34

NIH Publication No. 06-5316

Printed July 2006

National Institutes of Health

U.S. Department of Health

and Human Services

Principles of Drug Abuse 

Treatment for Criminal 

Justice Populations | A Research-Based Guide

National Institute on Drug Abuse




1. Drug addiction is a brain disease that affects 

behavior. Drug addiction has well-recognized cognitive, behavioral, 

and physiological characteristics that contribute to continued use of 

drugs, despite the harmful consequences. Scientists have also found 

that chronic drug abuse alters the brain’s anatomy and chemistry and 

that these changes can last for months or years after the individual 

has stopped using drugs. This transformation may help explain why 

addicts are at a high risk of relapse to drug abuse even after long 

periods of abstinence, and why they persist in seeking drugs despite 

deleterious consequences.

2. Recovery from drug addiction requires

effective treatment, followed by management

of the problem over time. Drug addiction is a serious prob-

lem that can be treated and managed throughout its course. Effective 

drug abuse treatment engages participants in a therapeutic process, 

retains them in treatment for an appropriate length of time, and helps 

them learn to maintain abstinence over time. Multiple episodes of 

treatment may be required. Outcomes for drug abusing offenders 

in the community can be improved by monitoring drug use and by 

encouraging continued participation in treatment.

3. Treatment must last long enough to produce 

stable behavioral changes. In treatment, the drug abuser 

is taught to break old patterns of thinking and behaving and to learn 

new skills for avoiding drug use and criminal behavior. Individuals with 

Principles of 

Drug Abuse 

Treatment for 

Criminal Justice 

Populations
 

severe drug problems and co-occurring disorders typically need longer 

treatment (e.g., a minimum of 3 months) and more comprehensive services. Early in treatment, the drug abuser begins a therapeutic process 

of change. In later stages, he or she addresses other problems related 

to drug abuse and learns how to manage the problem.

4. Assessment is the first step in treatment. A history of drug or alcohol use may suggest the need to conduct a comprehensive assessment to determine the nature and extent of an individual’s drug problems; establish whether problems exist in other areas 

that may affect recovery; and enable the formulation of an appropriate 

treatment plan. Personality disorders and other mental health problems are prevalent in offender populations; therefore, comprehensive 

assessments should include mental health evaluations with treatment 

planning for these problems.

5. Tailoring services to fit the needs of the

individual is an important part of effective drug 

abuse treatment for criminal justice populations.

Individuals differ in terms of age, gender, ethnicity and culture, problem severity, recovery stage, and level of supervision needed. Individuals also respond differently to different treatment approaches and 

treatment providers. In general, drug treatment should address issues 

of motivation, problemsolving, skill-building for resisting drug use and 

criminal behavior, the replacement of drug using and criminal activities with constructive nondrug using activities, improved problemsolving, and lessons for understanding the consequences of one’s behavior. Treatment interventions can facilitate the development of healthy 

interpersonal relationships and improve the participant’s ability to 

interact with family, peers, and others in the community.

6. Drug use during treatment should be carefully 

monitored. Individuals trying to recover from drug addiction may 

experience a relapse, or return, to drug use. Triggers for drug relapse 

are varied; common ones include mental stress and associations with 

peers and social situations linked to drug use. An undetected relapse 

can progress to serious drug abuse, but detected use can present opportunities for therapeutic intervention. Monitoring drug use 

through urinalysis or other objective methods, as part of treatment or 

criminal justice supervision, provides a basis for assessing and providing feedback on the participant’s treatment progress. It also provides 

opportunities to intervene to change unconstructive behavior—determining rewards and sanctions to facilitate change, and modifying 

treatment plans according to progress.

7. Treatment should target factors that are

associated with criminal behavior. “Criminal thinking” is 

a combination of attitudes and beliefs that support a criminal lifestyle 

and criminal behavior. These can include feeling entitled to have things 

one’s own way; feeling that one’s criminal behavior is justified; failing 

to be responsible for one’s actions; and consistently failing to anticipate or appreciate the consequences of one’s behavior. This pattern of 

thinking often contributes to drug use and criminal behavior. Treatment that provides specific cognitive skills training to help individuals 

recognize errors in judgment that lead to drug abuse and criminal 

behavior may improve outcomes.

8. Criminal justice supervision should incorporate 

treatment planning for drug abusing offenders, 

and treatment providers should be aware of correctional supervision requirements. The coordination of 

drug abuse treatment with correctional planning can encourage participation in drug abuse treatment and can help treatment providers 

incorporate correctional requirements as treatment goals. Treatment 

providers should collaborate with criminal justice staff to evaluate 

each individual’s treatment plan and ensure that it meets correctional 

supervision requirements as well as that person’s changing needs, 

which may include housing and childcare; medical, psychiatric, and 

social support services; and vocational and employment assistance. 

For offenders with drug abuse problems, planning should incorporate 

the transition to community-based treatment and links to appropriate postrelease services to improve the success of drug treatment 

PRINCIPLES
 

and re-entry. Abstinence requirements may necessitate a rapid clinical 

response, such as more counseling, targeted intervention, or increased 

medication, to prevent relapse. Ongoing coordination between treatment 

providers and courts or parole and probation officers is important in 

addressing the complex needs of these re-entering individuals.

9. Continuity of care is essential for drug

abusers re-entering the community. Those who complete prison-based treatment and continue with treatment in the 

community have the best outcomes. Continuing drug abuse treatment 

helps the recently released offender deal with problems that become 

relevant only at re-entry, such as learning to handle situations that 

could lead to relapse; learning how to live drug-free in the community; 

and developing a drug-free peer support network. Treatment in prison 

or jail can begin a process of therapeutic change, resulting in reduced 

drug use and criminal behavior postincarceration. Continuing drug 

treatment in the community is essential to sustaining these gains.

10. A balance of rewards and sanctions

encourages prosocial behavior and treatment

participation. When providing correctional supervision of individuals participating in drug abuse treatment, it is important to reinforce 

positive behavior. Nonmonetary “social reinforcers” such as recognition for progress or sincere effort can be effective, as can graduated 

sanctions that are consistent, predictable, and clear responses to 

noncompliant behavior. Generally, less punitive responses are used for 

early and less serious noncompliance, with increasingly severe sanctions issuing from continued problem behavior. Rewards and sanctions 

are most likely to have the desired effect when they are perceived as 

fair and when they swiftly follow the targeted behavior.

11. Offenders with co-occurring drug abuse and 

mental health problems often require an integrated 

treatment approach. High rates of mental health problems are 

found both in offender populations and in those with substance abuse 

problems. Drug abuse treatment can sometimes address depression, 

anxiety, and other mental health problems. Personality, cognitive, and 

other serious mental disorders can be difficult to treat and may disrupt 

drug treatment. The presence of co-occurring disorders may require an 

integrated approach that combines drug abuse treatment with psychiatric treatment, including the use of medication. Individuals with either a 

substance abuse or mental health problem should be assessed for the 

presence of the other.

12. Medications are an important part of 

treatment for many drug abusing offenders.

Medicines such as methadone and buprenorphine for heroin addiction 

have been shown to help normalize brain function, and should be made 

available to individuals who could benefit from them. Effective use of 

medications can also be instrumental in enabling people with cooccurring mental health problems to function successfully in society. 

Behavioral strategies can increase adherence to medication regimens.

13. Treatment planning for drug abusing 

offenders who are living in or re-entering the 

community should include strategies to prevent 

and treat serious, chronic medical conditions, 

such as HIV/AIDS, hepatitis B and C, and

tuberculosis. The rates of infectious diseases, such as hepatitis, 

tuberculosis, and HIV/AIDS, are higher in drug abusers, incarcerated 

offenders, and offenders under community supervision than in the 

general population. Infectious diseases affect not just the offender, 

but also the criminal justice system and the wider community. Consistent with Federal and State laws, drug-involved offenders should 

be offered testing for infectious diseases and receive counseling 

on their health status and on how to modify risk behaviors. Probation and parole officers who monitor offenders with serious medical 

conditions should link them with appropriate healthcare services, 

encourage compliance with medical treatment, and re-establish their 

eligibility for public health services (e.g., Medicaid, county health 

departments) before release from prison or jail. 

PRINCIPLES
 

CONTENTS

PRINCIPLES OF DRUG ABUSE TREATMENT

FOR CRIMINAL JUSTICE POPULATIONS ............. 1

PREFACE ............................................................. 9

ACKNOWLEDGMENTS....................................... 11

INTRODUCTION ................................................. 12

FREQUENTLY ASKED QUESTIONS (FAQS)......... 15

1. Why do people involved in the criminal

justice system continue abusing drugs? .............................. 15

2. Why should drug abuse treatment

be provided to offenders?...................................................... 16

3. How effective is drug abuse treatment

for criminal justice-involved individuals? ............................. 16

4. Are all drug abusers in the criminal justice

system good candidates for treatment? ............................... 17

5. Is legally mandated treatment effective? ............................. 18

6. Are relapse risk factors different in

offender populations? How should drug

abuse treatment deal with these risk factors?..................... 18

7. What treatment and other health

services should be provided to drug abusers

involved with the criminal justice system? ........................... 19

8. How long should drug abuse treatment last

for individuals involved in the criminal justice system?....... 20

9. How can rewards and sanctions be used

effectively with drug-involved offenders in treatment?........ 21

10. What is the role of medications in

treating substance abusing offenders? ................................ 22

11. How can the criminal justice and drug abuse

treatment systems reduce the spread of HIV/AIDS,

hepatitis, and other infectious diseases among

drug abusing offenders?....................................................... 24

12. What works for offenders with co-occurring

substance abuse and mental disorders?.............................. 25

13. Is providing drug abuse treatment to

offenders worth the financial investment?........................... 25

14. What are unique treatment needs for

women in the criminal justice system? ................................ 26

15. What are the unique treatment needs of

juveniles in the criminal justice system?.............................. 27

RESOURCES ...................................................... 29

REFERENCES.................................................... 32




Since it was established in 

1974, the National Institute 

on Drug Abuse (NIDA) has 

supported research on drug 

abuse treatment for individ-

uals who are involved with 

the criminal justice system. 

This guide is intended to describe the treatment principles and 

research findings that are of particular relevance to the criminal 

justice community and to treatment professionals working with 

drug abusing offenders. The guide is divided into three main sec-

tions: (1) the first distills research findings on the addicted offender 

into 13 essential principles; (2) the second contains a series of 

frequently asked questions (FAQs) about drug abuse treatment for 

those involved with the criminal justice system; and (3) the third is a 

resource section that provides Web sites for additional information. 

A summary of the research underlying both the principles and the 

FAQs is available on NIDA’s Web site at www.drugabuse.gov. PREFACE
10 11

Research on drug abuse and addiction runs the gamut from basic 

science to applied studies. We now understand the basic neurobiology of many addictions, along with what constitutes more effective 

treatment processes and interventions to help individuals progress 

through the stages of recovery. Increased understanding of the neurological, physiological, psychological, and social change processes 

involved will help us develop interventions to improve therapeutic 

engagement, stabilization of recovery, motivation for change, prevention of relapse, and long-term monitoring of the substance use 

problem over its course.

Scientific investigations spanning nearly four decades show that 

drug abuse treatment is an effective intervention for many substance 

abusing offenders. Because the goals of drug abuse treatment—to 

help people change their attitudes, beliefs, and behaviors—also 

apply to reforming criminal behavior, successful treatment can help 

reduce crime as well. Legal pressure can be important in getting a 

person into treatment and in improving retention. Once in a program, 

even those who are not initially motivated to change can eventually 

become engaged in a continuing therapeutic process. Through this 

process of change, the individual learns how to avoid relapse and to 

successfully disengage from a life of substance abuse and crime.

This booklet will provide a complement to NIDA’s Principles of 

Drug Addiction Treatment, A Research-Based Guide, which was 

prepared to assist those dealing with drug addiction both in and out 

of the criminal justice system. It relies primarily on drug abuse treatment research supported by NIDA, and focuses largely on individuals 

for whom drug addiction is a debilitating disease.

Nora D. Volkow, M.D.

Director

National Institute on Drug Abuse

Steven Belenko, Ph.D.

Center on Evidence-based 

Interventions for Crime and Addiction

Treatment Research Institute

Peter J. Delany, Ph.D.

Division of Treatment

and Recovery Research

National Institute on Alcohol

Abuse and Alcoholism

Richard Dembo, Ph.D.

Department of Criminology 

University of South Florida 

Kevin Knight, Ph.D.

Institute of Behavioral Research

Texas Christian University

Douglas Longshore, Ph.D. 

UCLA Integrated Substance 

Abuse Programs

Roger H. Peters, Ph.D.

Department of Mental

Health Law & Policy 

Florida Mental Health Institute 

University of South Florida 

ACKNOWLEDGMENTS

NIDA wishes to thank the following individuals for their guidance and 

comments during the development and review of this publication:

This publication was written by Bennett W. Fletcher, Ph.D. and 

Redonna K. Chandler, Ph.D., National Institute on Drug Abuse. 

Additional guidance was provided by Jack B. Stein, Ph.D., National 

Institute on Drug Abuse.

This publication is in the public domain and may be used or reproduced in its entirety without permission from NIDA or the authors. 

Citation of the source is appreciated.

The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names 

appearing in this publication are used only because they are considered essential in the context of the studies described here.

NIH Publication No. 06-5316

Printed July 2006

Gary D. Field, Ph.D. (Retired)

Mental Health Alignment Work Group

Oregon Department of Corrections

PREFACE
12 13

The connection between 

drug abuse and crime is 

well known.

Drug abuse is implicated in at least three types of drug-related 

offenses: (1) offenses defined by drug possession or sales, (2) 

offenses directly related to drug abuse (e.g., stealing to get money 

for drugs), and (3) offenses related to a lifestyle that predisposes the 

drug abuser to engage in illegal activity, for example, through association with other offenders or with illicit markets. Individuals who 

use illicit drugs are more likely to commit crimes, and it is common 

for many offenses, including violent crimes, to be committed by individuals who had used drugs or alcohol prior to committing the crime, 

or who were using at the time of the offense.

In 2003, nearly 6.9 million adults were involved with the criminal 

justice system, including 4.8 million who were under probation or 

parole supervision (Glaze & Palla, 2004). In its 1997 survey, the 

Bureau of Justice Statistics (BJS) estimated that about 70 percent 

of State and 57 percent of Federal prisoners used drugs regularly 

prior to incarceration (Mumola, 1999). A 2002 survey of jails found 

that 52 percent of incarcerated women and 44 percent of men met 

INTRODUCTION the criteria for alcohol or drug dependence (Karberg & James, 2005). 

Juvenile justice systems also report high levels of drug abuse. A 

survey of juvenile detainees in 2000 found that about 56 percent of 

the boys and 40 percent of the girls tested positive for drug use at the 

time of their arrest (National Institute of Justice, 2003).

The substance abusing offender may be encouraged or legally 

pressured to participate in drug abuse treatment. Even so, few drug 

abusing offenders actually receive treatment. 

The 1997 BJS survey showed that fewer 

than 15 percent of incarcerated offenders with drug problems had received 

treatment1 in prison. Nearly 36 percent 

of adult probationers who regularly 

abused drugs prior to incarceration 

said they had received treatment during 

their current sentences; only 17 percent 

said they were currently in a drug treatment 

program. Untreated substance abusing offenders are more likely to 

relapse to drug abuse and return to criminal behavior. This can bring 

about re-arrest and re-incarceration, jeopardizing public health and 

public safety and taxing criminal justice system resources. Treatment 

offers the best alternative for interrupting the drug abuse/criminal 

justice cycle for offenders with drug abuse problems.

Drug abuse treatment can be incorporated into criminal justice 

settings in a variety of ways. These include treatment as a condition 

of probation, drug courts that blend judicial monitoring and sanctions 

with treatment, treatment in prison followed by community-based 

treatment after discharge, and treatment under parole or probation supervision. Drug abuse treatment can benefit from the crossagency coordination and collaboration of criminal justice professionals, substance abuse treatment providers, and other social service 

agencies. By working together, the criminal justice and treatment 

systems can optimize resources to benefit the health, safety, and 

well-being of individuals and the communities they serve.

Treatment offers 

the best alternative 

for interrupting the 

drug abuse/criminal 

justice cycle.

1. Excludes participation in self-help (e.g., Alcoholics Anonymous) or drug 

education, alternatives that are often provided in addition to or in lieu of treatment.
14 15

FREQUENTLY ASKED 

QUESTIONS (FAQS)

1. Why do people involved in the criminal 

justice system continue abusing drugs?

The answer to this perplexing question spans basic neurobiological, 

psychological, social, and environmental factors.

The repeated use of addictive drugs eventually changes how the 

brain functions. Resulting brain changes, which accompany the transi-

tion from voluntary to compulsive drug use, affect the brain’s natural 

inhibition and reward centers, causing the addict to use drugs in spite 

of the adverse health, social, and legal consequences. Craving for 

drugs may be triggered by contact with the people, places, and things 

associated with prior drug use, as well as by stress. Forced abstinence 

without treat-

ment does not 

cure addiction. 

Abstinent indi-

viduals must still 

learn how to avoid 

relapse, including 

those who have 

been incarcer-

ated and may have 

been abstinent for 

a long period of 

time.

Potential risk factors for released offenders include pressures from 

peers and even family members to return to drug use and a criminal 

lifestyle. Tensions of daily life—violent associates, few opportuni-

ties for legitimate employment, lack of safe housing, even the need 

2. PET scans showing glucose metabolism in healthy brain and cocaine-addicted 

brains. Even after 100 days of abstinence, glucose metabolism has not returned to 

normal levels.

Normal Cocaine Abuser

(10 days of 

abstinence)

Cocaine Abuser

(100 days of 

abstinence)

Addictive Drugs Cause

Long-lasting Changes in the Brain

2

Source: Volkow et al., 1992, 1993.
16 17

to comply with correctional supervision conditions—can also create 

stressful situations that can precipitate a relapse to drug use.

Research on how the brain is affected by drug abuse promises to 

help us learn much more about the mechanics of drug-induced brain 

changes and their relationship to addiction. Research also reveals that 

with effective drug abuse treatment, individuals can overcome persistent drug effects and lead healthy, productive lives.

2. Why should drug abuse treatment 

be provided to offenders?

The case for treating drug abusing offenders is compelling. Drug 

abuse treatment improves outcomes for drug abusing offenders and 

has beneficial effects for public health and safety. Effective treatment 

decreases future drug use and drug-related criminal behavior, can 

improve the individual’s relationships with his or her family, and may 

improve prospects for employment.

Outcomes for substance abusing individuals can be improved when 

criminal justice personnel work in tandem with treatment providers on drug abuse treatment needs and supervision requirements. 

Treatment needs that can be assessed after arrest include substance 

abuse severity, mental health problems, and physical health. Defense 

attorneys, prosecutors, and judges need to work together during the 

prosecution and sentencing phases of the criminal justice process 

to determine suitable treatment programs that meet the offender’s 

needs. Through drug courts, diversion programs, pretrial release programs conditional on treatment, and conditional probation with sanctions, the offender can participate in community-based drug abuse 

treatment while under criminal justice supervision. In some instances, 

the judge may recommend that the offender participate in treatment 

while serving jail or prison time or require it as part of continuing correctional supervision postrelease.

3. How effective is drug abuse treatment 

for criminal justice-involved individuals?

Treatment is an effective intervention for drug abusers, including 

those who are involved with the criminal justice system. However, the 

FREQUENTLY ASKED QUESTIONS

effectiveness of drug treatment depends on both the individual and 

the program, and on whether interventions and treatment services are 

available and appropriate for the individual’s needs. To amend attitudes, beliefs, and behaviors that support drug use, the drug abuser 

must engage in a therapeutic change process. Longitudinal outcome 

studies find that those who participate in community-based drug 

abuse treatment programs commit fewer crimes than those who do 

not participate.

4. Are all drug abusers in the criminal justice 

system good candidates for treatment?

A history of drug use does not in itself indicate the need for drug 

abuse treatment. Offenders who meet drug dependence criteria 

should be given higher priority for treatment than those who do not. 

Less intensive interventions, such as drug abuse education or selfhelp participation, may be appropriate for those not meeting criteria 

for drug dependence. Services such as family-based interventions 

for juveniles, psychiatric treatment, or cognitive-behavioral “criminal 

thinking” interventions may be a higher priority for some offenders, 

and individuals with mental health 

problems may require specialized 

services (see FAQ Nos. 6 and 12).

Low motivation to participate in 

treatment or to end drug abuse 

should not preclude access to 

treatment if other criteria are 

met. Motivational enhancement 

interventions may be useful in these 

cases. Examples include motivational 

interviewing and contingency management techniques, which often 

provide tangible rewards in exchange for meeting program goals. 

Legal pressure that encourages abstinence and treatment participation may also help these individuals by improving retention and catalyzing longer treatment stays.

Drug abuse treatment is also effective for offenders who have a history of serious and violent crime, particularly if they receive intensive, 

targeted services. The economic benefits in avoided crime and costs 

Outcomes can be 

improved when criminal 

justice personnel 

work in tandem with 

treatment providers.
18 19

to crime victims (e.g., medical costs, lost earnings, and loss in quality 

of life) may be substantial for these high-risk offenders. Treating them 

requires a high degree of coordination between drug abuse treatment 

providers and criminal justice personnel to ensure that treatment and 

criminogenic needs are appropriately addressed.

5. Is legally mandated treatment effective?

Often the criminal justice system can apply legal pressure to 

encourage offenders to participate in drug abuse treatment; or treatment can be mandated, for example, through a drug court or as a 

condition of pretrial release, probation, or parole. 

A large percentage of those admitted to drug 

abuse treatment cite legal pressure as an 

important reason for seeking treatment. 

Most studies suggest that outcomes for 

those who are legally pressured to enter 

treatment are as good as or better than 

outcomes for those who entered treatment 

without legal pressure. Those under legal 

pressure also tend to have higher attendance 

rates and to remain in treatment for longer periods, which can also 

have a positive impact on treatment outcomes.

6. Are relapse risk factors different in 

offender populations? How should drug abuse 

treatment deal with these risk factors?

Often, drug abusing offenders have problems in other areas. Examples include family difficulties, limited social skills, educational and 

employment problems, mental health disorders, infectious diseases, 

and other medical problems. Treatment should take these problems 

into account, because they can increase the risk of drug relapse and 

criminal recidivism if left unaddressed.

Stress is often a contributing factor to relapse, and offenders who 

are re-entering society face many challenges and stressors, including reuniting with family members, securing housing, and complying 

with criminal justice supervision requirements. Even the many daily 

Legal pressure can 

increase treatment 

attendance and 

improve retention.

decisions that most people face can be stressful for those recently 

released from a highly controlled prison environment. 

Other threats to recovery include a loss of support from family 

or friends, which incarcerated people may experience. Drug abusers returning to the community may also encounter family, friends, 

or associates still involved in drugs or 

crime and be enticed to resume a 

criminal and drug using lifestyle. 

Returning to environments or 

activities associated with prior 

drug use may trigger strong 

cravings and cause a relapse. A 

coordinated approach by treatment 

and criminal justice staff provides 

the best way to detect and intervene 

with these and other threats to recovery. In any case, treatment is 

needed to provide the skills necessary to avoid or cope with situations 

that could lead to relapse.

Treatment staff should identify the offender’s unique relapse risk 

factors and periodically re-assess and modify the treatment plan as 

needed. Generally, continuing or re-emerging drug use during treatment requires a clinical response—either increasing the “dosage” or 

level of treatment, or changing the treatment intervention. 

7. What treatment and other health 

services should be provided to drug abusers 

involved with the criminal justice system?

One of the goals of treatment planning is to match evidence-based 

interventions to individual needs at each stage of drug treatment. Over 

time, various combinations of treatment services may be required. 

Evidence-based interventions include cognitive-behavioral therapy to 

help participants learn positive social and coping skills, contingency 

management approaches to reinforce positive behavioral change, and 

motivational enhancement to increase treatment engagement and 

retention. In those addicted to opioid drugs, agonist medications can 

also help normalize brain function, and antagonist medications can 

facilitate abstinence. For juvenile offenders, treatments that involve 

Returning to 

environments associated 

with drug use may 

trigger cravings and 

cause a relapse.

FREQUENTLY ASKED QUESTIONS
20 21

the family and other aspects of the drug abuser’s environment have 

established efficacy. 

Drug abuse treatment plans for incarcerated offenders can anticipate their eventual re-entry into the community by incorporating 

relevant transition plans and services. Drug abusers often have mental 

and physical health, family counseling, parenting, educational, and 

vocational needs, so medical, psychological, and social services are 

often crucial components of successful treatment. Case management 

approaches can be used to provide assistance in obtaining drug abuse 

treatment and community services.

8. How long should drug abuse 

treatment last for individuals involved 

in the criminal justice system?

While individuals progress through drug abuse treatment at 

different rates, one of the most reliable findings in treatment 

research is that lasting reductions in criminal activity and drug abuse 

are related to length of treatment. Generally, better outcomes are 

associated with treatment that lasts longer than 90 days, with the 

greatest reductions in drug abuse and criminal behavior accruing to 

those who complete treatment. Again, legal pressure can improve 

retention rates.

A longer continuum of treatment may be indicated for individuals 

with severe or multiple problems. Research has shown that participation in a prison-based therapeutic community followed by community-based treatment after release can reduce the risk of recidivism to 

criminal behavior as well as relapse to drug use. 

Early phases of treatment help the participant stop using drugs and 

begin a therapeutic process of change. Later stages address other 

problems related to drug abuse and, importantly, help the individual 

learn how to self-manage the drug problem. 

Because addiction is a chronic disease, drug relapse and return to 

treatment are common features of an individual’s path to recovery, so 

treatment may need to extend over a long period of time and across 

multiple episodes of care. It is also the case that those with the most 

severe problems can participate in treatment and achieve positive 

outcomes.

9. How can rewards and sanctions 

be used effectively with druginvolved offenders in treatment?

The systematic application of behavioral management principles 

underlying reward and punishment can help individuals reduce their 

drug use and criminal behavior. Rewards and sanctions are most likely 

to change behavior when they are certain to follow the targeted behavior, when they follow swiftly, and when they are perceived as fair.

It is important to recognize and reinforce progress toward responsible, abstinent behavior. Rewarding positive behavior is more effective in producing long-term positive change than punishing negative 

behavior. Nonmonetary rewards such as social recognition can be as 

effective as monetary rewards. A graduated range of rewards given 

for meeting predetermined goals can be an effective strategy when 

used in conjunction with behavioral management approaches such 

as contingency management. In community-based treatment, contingency management strategies may use voucher-based incentives 

or rewards, such as bus tokens, to reinforce abstinence (measured 

0

0.2

0.4

0.6

0.8

Proportions of Months Not Using Drugs

Years After Work Release

Source: Butzin, et al., 2005.

Year 1 Years 2–3 Years 4–5

No treatment

No treatment 

completion

Complete–no aftercare

Complete & aftercare

FREQUENTLY ASKED QUESTIONS
22 23

by negative drug tests) or to shape progress toward other treatment 

goals, such as program session attendance or compliance with medication regimens. Contingency management is most effective when the 

contingent reward closely follows the behavior being 

monitored.

Graduated sanctions, which invoke less 

punitive responses for early and less 

serious noncompliance and increasingly 

severe sanctions for more serious or 

continuing problems, can be an effective tool in conjunction with drug testing. 

The effective use of graduated sanctions 

involves consistent, predictable, and clear 

responses to noncompliant behavior.

Drug testing can determine when an individual is having difficulties with recovery. The first response to drug use detected through 

urinalysis should be clinical—for example, an increase in treatment 

intensity or a change to an alternative treatment. This often requires 

coordination between the criminal justice staff and the treatment provider. (Note that more intensive treatment should not be considered a 

sanction, but rather a routine progression in healthcare practice when 

a treatment appears less effective than expected.)

Behavioral contracting can employ both rewards and sanctions. A 

behavioral contract is an explicit agreement between the participant 

and the treatment provider or criminal justice monitor (or all three) 

that specifies proscribed behaviors and associated sanctions, as well 

as positive goals and rewards for success. Behavioral contracting can 

instill a sense of procedural justice because both the necessary steps 

toward progress and the sanctions for violating the contract are specified and understood in advance.

10. What is the role of medications in 

treating substance abusing offenders?

Medications can be an important component of effective drug abuse 

treatment for offenders. By allowing the body to function normally, 

they enable the addict to leave behind a life of crime and drug abuse. 

Opiate agonist medications, which work by replacing neurotransmitIt is important 

to recognize and 

reinforce progress 

toward responsible, 

abstinent behavior.

ters in brain cells that have become altered or desensitized as a result 

of drug abuse, tend to be well tolerated and can help an individual 

remain in treatment. Antagonist medications, which work by blocking 

the effects of a drug, are effective but often are not taken as prescribed. Despite evidence of their effectiveness, addiction medications 

are underutilized in the treatment of drug abusers within the criminal 

justice system. Still, some jurisdictions have found ways to successfully implement medication therapy for drug abusing offenders.

Effective medications have been developed for opiates/heroin and 

alcohol:

Opiates/Heroin. Long-term opiate abuse results in a desensitization of the brain’s opiate receptors to endorphins, the body’s 

natural opioids. Methadone replaces these natural endorphins, 

stabilizing the craving that otherwise results in compulsive use of 

heroin or other illicit opiates. Methadone is 

effective in reducing opiate use, drugrelated criminal behavior, and HIV risk 

behavior. Buprenorphine is a partial 

agonist and acts on the same receptors as morphine (a full agonist), but 

without producing the same high, level 

of dependence, or withdrawal symptoms. Suboxone is a unique formulation 

of buprenorphine that contains naloxone, an 

opioid antagonist, which limits diversion by causing severe withdrawal symptoms in those who inject it to get “high,” but has no 

adverse effects when taken orally. Naltrexone, an opiate antagonist, 

blocks the effects of opiates.

Alcohol. Disulfiram (also known as Antabuse) is an aversion therapy 

that induces nausea if alcohol is consumed. Acamprosate works by 

restoring normal balance to the brain’s glutamate neurotransmitter 

system, helping to reduce alcohol craving. Naltrexone, which blocks 

some of alcohol’s pleasurable effects, is also FDA-approved for 

treatment of alcohol abuse. 

•

•

Medications can 

be an important 

component of 

effective addiction 

treatment for 

offenders.

FREQUENTLY ASKED QUESTIONS
24 25

11. How can the criminal justice and drug 

abuse treatment systems reduce the spread 

of HIV/AIDS, hepatitis, and other infectious 

diseases among drug abusing offenders?

It is critical for the criminal justice and drug abuse treatment systems to be involved in efforts to reduce the spread of HIV/AIDS and 

other infectious diseases, which occur at higher rates among drug 

abusers in the criminal justice system than among the general population. The prevalence of AIDS has been estimated to be approximately 

five times higher among incarcerated offenders than the general 

population, and rates of HIV are also higher than in the general population. In addition, individuals in the criminal justice system represent 

a significant portion of hepatitis B, hepatitis C, and tuberculosis cases 

in the United States. Although most infectious diseases are contracted 

in the community and not in correctional settings, they must be treated 

in the correctional setting once diagnosed.

Infectious diseases among offenders who are re-entering or living 

within the community present a serious public health challenge. While 

incarcerated, offenders often have access to adequate healthcare, 

which offers opportunities for integrating 

strategies to address medical, mental 

health, and drug abuse problems. 

Offenders with infectious diseases 

who are returning to their communities should be linked with 

community-based medical care 

prior to release. Community health, 

drug treatment, and criminal justice 

agencies should work together to offer 

education, screening, counseling, prevention, and treatment programs 

for HIV/AIDS, hepatitis, and other infectious diseases to offenders in or 

returning to the community. Drug abuse treatment can decrease the 

spread of infectious disease by reducing high-risk behaviors such as 

needle sharing and unprotected sex.

The need to negotiate access to health services and adhere to 

complex treatment protocols places a large burden on the addicted 

The prevalence of AIDS 

is five times higher 

among incarcerated 

offenders than the 

general population.

offender, and many offenders fall through the cracks. Untreated or 

deteriorating medical or mental health problems increase the risk of 

relapse to drug abuse and to possible re-arrest and re-incarceration.

12. What works for offenders with co-occurring 

substance abuse and mental disorders?

It is important to adequately assess mental disorders and to address 

them as part of effective drug abuse treatment. Many types of cooccurring mental health problems can be successfully addressed 

in standard drug abuse treatment programs. However, individuals 

with serious mental disorders may require an integrated treatment 

approach designed for treating patients with co-occurring mental 

health problems and substance use disorders. Although not readily 

available, specialized therapeutic community “MICA” (for “mentally ill 

chemical abuser”) programs are promising for patients with co-occurring mental and addictive problems.

Much progress has been made in developing effective medications 

for treating mental disorders, including a number of antidepressants, 

mood stabilizers, and antipsychotics. These medications may be critical for treatment success with offenders who have co-occurring mental disorders such as depression, anxiety disorder, bipolar disorder, or 

psychosis. Cognitive-behavioral therapy can be effective for treating 

mental health problems, particularly when combined with medications. Contingency management can improve adherence to prescribed 

medications, and intensive case management may be useful for linking severely mentally ill individuals with drug abuse treatment, mental 

health care, and community services.

13. Is providing drug abuse treatment to 

offenders worth the financial investment?

In 2002, it was estimated that the cost to society of drug abuse was 

$180.9 billion (Office of National Drug Control Policy, 2004), a substantial portion of which—$107.8 billion—is associated with drug-related 

crime, including criminal justice system costs and costs borne by 

victims of crime. The cost of treating drug abuse (including research, 

FREQUENTLY ASKED QUESTIONS
26 27

training, and prevention efforts) was estimated to be $15.8 billion, a 

fraction of these overall societal costs.

Drug abuse treatment is cost effective in reducing drug use and 

bringing about associated healthcare, crime, and incarceration cost 

savings. Positive net economic benefits are 

consistently found for drug abuse treatment 

across various settings and populations. The 

largest economic benefit of treatment is 

seen in avoided costs of crime (incarceration and victimization costs), with greater 

economic benefits resulting from treating 

offenders with co-occurring mental health 

problems and substance use disorders. Residential prison treatment is more cost effective 

if offenders attend treatment postrelease, according to research. Drug 

courts also convey positive economic benefits, including participantearned wages and avoided incarceration and future crime costs.

14. What are unique treatment needs for 

women in the criminal justice system?

Although women are incarcerated at far lower rates than men, the 

number and percentage of incarcerated women have grown substantially in recent years. Between 1985 and 1995, the number of men in 

prisons and jails doubled, while the number of incarcerated women 

tripled. Women in prison are likely to have a different set of problems 

and needs than men. Surveys indicate that female offenders used 

more drugs more frequently prior to incarceration than males, and 

a higher percentage of females (54 percent compared to 50 percent) 

had used drugs in the month before committing their offense. In 

addition to being more likely to have a substance abuse problem, 

approximately 50 percent of female offenders are likely to have histories of physical or sexual abuse. Women are also more likely than 

men to be victims of domestic violence. Past or current victimization 

can contribute to drug or alcohol abuse, depression, post-traumatic 

stress disorder, and criminal activity. Female offenders are also 

more likely to have mental illnesses, employment problems, and 

childrearing responsibilities. 

The largest 

economic benefit 

of treatment is 

seen in avoided 

costs of crime.

Treatment programs serving both men and women can provide 

effective treatment for their female clients. However, gender-specific 

programs may be more effective for female offenders, particularly those 

with histories of trauma and abuse. Female offenders are more likely 

to need medical and mental health services, childcare services, and 

assistance in finding housing and employment. Following a comprehensive assessment, women with mental health disorders should receive 

appropriate treatment and case management, including victim services 

as needed. For female offenders with children, parental responsibilities 

can conflict with their ability to participate in drug treatment. Regaining or retaining custody of their children can also motivate mothers to 

participate in treatment. Treatment programs may improve retention by 

offering childcare services and parenting classes.

15. What are the unique treatment needs 

of juveniles in the criminal justice system?

In recent years, there has been a dramatic increase in the number 

of juveniles with substance abuse problems involved in the criminal 

and juvenile justice systems. From 1986 to 1996, drug-related juvenile 

Substance abuse, mental health, and health problems 

and treatment in a sample of incarcerated women

0 20 40 60 80 100

Any drug problem

Multiple drugs

Alcohol

Cocaine

Any mental health

Depression

Anxiety

Dental

Reproductive health

Trauma/injury

Cardiovascular

STDs

Substance abuse Tx

Mental health Tx

Psychotropic medications 

(N=60) 

Source: Staton, et al., 2003.

Note: Graph shows lifetime percentages except for multiple drugs, alcohol, and 

cocaine, which are the percent reporting use in the 30 days prior to incarceration.

FREQUENTLY ASKED QUESTIONS
28 29

incarcerations increased nearly threefold. In 2002, about 60 percent of 

detained boys and nearly half of the girls tested positive for drug use. 

The number of juvenile court cases involving drug offenses more than 

doubled between 1993 and 1998, and 116,781 adolescents under the 

age of 18 were arrested for drug violations in 2002. One study found 

that about one-half of both male and female juvenile detainees met 

criteria for a substance use disorder (Teplin et al., 2002).

Juveniles entering the criminal justice system can bring a number of 

serious issues with them—substance abuse, academic failure, emotional disturbances, physical health issues, 

family problems, and a history of physical or sexual abuse. Girls comprise 

nearly one-third of juvenile arrests, 

a high percentage reporting some 

form of emotional, physical, or sexual 

abuse. Effectively addressing these 

issues requires their gaining access to 

comprehensive assessment, treatment, 

case management, and support services 

appropriate for the age and developmental 

stage. Assessment is particularly important, because not all adolescents who have used drugs need treatment. For those who do, there 

are several points in the juvenile justice continuum where treatment 

has been integrated, including juvenile drug courts, community-based 

supervision, juvenile detention, and community re-entry.

Families play an important role in the recovery of substance-abusing 

juveniles, but this influence can be either positive or negative. Parental 

substance abuse or criminal involvement, physical or sexual abuse by 

family members, and lack of parental involvement or supervision are 

all risk factors for adolescent substance abuse and delinquent behavior. Thus, the effective treatment of juvenile substance abusers often 

requires a family-based treatment model that targets family functioning and the increased involvement of family members. Effective 

adolescent treatment approaches include Multisystemic Therapy, Multidimensional Family Therapy, and Functional Family Therapy. These 

interventions show promise in strengthening families and decreasing 

juvenile substance abuse and delinquent behavior.

Effective treatment 

of juvenile substance 

abusers often requires 

a family-based 

treatment model.

RESOURCES

Many resources are

available on the Internet.

The following are 

useful links:

General Information

NIDA Web site: www.drugabuse.gov

Inquiries about NIDA’s research on drug abuse treatment and the 

criminal justice system: Division of Epidemiology, Services and

Prevention Research (301) 443-6504

General Inquires: NIDA Public Information Office (301) 443–1124

Federal Resources

National Institute of Mental Health (NIMH) www.nimh.nih.gov

National Institute on Alcohol Abuse 

and Alcoholism (NIAAA) www.niaaa.nih.gov

National Institute of Justice (NIJ) www.ojp.usdoj.gov/nij

The Office of Juvenile Justice and 

Delinquency Prevention (OJJDP) www.ojjdp.ncjrs.org

National Institute of Corrections (NIC) www.nicic.org

Federal Bureau of Prisons

Substance Abuse Treatment

www.bop.gov/inmate_

programs/substance.jsp

National Criminal Justice Reference Service www.ncjrs.gov

Bureau of Justice Assistance Residential 

Substance Abuse Treatment (RSAT)

www.ojp.usdoj.gov/BJA/

evaluation/psi_rsat

FREQUENTLY ASKED QUESTIONS
30 31

Other Resources

Drug Strategies www.drugstrategies.org

Re-Entry Policy Council www.reentrypolicy.org

University of Washington 

Alcohol and Drug Abuse Institute

www.adai.washington.

edu/instruments

American Society of Addiction Medicine www.asam.org

TASC (Treatment Accountability 

for Safer Communities) www.nationaltasc.org

National Drug Court Institute www.ndci.org

Statistics

Bureau of Justice Statistics (BJS) 

Statistics on Drugs and Crime

www.ojp.usdoj.gov/

bjs/drugs.htm

Office of Applied Studies, Substance Abuse and 

Mental Health Services Administration (SAMHSA) www.oas.samhsa.gov

Research Centers and Programs

NIDA Criminal Justice Drug Abuse 

Treatment Studies (CJ-DATS) www.cjdats.org

Institute of Behavioral Research at Texas 

Christian University (IBR-TCU) www.ibr.tcu.edu

UCLA Integrated Substance

Abuse Programs (ISAP) www.uclaisap.org

University of Delaware 

Center for Drug and Alcohol Studies (CDAS) www.udel.edu/cdas

University of Maryland 

Bureau of Governmental Research www.bgr.umd.edu

University of New Mexico Center on Alcoholism, 

Substance Abuse, and Addictions http://casaa.unm.edu

Rutgers University Center for Mental Health 

Services & Criminal Justice Research www.cmhs-cjr.rutgers.edu

Urban Institute www.urban.org

The National Center on Addiction and 

Substance Abuse at Columbia University www.casacolumbia.org

RESOURCES

Screening and Assessment—Adults

Institute of Behavioral Research, Texas Christian 

University (TCU) Assessment Instruments

Researchers in the Institute of Behavioral Research at TCU have 

developed a number of useful instruments to screen individuals for 

drug use, to identify problem areas and determine client service 

needs, and to track progress through treatment. 

There are also tools to measure the program’s need for training 

and to help program directors and staff improve the quality of treatment. These measurement tools, which are listed below, can be found 

through the Web site listed below, at right.

TCU Drug Screen II (TCUDS)

(Available in English and Spanish)

www.ibr.tcu.edu/resources/

rc-correvaltrt.html

TCU Survey of Program Training Needs 

(PTN-S and PTN-D for Criminal Justice)

TCU Survey of Organizational Functioning

TCU-CJ-CESI (Client Evaluation of Self at 

Intake) Pretreatment Survey of Correctional 

Populations (Available in English and Spanish)

CJ-CEST Survey of Correctional Populations

(Client Evaluation of Self and Treatment)

(Available in English and Spanish)

Criminal Thinking Scales (CTS)

Chestnut Health Systems Global 

Appraisal of Individual Needs (GAIN) www.chestnut.org/LI/gain

Treatment Research Institute - The 

Addiction Severity Index (ASI) www.tresearch.org/asi.htm

Screening and Assessment—Adolescents

Overview of screening and assessment tools www.drugstrategies.org/

teens/screening.html

Economic Resources

Drug Abuse Treatment Cost 

Analysis Program (DATCAP) www.datcap.com
32 33

REFERENCES

Butzin, C.A.; Martin, S.S.; and Inciardi, J.A. Treatment during transition from 

prison to community and subsequent illicit drug use. Journal of Substance Abuse 

Treatment 28(4):351–358, 2005.

Glaze, L.E. and Palla, S. Probation and parole in the United States, 2003. 

Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of 

Justice Statistics, 2004.

Karberg, J.C. and James, D.J. Substance dependence, abuse, and treatment of 

jail inmates, 2002. Washington, DC: U.S. Department of Justice, Office of Justice 

Programs, Bureau of Justice Statistics, 2005.

Mumola, C.J. Substance abuse and treatment, state and federal prisoners, 1997. 

Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of 

Justice Statistics, 1999.

National Institute of Justice. 2000 Arrestee Drug Abuse Monitoring: Annual Report

(pp. 135–136). Washington, DC: U.S. Department of Justice, Office of Justice 

Programs, 2003.

Office of National Drug Control Policy. The Economic Costs of Drug Abuse in the 

United States, 1992–2002. Washington, DC: Executive Office of the President, 2004.

Staton, M.; Leukefeld, C.; and Webster, J.M. Substance use, health, and mental 

health: Problems and service utilization among incarcerated women. International 

Journal of Offender Therapy and Comparative Criminology 47(2):224–239, 2003. 

Teplin, L.A.; Abram, K.M.; McClelland, G.M.; Dulcan, M.K.; and Mericle, 

A.A. Psychiatric disorders in youth in juvenile detention. Archives of General 

Psychiatry 59(12):1133–1143, 2002.

Volkow, N.D.; Hitzemann, R.; Wang, G.J.; Fowler, J.S.; Wolf, A.P.; and Dewey, S.L.

Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184–

190, 1992.

Volkow, N.D.; Fowler, J.S.; Wang, G.J.; Hitzemann, R.; Logan, J.; Schlyer, D.; Dewey, 

S.; and Wolf, A.P. Decreased dopamine D2 receptor availability is associated with 

reduced frontal metabolism in cocaine abusers. Synapse 14:169–177, 1993.

For More Information

For more information about other research-based

publications on drug abuse and addiction, visit NIDA’s Web site

 at www.drugabuse.gov, or call the National Clearinghouse 

for Alcohol and Drug Information at 1-800–729–6686.