CORONADO, CALIF. – Treatment and continuing care are two key components to a chronic care approach to effective recovery for patients with a substance abuse problem.
But in a correctional setting, that basic model faces several challenges and is sometimes impossible to employ, Dr. Jack Kuo said at the annual meeting of the American Academy of Addiction Psychiatry.
Frequent lockdowns, lack of communication between mental health and substance abuse staff, and access to drugs by inmates are just a few obstacles he faces as a staff psychiatrist for the California Department of Corrections and Rehabilitation.
“Many people think that prisoners with substance abuse problems are abstinent because they are in prison,” he said. “Unfortunately, that's not always the case. They have access through various types of smugglings, sometimes through visitors to the inmates, sometimes through guards, sometimes through medical personnel. You do have a number of illegal drugs that make their way into the system.”
Abuse of prescription medications is common, he said, and inmates “will manufacture complaints to get their hands on these products.” A popular drug of abuse is Wellbutrin, “which a lot of them will crush and snort as a cheap stimulant. A lot of them will also use Seroquel or other types of sedating medications.”
Interventions that have been demonstrated in research studies to be effective for drug-abusing offenders include residential substance abuse treatment, cognitive-behavioral therapy, contingency management, and medications. However, treatment must last an average of 90 days to produce stable behavior change, Dr. Kuo said. That's difficult to achieve in a state prison system like California's, where lockdowns because of infighting or gang violence shut down prison yards for months at a time and medications such as methadone, naltrexone, and buprenorphine cannot be used.
In addition, some correctional officers may frown upon efforts to rehabilitate inmates with a history of substance abuse. “They figure, 'hey these people did something that's illegal. That's why they're locked up. Why should they get treatment?' Overcoming those types of attitudes can be fundamental to providing treatment.”
The California Department of Corrections and Rehabilitation provides services to 9,200 inmates in 22 prisons. All programs use the therapeutic community model and are operated by private companies. A report issued in February 2007 by the California Office of Inspector General found that despite an annual cost of $36 million, the state's in-prison substance abuse treatment programs have little or no effect on recidivism.
To improve the current system, Dr. Kuo recommends integrated public health and safety strategies that involve research-based treatment under close supervision, the opportunity to avoid incarceration or a criminal record when possible, and consequences for noncompliance. Treatment that emphasizes contingency management holds the most promise, he said.
“Treatment does not need to be voluntary to be effective,” added Dr. Kuo, who is also a psychiatrist with Promises Treatment Centers in Malibu, Calif. “Strong motivation can facilitate the treatment process. Sanctions or incentives related to family, employment, or the criminal justice system can significantly increase treatment entry and retention rates and the success of drug treatment interventions. It is important to use rewards and sanctions to encourage prosocial behavior and treatment progress.”
Research has shown that using rewards to recognize progress is an effective way to change behavior. “Rewards can take many forms, including certificates of achievement or verbal praise from an authority figure such as a judge,” he said. “Establishing an attitude of 'catching people doing things right' creates a positive environment for fostering and maintaining behavior change.”