A debate rages between the penal system and the mental health system. The question is how we handle addicted individuals who commit nonviolent crimes (such as carrying illegal substances). At the core of the debate, it’s rehab vs. prison for addiction having a showdown. But this debate is often held away from the plethora of research and evidence that we now have. A disturbing statistic about modern American society is that we incarcerate a greater percentage of our population than any other country in the world. About 2.3 million Americans are in prison. Many experts would say it is the war on drugs that has led to such a huge prison population. Mandatory minimum sentencing laws have led to the incarceration of millions of minor drug offenders, drug addicts and the mentally ill. Should we be treating these people as criminals or patients? What benefits society most? The primary goal of the American legal system is to keep society safe. So how do we keep addicts from breaking laws and harming others? We believe the answer is in comprehensive, evidence-based addiction treatment.
Addicts as Criminals
Some statistics show that as many as 65% of the incarcerated population is addicted to drugs. Instead of rehab, imprisoned addicts do time. In fact, only about 11% of these inmates get any kind of treatment for their addictions. They waste time and come out of prison without the necessary skills to be sober or to live a lifestyle that doesn’t include drugs and illicit activities. The main culprit in incarcerating so many addicts is the Sentencing Reform Act of 1984. Legislators had good intentions when passing the law. They wanted to take discretion in sentencing away from judges because there were huge discrepancies among similar cases. Unfortunately, it led to a similar law in 1986, the Anti-Drug Abuse Act, which imposed mandatory minimum sentences for drug crimes. Judges are given little freedom to exercise leniency. Only in a couple of instances, such as cooperation with the government, can a judge reduce the minimum sentence. Mandatory minimum sentencing for drug crimes was spurred by the crack epidemic of the 1980s. The drug was new and terrible and it led to a lot of crime, including violent crime. However, the inability of judges to exercise leniency, or to sentence minor offenders to treatment instead of time in prison, has led to unprecedented numbers of addicts in prison. Most of these addicts have committed non-violent crimes.
The Cost of Rehab vs. Incarceration
For the government, cost is always a consideration. However, the cost-effectiveness of rehab vs. incarceration is striking. The average annual cost to incarcerate someone is $24,000. In contrast, the cost of drug rehab is around $4,700. Any argument in favor of prison, instead of rehab, based on cost is baseless. Since most drug addicts receive no addiction treatment whatsoever while incarcerated, prison leaves society still needing to pay the cost of addiction rehab after paying for prison. It is estimated that the cost of drug abuse to society is $193bn. But, the cost of drug abuse treatment is $14.6bn. This means that funding drug addiction treatment is extremely cost-effective in the grand scheme of things. Drug rehab can reduce costs in the following areas:
- Health care
- Lost productivity
- Crime
- Incarceration
- Victimization – a former drug addict who stays sober as a result of addiction treatment won’t harm others to feed an addiction
Other studies have shown that prioritizing rehab instead of prison could save billions of dollars.
Detoxing in Rehab vs. Prison
Detoxing in prison is an unpleasant experience for many addicts. It may include suffering through withdrawal symptoms with no medical care and supervision. This can be a painful experience to have to go through. Going through withdrawals without proper treatment can also increase the risk of relapse if drugs are available in prison, which is quite common. In many prisons, inmates with opioid use disorders do not get the medication they need for withdrawals. Many will receive clonidine, which can help with some physical withdrawal symptoms, such as chills and agitation. But it is not as effective as methadone and buprenorphine in the treatment of opioid addiction. Detoxing at a drug rehab center, in contrast, is quite a different experience. During a medical detox at an addiction treatment facility, a specialized team makes sure that the patient’s physical and mental health is taken care of. They receive round-the-clock supervision and care. A drug rehab team also provides the most effective medication for managing withdrawal symptoms.
Rehab Programs in Prison
One alternative to the rehab vs. prison debate is rehab in prison. Research shows that treating prisoners’ drug addiction during and after incarceration helps to keep them sober, out of prison and employed. Spending less on drug rehab programs in prison can result in greater costs in the long-term. This is because drug-addicted inmates may fall into a pattern of addiction again upon release. They are also more likely to commit further crimes and to be out of work. Other studies demonstrate that drug rehab in prison reduces re-incarceration rates in repeat offenders. In addiction rehab, a recovering drug addict can focus solely on getting sober. In prison, on the other hand, drug rehab is not a priority. This means addiction treatment can be incomplete and not specific to the individual’s needs. Prisons have a bad track record when it comes to providing high-quality health services. This is because, as a court in California ruled, prisons are too overcrowded. In 2011, the California prison population was double what the prison system was designed to handle. The court ordered prisons to significantly reduce the number of inmates. However, overcrowding is still a huge issue in Californian correction facilities. The sheer number of people incarcerated in prisons in California means that inmates do not receive adequate healthcare. The result of this means that many inmates (including those not on death row) die while in prison and continue to suffer from poor mental health. A prison’s drug rehab program may lack the comprehensive approach found in an addiction treatment facility. For instance, a prison may lack mental health professionals needed to address the root causes of addiction. Addicts miss out on the wide range of evidence-based treatments that are in many well-equipped drug rehab centers. For instance, a study found that less than 20% of prisoners with drug abuse problems received formal treatment in prison. Sarah Wakeman, assistant professor of medicine at Harvard University, says that “addiction care [in the US prison system] doesn’t meet community standards.” In prison, inmates may be offered clonidine for detoxing, as we have seen. But most prisoners with opioid addiction do not receive methadone maintenance treatment. Only a minority of inmates (in both state and federal prisons) participated in effective support groups, such as Alcoholics Anonymous. Many prisons lack the therapies that have been shown to help recovering addicts stay abstinent. These therapies include cognitive therapies that teach coping skills, motivational therapies, reentry programs to help inmates reintegrate back into society, and community-based treatment.
The Success Rates of Rehab vs. Prison
Without drug addiction treatment in prison, a high percentage of inmates will relapse and commit further crimes. The Bureau of Justice Statistics show that less than 1% of inmates with drug problems in state prisons get help detoxing. Also, only 6.5% receive drug counseling, and 0.3% get medication to help them maintain abstinence from their drug of abuse. This is why so many inmates relapse upon release. One study found that, for prisoners released in Washington State, overdose mortality rates were 12-fold higher than what you would see in the general population. Accidental overdoses were responsible for a quarter of all deaths post-release. These overdoses involved cocaine, opioids, alcohol, and multiple drugs used in combination. Researchers say inmates often relapse after prison because they return to stressful environments that trigger a relapse. These researchers recommend that inmates who leave prison need structured drug treatment programs and reduction of environmental triggers to prevent relapse. Studies demonstrate that addicted inmates who stayed on methadone while they were locked up were twice as likely to continue rehab treatment upon release. In contrast, those who went through methadone treatment in prison were more likely to abuse heroin or other opioids when they left prison. One study discovered that inmates who received methadone treatment in prison were 32 times more likely to continue with such treatment one day after release. 30 days after release, 41% of inmates were still visiting a community-based methadone provider. Methadone therapy reduces drug abuse, crime, HIV and overdose. Unfortunately, most prisons don’t provide addicted inmates with methadone. This is due to a variety of reasons. Firstly, for prisoners already taking methadone, some prisons will quickly taper them off the drug because they view the substance as highly addictive. Prisons may also force an inmate to stop using methadone without any tapering. There are also logistical challenges in offering methadone. To provide methadone, a prison has to have a license to act as a methadone clinic or partner up with a community clinic. But sometimes, the nearest methadone clinic could still be very far away, which makes methadone treatment for inmates impractical. Also, a particular county may not have a doctor with a license to provide methadone treatment. When inmates don’t have access to effective medication for addiction, this increases the likelihood of relapse. In an addiction treatment facility, a comprehensive mental health team works to prevent relapse. Moreover, they also provide addicts the tools and resources for dealing with relapse in a healthy manner if it does occur. Drug addiction treatment can be a long-term process that requires constant modification, because drug addiction is a chronic disease. If we incarcerate drug addicts without drug rehab, then they lose the opportunity to gain the coping skills to start fighting addiction on their own.
Does the Criminal Justice System Do Better with Mental Illness?
The mentally ill don’t fare much better when it comes to law enforcement and the court system. In many ways, the issue is related to drug offenses. Many drug abusers and addicts also struggle with mental illness. We treat neither addiction nor mental illness in prisoners to any great extent. In some cases, a mentally ill prisoner has had nothing to do with drugs. We arrest them for a crime instead of treating them for a mental health condition. Police often arrest mentally ill people because they lack the training and education to recognize or to deal with someone struggling with a mental condition, such as psychosis. Resources for mental health education, training and preparation are severely lacking in law enforcement. The mentally ill are more vulnerable than other inmates to police violence. It is estimated that half of people shot or killed by police have a mental health issue. Once in prison, the mentally ill, like drug addicts, do not receive treatment. They are often the victims of abuse in prison, because they act out, break the rules or disturb other inmates.
Addictions and Mental Health Illnesses Are Illnesses that Require Treatment
The statistics and facts of rehab vs. prison are clear: mental illness and drug addiction have been criminalized in this country. Instead of entering the criminal justice system, these people need mental health treatment. Also, as we have seen, research shows that when looking at rehab vs. prison, punishment wastes money and often fails to meet an addict’s (or society’s) needs. Both mental illness and addiction are medical conditions that require medical care. Those suffering won’t find what they need in prison, and they won’t get treatment until our system changes.