criminal justice supervision with added supports for people with mental and substance use disorders to prevent violations or offenses that may result in another jail or prison stay.

Medication-Assisted Treatment (MAT)

MAT can be utilized for drug-dependent individuals within the criminal justice populations. Currently, within the criminal justice system, MAT is used primarily for pregnant women to detoxify and is minimally used for reentry. There are ongoing studies surrounding MAT, as well as efforts to expand the use of MAT within the current correctional infrastructure. Efforts to expand MAT include training, education, reducing stigma, and increasing funding. Expansion of MAT within community correctional settings will also require increased collaboration with community providers in order to enhance the appropriate pharmacotherapy for individuals under community correction supervision. Concerns of correctional facilities surrounding MAT have included liability, staffing, regulation, and funding. More information can be found at the SAFE wiki article titled, "Expand the Use of MAT/MAR in Correctional Facilities."

Relevant Research

• Impact of Mature Drug Court over 10 Years of Operation: Recidivism and Costs -- This study examined the impact and costs of a primarily pre-plea drug court on the total population of drug court-eligible offenders over a 10-year period in Portland, Oregon. Results included reduced recidivism for drug court participants up to 14 years after drug court entry compared to eligible offenders that did not participate. Drug court judges that worked longer with the drug court had better participant outcomes. Judges that rotated through the drug court twice had better participant outcomes the second time than the first. Compared to traditional criminal justice system costs, there was an average of $1,392 lower cost per drug court participant. Reduced recidivism and other long-term program outcomes resulted in public savings of $79 million over 10 years.

• Evaluating Treatment Drug Courts in Kansas City, Missouri and Pensacola, Florida: Final Reports for Phase I and Phase II Using retrospective data, researchers found that drug courts reduced recidivism among program participants in contrast to comparable probationers. This study found that within a two-year follow-up period, the felony re-arrest rate decreased from 40 percent before the drug court to 12 percent after the drug court started in one county, and the felony re-arrest rate decreased from 50 percent to 35 percent in another county.

• Criminal Justice Drug Abuse Treatment Studies (CJ-DATS). This study surveyed criminal justice agencies affiliated with the CJ-DATS to assess the use of MAT. It summarizes factors influencing use of MAT by survey responses according to availability, barriers & intentions.

Impactful Federal, State, and Local Policies

SAFE Project is dedicated to providing communities with the most relevant and innovative materials. We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration and will add additional resources.

Available Tools and Resources

• American Acadamy of Addiction Psychiatry. Cultivating Law and Medicine Partnerships to Support Justice-Involved Individuals With Substance Use Disorders – Digital Guide.

• Comprehensive Opioid, Stimulant, and Substance Use Program (COSSUP). The website offers profiles of COSSUP sites across the nation, information on COSSUP demonstration projects, and access to technical assistance and peer-to-peer learning opportunities.

• National Drug Court Resource Center provides evidence-based practice standards set forth by subject matter experts, researchers, and policy makers. Their website also includes resources associated with a variety of different types of courts.

• Opioid Response Network Community Supervision and MOUD Toolkit: A free online learning series to help probation officers and treatment providers enhance client recovery during supervision.

• Police, Treatment and Community Collaborative (PTACC) provides a webinar titled "Starting Your Pre-Arrest Diversion (PAD) Effort: Law Enforcement, Behavioral Health, and Community Together." This provides information on pre-arrest diversion models.

• SAFE Project through collaboration with PTACC has published "Law Enforcement Pre-Arrest Diversion Guide." This guide contains coverage of a variety of diversion pathways and several case studies.

• SAMHSA has published "After Incarceration: A Guide to Helping Women Reenter the Community." This guide was created for individuals who provide or coordinate reentry services for women involved in the criminal justice system, including corrections staff, reentry organizations, substance use disorder and mental health treatment providers, reentry specialists, and peer specialists.

Promising Practices

A Way Out (Lake County, IL) “A Way Out” is a Lake County, Illinois Law Enforcement Assisted Diversion (LEAD) pilot program, designed to fast-track users to substance abuse programs and services. This program is available 24 hours a day, 7 days a week, at participating police departments across Lake County. It ensures that no criminal charges will be sought for those who may be in possession of narcotics or paraphernalia, if assistance is sought out by the prospective program participant. “A Way Out” is a program developed by the Lake County Opioid Initiative to create additional treatment access points, reduce crime, reduce substance-related harms, re-frame the role law enforcement plays in community safety, and unite the community. For too long, substance use has been stigmatized and dealt with as a criminal issue. Substance use is a public health problem that needs to be addressed as such. Lake County Opioid Initiative is committed to developing innovative ways to create positive change regarding substance use and mental health.

The Hope Initiative (Nashville, NC) The HOPE Initiative was the first pre-arrest diversion program in North Carolina. Its purpose is to assist those individuals with substance use disorder find treatment options, get into treatment, and begin recovery. While other programs were centered on opioids, the HOPE Initiative was willing to accept any substance use disorder. Partnerships were established with the local district attorney’s office, the Eastpointe Local Management Entity, UNC Nash Hospital, Coastal Plain Hospital (Detox facility), Police Assisted Addiction and Recovery Initiative (PAARI), and many others. The program allows individuals to come to the Nashville Police Department to start their recovery process by turning over any drugs and/or paraphernalia without fear of charges. The first organization in the HOPE Initiative served 320 clients in 2 years. The program is funded through donations, grants, and fundraisers.

Plymouth County Outreach (Plymouth County, MA) Plymouth County Outreach (PCO) was developed through the Public Safety, Community Coalition, and the Faith Based Subcommittees of the Plymouth County Drug Abuse Task Force. Since its inception, PCO has fostered an innovative law enforcement/non law enforcement collaboration which includes faith-based coalitions, the District Attorney’s Office, The Sheriff’s Department, all 27 police departments, 5 major hospitals, the Division of Children and Families, recovery coaches, District Court Probation, and the Police Assisted Addiction and Recovery Initiative (PAARI). The two main aspects of the program are overdose follow-up and community drop-in centers. Within 12-24 hours of an overdose, an outreach team consisting of plainclothes officers, a licensed clinician, and/or a recovery coach will conduct a home visit of the overdose survivor. The intent of the outreach effort is to provide resources and support to those with substance use disorders and/or their families with the hope of getting people into treatment and connecting family/friends with existing resources in the county. Drop-in center are held each week in various sites across Plymouth County. These centers host a growing number of health care providers who help with treatment options and train and distribute Narcan for free.

Arlington Opiate Outreach Initiative (Arlington, MA) This community-based strategy has two major components. First is the proactive outreach to known substance users. This involves the police department clinician reaching out to the known population of persons with substance use disorders to support them in developing a plan to ensure their survival, to provide access to services, and to facilitate the long-term process of recovery. The second component is the Arlington Community Training & Support (Arlington ACTS) which involves a series of community-based meetings. These are co-facilitated by the police department’s clinician and a community substance abuse intervention expert and are aimed at creating a supportive non-judgmental environment for substance users and their families.

Drug Abuse Response Team (Toledo, OH) The Lucas County Sheriff’s Office developed the Drug Abuse Response Team (DART) model. Lucas County credits it with diverting more than a thousand people from the criminal-justice system and into treatment during its first 4 years. 70% of participants successfully entered detox and treatment programs. The Ohio legislature has since approved a pilot grant program to assist other Ohio counties in implementing a DART program. 39 programs received grant funding for 21-month-long pilots. The Lucas County DART program has over 20 officers from several area law enforcement agencies, including Toledo PD, the Sheriff’s Department, and the Division of Children and Families. Each officer works with parents with substance use disorder whose children have been put in foster care, in order for parents to get access to treatment so that the family can be reunited.

Quick Response Team (Hamilton County, OH) The Hamilton County Heroin Task Force partnered with law enforcement, fire departments and social workers to create a team that follows up with overdose victims and offers them addiction treatment. The goal is to have a first responder follow up with overdose victims within the “recovery window” (72 hours after an overdose reversal) and to provide a warm hand off to treatment options. Teams work to find overdose survivors using a database maintained by the Greater Cincinnati Fusion Center, a public safety data-collecting agency. Teams also use “predictive analysis” to track drug activity to target potential overdoses with the help of University of Cincinnati’s Institute of Crime Science. QRT has since been launched as a national model.

Law Enforcement Assisted Diversion (King County, WA) Law Enforcement Assisted Diversion (LEAD) is a pre-booking diversion program developed in King County, Washington to address low-level drug and prostitution crimes in Seattle and King County. The program allows law enforcement officers to redirect low-level offenders engaged in drug or prostitution activity to community-based services, instead of jail and prosecution. By diverting eligible individuals to services, LEAD is committed to improving public safety and public order and reducing the criminal behavior of people who participate in the program. The King County LEAD program has evolved to a national model with a national support organization, the LEAD National Support Bureau, which assists departments in establishing LEAD programs.

Stop, Triage, Engage, Educate and Rehabilitate (Montgomery County, MD) The STEER Program in Montgomery County, MD, is a pre-booking law enforcement and drug treatment and recovery linkage program that aims to provide rapid identification, deflection, and access to treatment for drug-involved individuals as an alternative to conventional arrest. Individuals are assigned a care-coordinator who focuses on rapid treatment access, retention, motivation, engagement, and completion and conducts a full clinical assessment and referral. Police officers use a screening tool to decide whether a person is a candidate for this deflection. The risk assessment may be used by a police officer who is responding to a call for service or in an on-view situation. Charges can be held in abeyance while the person is seeking services. STEER operates around the core value proposition of deflection, namely ensuring the “correct” movement of citizens either into the criminal justice system or away from it. As a result of moving people towards the human services system, STEER exemplifies the following outcomes:

• reducing crime
• (re) building community relations
• reducing drug use
• restoring the lives of citizens

Pre-Arrest Diversion/Adult Civil Citation (Leon County/Tallahassee, FL) As a model pre-arrest diversion program, the Leon County/Tallahassee PAD/ACC program holds offenders accountable for their crime; but, instead of being arrested and prosecuted by the traditional criminal justice system, the person receives civil sanctions, e.g., community service, and behavioral health intervention services. Following referral by law enforcement, one essential elements of the program is the use of evidence-based behavioral health intervention services to reduce the likelihood of future criminal activity. The PAD/ACC program also works to avoid an arrest record for those who successfully complete the program. The decision to arrest or refer for behavioral health assessment and intervention services is best made by the law enforcement officer who is on the scene and understands the nature of the offense at the time it occurred. Since its inception, the Leon County/Tallahassee PAD/ACC program has had over 1300 participants. The Civil Citation model has grown throughout the State of Florida. Today the Civil Citation Network (CCN) assists communities in implementation of the Civil Citation model.

Crisis Intervention Teams (Memphis, TN) The Crisis Intervention Team (CIT) program is a community partnership working with mental health consumers and family members. Officers are part of a specialized team which can respond to a crisis at any time, and they will work with the community to resolve each situation in a manner that shows concern for the citizen’s well-being. The CIT is made up of volunteer officers from each Uniform Patrol Precinct. CIT officers are called upon to respond to crisis calls that present those officers, face-to-face, with complex issues relating to mental illness. CIT officers also perform their regular duty assignment as patrol officers. The Memphis Police Department has 268 CIT officers who participate in specialized training under the instructional supervision of mental health providers, family advocates, and mental health consumer groups. Due to the training, CIT officers can, with confidence, offer a more humane and calm approach. These officers maintain a 24/7 coverage.

Virginia Recovery and Re-Entry Project. The VRR Project serves individuals with SUDs during incarceration and through the re-entry process, with a peer-to-peer approach to recovery. The McShin Foundation and SAMHSA’s Building Communities of Recovery Initiative funded two new recovery jail programs in Riverside Regional Jail and Rappahannock Shenandoah Warrenton (RSW) Regional Jail. Recovery support services are provided five days a week in RSW and three days a week in Riverside. In follow-up to participation in these VRR programs, residential recovery program scholarships were offered to twenty individuals. VRR uses a wide variety of resources to promote long-term recovery support networks and services.