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IN NOVEMBER 2000,
CALIFORNIA voters approved the Substance Abuse and Crime Prevention Act:
Proposition 36, an initiative requiring treatment in lieu of incarceration
for non-violent drug offenders. Participants must plead guilty to their
drug charges and agree to undergo treatment. They are then placed on
probation. Those not meeting standards for participation are "deleted"
from the program, and the original sentence is imposed.
Counties have
considerable latitude in implementing Prop 36. Sacramento County's plan
has been developed and monitored by a "multidisciplinary implementation
committee," a cooperative effort between the Sacramento County Drug and
Alcohol Division as lead agency, and the courts, public defender, district
attorney, probation, state parole, and a group of selected local drug
treatment providers. I have been a treatment provider member of this
committee, which has met monthly since early 2001. Hopefully, what follows
accurately represents the process. The conclusions, however, are my own.
Drug treatment is no
different than any other medical or behavioral treatment: it should have
scientific evidence of validity and must be used at the proper dose or
duration.
Over the first three
years of the initiative, the implementation committee has developed a
comprehensive array of treatment services that certainly fulfill the first
criteria. But there have been problems over allowing participants
sufficient time to benefit from these services. In fact, the program has
two somewhat conflicting goals: protecting short-term public safety by
incarcerating those using drugs, and protecting long-term public safety by
giving participants sufficient time to benefit from treatment.
County probation and
the district attorney were very concerned that addicts not see Prop 36 as
a "get out of jail free card," i.e., a license to use drugs with impunity,
potentially endangering public safety. They set very demanding standards
for compliance - so almost half of participants never received even a
minimum effective dose of treatment (three months) prior to being deleted.
Successful drug
treatment is highly correlated with time in treatment, and it takes at
least 3-6 months before any long-term benefit can be measured. Most
patients we routinely treat are too impaired to quickly comply with all
the treatment, urine testing, and probation requirements this program
demanded. Many of the most impaired were deleted very quickly.
As frustrating as the
model was from a treatment perspective, there was a competing need to
assure this major change in policy could be implemented without adversely
affecting public safety. This is a highly politicized issue and safety
problems could jeopardize the whole program.
Our community must
understand the high deletion rate results from the priority given to
short-term public safety, not from treatment failure. Court and probation
monitoring has been intense, and there has been no evidence of negative
community fallout attributable to Prop 36.
Crime is going down
locally and statewide, as are drug arrests. The efforts of probation, the
district attorney, and the judges have shown that Prop 36 can be
implemented, while also protecting public safety.
Those entering Prop
36 programs have longer histories of addiction and longer involvement with
the criminal justice system than anticipated. A majority of drug addicts
have co-existing mental illness. The vast majority of offenders have never
had adequate drug or mental health treatment during years of cycling
through the criminal justice system. It is like incarcerating people for
high blood sugars, and not treating their diabetes. What else could be
expected but years of recidivism?
UCLA researchers
recently reported that half of a group of 20-year-old heroin addicts,
incarcerated in California prisons in the 1970s, were dead 33 years later.
Less than 6 percent of them ever had effective drug treatment. Only 10
percent ever achieved a stable abstinence. A majority were repeatedly
incarcerated, supporting other recidivism data that show arrests and
incarcerations are not answers to long-term public safety needs. Untreated
addicts come out of jail unchanged, and often come out of prison worse
because of traumatic prison environments.
The problem of
severely impaired long-term addicts became apparent when patients who were
schizophrenic, or manic, or depressed, were "deleted" for failing a
compliance standard they could not possibly achieve. Both their drug
treatment and psychiatric care were stopped
Cognitive impairment
is very common among Prop 36 participants, because of toxic drug effects
and the disorganizing effect of untreated mental illness. This is a major
reason why many participants cannot meet our standards. As these cases
came through the system, there was philosophical agreement that some
patients required more flexibility. And the court process became more open
to clinical input documenting overall progress in treatment and mitigating
factors that impaired compliance with the program.
Sacramento's plan is
perhaps unique in the state in the high level of law enforcement funding
and supervision. Of local funds, 27 percent go to the probation department
to support perhaps the most intensive supervision of participants in the
state. In San Francisco County, by contrast, all the money goes to
treatment, and offenders became routine probation cases - as they used to
be in Sacramento prior to Prop 36.
There is a unique
interaction between probation and treatment providers. Officers are
stationed some of the time at the treatment facilities where they directly
supervise probationers. To make this work, officers must support and
function in a more flexible model than traditional criminal supervision.
They must recognize the high incidence of mental illness in this
population. Half of Prop 36 participants have identified mental health
needs on admission, and many more will have needs that become apparent
during treatment.
Officers need to be
sensitive to the deleterious effects of mental illness on recovery from
drugs; otherwise, they may misconstrue problems with compliance as merely
lack of motivation or "conning." Probation officers who support efforts at
recovery, in addition to monitoring for evidence of anti-social behaviors,
can enhance compliance with treatment. This supports both short and
long-term public safety. Local public safety is actually better addressed
under Prop 36 than ever before, because intensive probation supervision is
paired for the first time with public safety effects of treatment.
So, does this program
reduce recidivism (i.e., promote long-term public safety) enough to
justify its costs? The county's "Two Year Evaluation Report" was recently
released. The Criminal Justice Research Foundation compared a pre-Prop 36
group of local offenders with Prop 36 participants and found the
following.
Prop 36 participants
have significantly lower re-arrest and conviction rates. Those arrested
are detained 20 days less in jail, and the length of time between arrests
is nearly double. Most importantly, 71 percent of participants who had
more than 6 months of treatment had no subsequent misdemeanor or felony
convictions. (Each arrest costs $8,000 to process, not counting
incarceration costs. So reductions in arrests, and jail or prison time,
have great potential cost savings).
Sixty-seven percent
of all drug tests are negative, with negative tests increasing to 85
percent after six months in treatment. This is a significant impact on
drug use and demonstrates the correlation between recovery from drugs and
longer time in treatment. Twenty percent of participants successfully
completed treatment. Ten percent had their charges dropped - which
required not just completing 12-18 months of treatment, but also meeting
seven additional probation criteria.
Heroin addicts are
only 10 percent of Prop 36 participants, but, without medical treatment
with methadone, theirs is perhaps the most chronic addiction of all.
Statewide, methadone is still stigmatized by much of the criminal justice
system and not allowed in some jurisdictions despite its dramatic crime
reduction effect. For public safety planning, it is important to document
how heroin addicts fare in a county with methadone available for all who
need and desire it.
Patients referred to
our methadone program average 44 years of age and 21 years of addiction,
compared to a statewide average of 10 years of addiction. They do not
respond to short-term treatment, and rarely respond to treatments that do
not include methadone. Of 239 referrals to our program over three years,
89 percent started treatment and only 7 percent dropped out after entering
treatment. So 82 percent of patients referred for methadone actively
engaged in treatment.
This speaks to a
strong motivation for treatment among opiate addicts. Seventy-five percent
of drug tests of methadone patients were negative for illicit drugs, and
the same linear increase in negative tests over time appeared in the
overall county report. Twenty-percent of our patients completed 18 months
of treatment. Despite longer addictions and high levels of mental illness,
these patients had the same treatment completion rate as other Prop 36
participants.
Eighty percent of
patients were "deleted." They averaged only five months in treatment; most
wanted more treatment and were showing progress. The courts have come to
recognize the need for treatment beyond Prop 36; at times, they have
imposed alternative sentences for patients showing progress, allowing
treatment to continue even after the person was deleted.
These outcomes
support the effectiveness of methadone treatment for chronically addicted
opiate addicts. They also show that methadone treatment can be
successfully integrated into a criminal justice monitoring system. Our
data from the third year of the program show that early deletions from
Prop 36 have significantly decreased, reflecting efforts by the
implementation team to allow more time for treatment.
There have been
complaints in the press from Sacramento police about Prop 36, calling it a
"travesty of justice." Once they arrest someone, officers are out of the
Prop 36 loop. So they fear the worst. Treatment is not an easy concept for
officers trained mainly to recognize intoxication and arrest drug users.
The county should
find a way of involving cops in understanding the local process. Not only
do they devalue the successful efforts of probation and district attorney
to protect public safety, but they miss the important role police play.
Cops often provide the first step in recovery, by arresting an
out-of-control addict. However, without proper treatment, including mental
health care, arrests become part of a futile and costly re-cycling of drug
addicts.
July 1, 2004, ended
the first three years in the five years of funding guaranteed by the
initiative. The Legislature must decide whether to renew funding, but
mandated treatment will continue unless an unlikely two-thirds vote of
legislators changes it.
The multidisciplinary
approach our county has developed will serve our community well beyond the
five years of Prop 36: it is exactly the kind of systems approach required
by a costly and complex behavioral, psychiatric, medical, social, and
legal problem like drug addiction.
Our local Prop 36
approach is working to strike a balance between short-term and long-term
public safety needs. To date the emphasis on short-term public safety has
resulted in a high rate of early deletions. We are now working on ways to
safely maintain patients in treatment for periods more likely to result in
long-term recovery for a larger number of participants.
Nevertheless, the act
has already successfully lived up to its name, by significantly reducing
drug use and demonstrating reductions in recidivism.
This article is published in the 2004 Nov/Dec Vol
55/No6 edition of the Sierra Sacramento Valley Medicine.
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