The Undiagnosed Epidemic of Incarceration

Prison once again a place for addicts and the mentally ill.

Readers may remember the dark day of January 1, 2008, when the U.S. set an all-time record: One out of every 100 adults was behind bars. That’s more than 2.3 million people. That’s 25% of all the prisoners in the world—and the world includes some very nasty nations. What gives?

You know the answer: drug crimes. Can it really be a coincidence that over the past 40 years, ever since President Richard Nixon first declared war on drugs, the number of people housed in U.S. prisons has gone up by more than 600%? Are we really just that much more vicious and larcenous than we used to be? 600% more unlawful than we were as a people in 1971? Last month, a group of medical professionals from the Division of Infectious Diseases at Brown Medical School, and the Center for Prisoner Health and Human Rights, both in Providence, Rhode Island, co-authored an article for the New England Journal of Medicine entitled “Medicine and the Epidemic of Incarceration in the United States.” The investigators conclude that the explosion in the prison population is a direct result of “our country’s failure to treat addiction and mental illness as medical conditions. The natural history of these diseases often leads to behaviors that result in incarceration.” Packed prisons are also the result of a broader movement over the past 40 years to shift the burden of care for addiction and mental illness over to the prison system. “Deinstitutionalization of the mentally ill over the past 50 years and severe punishment for drug users starting in the 1970s have shifted the burden of care for addiction and mental illness to jails and prisons,” the authors argue.

Do the social costs of this massive transfer of addicts and the mentally ill to the U.S. prison system outweigh the benefits? According to the NEJM article by Josiah D. Rich and co-workers, “more than 50% of inmates meet the DSM-IV criteria for drug dependence or abuse, and 20% of state prisoners have a history of injection-drug use.” Rich estimates that up to a third of all heroin users pass through the criminal justice system each year. These figures are shockingly high, compared to the general population, even allowing for a higher level of drug use among the criminal population.

“The largest facilities housing psychiatric patients in the United States are not hospitals but jails,” they write. “More than half of inmates have symptoms of a psychiatric disorder… yet correctional facilities are fundamentally designed to confine and punish, not to treat disease.” Furthermore, as most people are aware, the punishment is not meted out equally: “By middle age, black men in the United State are more likely to have spent time in prison than to have graduated from college or joined the military and they are far more likely than whites to be sent to prison for drug offenses despite being no more likely that whites to use drugs.”

And there is one aspect of the sorry situation that receives almost no attention at all: Most prisoners are eventually released. This post-release period, says the NEJM article, “presents extraordinary risks to individuals and costs to society.” In the first two weeks after release, former inmates are 129 times more likely to die from a drug overdose than the average man or woman on the street. They are 12 times more likely to die, period. And here’s a nice touch: Most of them don’t have Medicaid or other medical insurance, and there is usually no primary care follow-up to assure that they have access to affordable medications, if they need them. Inevitably, these are among the people who make the local emergency room their primary care facility, at great cost to everyone involved.  As the article states: "Addressing the health needs of this vulnerable population is thus not only an ethical imperative, but also of crucial importance from both a fiscal and a public health perspective."

State spending on correctional institutes is now the second fastest growing sector of government spending, after Medicaid. According to the authors, five states now spend more on prisons than they spend on higher education. “Locking up millions of people for drug-related crimes has failed as a public-safety strategy and has harmed public health in the communities to which these men and women return.”

The authors make it clear that, for addicts, drug and mental health treatment programs are humane and sensible alternatives to incarceration. They are also cost-effective: In Rhode Island, for example, the price for putting someone behind bars for a year is $41,000—or $110,000, if we are talking about the new super maximum-security facilities. Why haven’t politicians seized on all of this as a budgeting issue; as a cost-effective way to address drug and alcohol addiction without clogging up the criminal justice system, and creating embarrassing rates of incarceration? The authors have an answer: the fear of being tagged as “soft on crime.” If addiction is a craven failure of will power leading to the violation of social norms, as so many citizens seem to think, than prison is where addicts belong. The result: political pandering on the drug issue, by politicians suffering from a craven failure of will.


Here is where President Obama’s Affordable Care Act could really end up making a difference. Former prisoners will have a good shot at health coverage, and a policy that links together community health centers and academic medical centers could radically improve care during the critical post-release period. As Rich and colleagues argue: “Such access could redirect many people with serious illnesses away from the revolving door of the criminal justice system, thereby improving overall public health in the communities to which prisoners return and decreasing the costs associated with reincarceration due to untreated addiction and mental illness.”

Rich JD, Wakeman SE, & Dickman SL (2011). Medicine and the epidemic of incarceration in the United States. The New England journal of medicine, 364 (22), 2081-3 PMID: 21631319

Pic http://scrapetv.com 

Drugs and Prison

The American Disgrace.

For years, drug policy discussions have foundered on a fundamental dilemma: If illegal and addictive drugs are freely available in the nation’s prison system—and there is no one who says otherwise—then how can we as a society expect to control the consumption of drugs outside the prison walls? Moreover, should people be jailed at all for simple possession?

In 1982, President Ronald Reagan inaugurated the “war on drugs." From 1980 to 1997, writes Glenn C. Loury in his book Race, Incarceration, and American Values, the number of people in prison for drug offenses increased more than 1,000 %. Only one out of five drug convictions involved any sort of distribution beyond simple possession, says Loury, although there is often dispute about these numbers and how they are derived.

In “Can Our Shameful Prisons Be Reformed?” which appeared in the November 19 issue of the New York Review of Books, David Cole argues that African-Americans “have borne the brunt of this war.” While white drug offenders in prison increased by more than 100 % from 1985 to 1991, the prison population of black drug offenders soared by 465 %. Citing figures from The Sentencing Project, Cole asks whether we are willing to accept “a system in which one out of every three black males born today can expect to spend time in jail during his life?”

America’s prison disgrace is everyone’s problem, however. Cole informs us that a new prison is opened in the U.S. every week, and that imprisoning someone costs $20,000 a year and up. We spend $7 billion on jails in 1980. Today, writes Cole, the figure is $60 billion.

Where are we going wrong? The answer is straightforward, and unavoidable: The War on Drugs. According to FBI crime statistics cited by Cole, the U.S. last year arrested 1.7 million people for drug crimes. “Since 1989, more people have been incarcerated for drug offenses than for all violent crimes combined,” writes Cole. “Yet much like Prohibition, the war on drugs has not ended or even significantly diminished drug use.” In addition, “about half of property crime, robberies, and burglaries are attributable to the inflated cost of drugs caused by criminalizing them.”

At the heart of the problem lies a long-standing dilemma. The American prison system does next to nothing for drug addicts, except assure them of a steady supply. The justice system does not systematically help drug addicts avoid prison, or reintegrate them into society when they get out. And, since a high number of chronic drug abusers also suffer from other mental disorders, the lack of consistent, well-funded, effective programs for ex-offenders virtually guarantees a revolving-door cycle of repeated incarcerations. For those drug felons who are not themselves addicts, and who are in prison due to simple possession charges, a program of mass parole would ease prison crowding significantly. There is really no reason why many of the prisoners in this class should have been locked up at all, but for draconian legislation passed in the heat of passion—like New York’s Rockefeller laws--about one drug “epidemic” or another.

In addition to converting the swords of the drug war into the ploughshares of job programs, education, and housing assistance, we need to recognize and act upon the obvious fact that young people who are in school are far less likely to end up in prison. Schools are a far more cost-effective solution than prisons. In addition, a RAND Corporation study cited by Cole concluded that treatment is "fifteen times more effective at reducing drug-related crime than incarceration."

In the end, the need for action is undeniable. As Cole writes, “The very fact that the US record is so much worse than that of the rest of the world should tell us that we are doing something wrong.”

Graphics Credit: http://correctionsproject.com

Drug Addiction Goes Untreated in Prison

Only 20% of addicted inmates get rehab.

Among the many ironies of the American War on Drugs, the situation of drug abusers in prison ranks high on the list. Despite decades of research showing that drug treatment can be effective, the federal government has failed to offer it consistently, on demand, for prisoners who need rehabilitation. The National Institute on Drug Abuse estimates that only one-fifth of inmates needing formal treatment are able to get it.

Why aren’t imprisoned drug addicts getting treatment, instead of ready access to a continuing supply of whatever they are addicted to? “Addiction is a stigmatized disease that the criminal justice system often fails to view as a medical condition,” says the report’s lead author, Dr. Redonna K. Chandler, chief of NIDA’s Services Research Branch. “As a consequence, its treatment is not as available as it is for other medical conditions.”

The report, published in the Journal of the American Medical Association (JAMA) found that roughly half of all prisoners suffer some degree of drug dependency. “Treating drug abusing offenders improves public health and safety,” asserts co-author and NIDA director Dr. Nora D. Volkow, citing increased risk of infectious diseases like HIV and hepatitis C among addicts. “Providing drug abusers with treatment also makes it less likely that these abusers will return to the criminal justice system.”

While the high cost of treatment is often cited as a reason for its general absence from the prison infrastructure, Chandler says the cost benefits of treating drug-involved offenders is obvious: “A dollar spent on drug courts saves about $4 in avoided costs of incarceration and health care; and prison-based treatment saves between $2 and $6.”

Adds Volkow: “Viewing addiction as a disease does not remove the responsibility of the individual. It highlights the responsibility of the addicted person to get drug treatment and society’s responsibility to make treatment available.”

Photo Credit: www.thecyncom