Compulsory

Treatment of

Drug Abuse:

Research and

Clinical Practice

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service • National Institutes of Health
Compulsory Treatment of Drug

Abuse: Research and Clinical

Practice

Editors:

Carl G. Leukefeld, D.S.W.

Frank M. Tims, Ph.D.

Division of Clinical Research

National Institute on Drug Abuse

NIDA Research Monograph 86

1988

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Institute on Drug Abuse

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Rockville, MD 20657

For sale by the Suprintendent of Documents, U.S. Government Printing Office

Washington, DC 20402
NIDA Research Monographs are prepared by the research divisions of the

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areas and techniques, the content of state-of-the-art conferences, and

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Temple University School of Medicine

Philadelphia, Pennsylvania

SYDNEY ARCHER, Ph.D.

Rensselaer Polytechnic lnstitute

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RICHARD E. BELLEVILLE, Ph.D.

NB Associates. Health Sciences

RockviIle. Maryland

KARST J. BESTEMAN

Alcohol and Drug Problems Association

of North America

Washington, D. C.

GILBERT J. BOTVIN, Ph.D.

Cornell University Medical College

New York, New York

JOSEPH V. BRADY, Ph.D.

The Johns Hopkins University School of

Medicine

Baltimore, Maryland

THEODORE J. CICERO, Ph. D.

Washington University School of

Medicine

St Louis, Missouri

MARY L. JACOBSON

National Federation of Parents for

Drug-Free Youth

Omaha, Nebraska

REESE T. JONES, M.D.

Langley Porter Neuropsychiatric lnstitute

San Francisco, California

DENISE KANDEL, Ph.D.

College of Physicians and Surgeons of

Columbia University

New York, New York

HERBERT KLEBER, M.D.

Yale University School of Medicine

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RICHARD RUSSO

New Jersey Stare Department of Health

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NIDA Research Monograph Series

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Director, NIDA

THEODORE M. PINKERT, M.D., J.D.

Acting Associate Director for Science. NIDA

Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857
Compulsory Treatment of Drug

Abuse: Research and Clinical

Practice
ACKNOWLEDGMENT

This monograph is based upon papers and discussion from a technical

review on civil commitment for drug abuse which took place on

January 26 and 27, 1987, in Rockville, MD. The review meeting was

sponsored by the Office of Science and the Division of Clinical

Research, National Institute on Drug Abuse.

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Opinions expressed in this volume are those of the authors and do

not necessarily reflect the opinions or official policy of the National

Institute on Drug Abuse or any other part of the U.S. Department of

Health and Human Services.

National Institute on Drug Abuse

NIH Publication No. 94-3713

Formerly DHHS Publication No. (ADM) 88-1578

Printed 1988 Reprinted 1994

NIDA Research Monographs are indexed in the Index Medicus. They

are selectively included in the coverage of American Statistics Index,

Biosciences Information Service, Chemical Abstracts, Current

Contents, Psychological Abstracts, and Psychopharmacology Abstracts.

iv
Contents

Page

An Introduction to Compulsory Treatment for

Drug Abuse: Clinical Practice and Research . . . . . . . . . . 1

Carl G. Leukefeld and Frank M. Tims

The Efficacy of Civil Commitment in Treating Narcotic

Addiction . . . . . . . . . . . . . . . . . . . . . . . . 8

M. Douglas Anglin

Clinical Experience With Civil Commitment. . . . . . . . . . . 35

James F. Maddux

The Criminal Justice Client in Drug Abuse Treatment. . . . . . . 57

Robert L. Hubbard, James J. Collins,

J. Valley Rachal, and Elizabeth R. Cavanaugh

Legal Status and Long-Term Outcomes for Addicts in

the DARP Followup Project . . . . . . . . . . . . . . . . .81

D. Dwayne Simpson and H. Jed Friend

Treatment Alternatives to Street Crime . . . . . . . . . . . . 99

L. Foster Cook, Beth A. Weinman et al.

The Criminal Justice System and Opiate Addiction:

A Historical Perspective . . . . . . . . . . . . . . . . . 108

Herman Joseph

Some Considerations on the Clinical Efficacy of Compulsory

Treatment: Reviewing the New York Experience . . . . . . . 126

James A. lnciardi

v
Identifying Drug-Abusing Criminals . . . . . . . . . . . . . 139

Eric D. Wish

Legal Pressure in Therapeutic Communities . . . . . . . . . 160

George De Leon

Basic Issues Pertaining to the Effectiveness of Methadone

Maintenance Treatment . . . . . . . . . . . . . . . . . 178

John C. Ball and Eric Corty

Civil Commitment—International Issues . . . . . . . . . . . 192

Barry S. Brown

The Costs of Crime and the Benefits of Drug Abuse

Treatment: A Cost-Benefit Analysis Using TOPS Data . . . . . 209

Henrick J. Harwood, Robert L. Hubbard,

James J. Collins, and J. Valley Rachel

Compulsory Treatment: A Review of Findings . . . . . . . . 236

Carl G. Leukefeld and Frank M. Tims

List of NIDA Research Monographs. . . . . . . . . . . . . 252

vi
An Introduction to Compulsory

Treatment for Drug Abuse:

Clinical Practice and Research

Carl G. Leukefeld and Frank M. Tims

INTRODUCTlON

Civil commitment as a form of compulsory treatment for the treatment of drug abusers has been legally possible in the United States

in the last 25 years (California Civil Addict Program, New York State

Civil Commitment, and the Federal Narcotic Addict Rehabilitation Act

(NARA)). The focus of civil commitment procedures has been on the

compulsive drug abusers, especially antisocial addicts responsible for

committing large numbers of criminal acts. Today the concept has

been suggested, by individuals in both the drug abuse and criminal

justice fields, for users of intravenous drugs, who are at risk for

contracting and transmitting the acquired immunodeficiency syndrome

(AIDS) virus and who are unwilling to enter treatment voluntarily.

The concept of compulsory treatment as a mechanism for reducing

the prevalence of drug abuse and the consequences of that abuse, for

both those individuals and U.S. society at large, is not new.

Compulsory treatment may be defined as activities that increase the

likelihood that drug abusers will enter and remain in treatment,

change their behavior in a socially desirable way, and sustain that

change. While the implementation and outcomes of the above civil

commitment programs differ to some extent, their intent and enabling

legislation were quite similar, as were their commitment procedures.

Their purpose was to control and rehabilitate the compulsive drug

abuser by providing drug abuse treatment, monitoring drug use, and

providing reasonable sanctions for program infractions.

Although the Federal and State civil commitment programs were only

in full operation for about a decade, 1965 to 1975, and were replaced

by a system of community drug treatment programs, the desire for

community programs to induce larger numbers of addicts into

1
treatment and the high number of prisoners with addiction histories

suggest that civil commitment be reexamined. Concern about the

spread of AIDS among intravenous drug abusers and from intravenous

drug abusers to their sexual partners and children has given renewed

impetus to such reexamination.

The relationship between heroin addiction and crime is well established (Anglin, this volume; Nurco 1986). Likewise, the relationship

of intravenous drug use and AIDS is well established, with 25 percent

of all AIDS cases related to intravenous drug use. This review

presents the convergence of knowledge regarding drug abuse treatment effectiveness with the emergence of the current AIDS problem

among intravenous drug abusers. AIDS is spreading among intravenous drug abusers through sharing of needles contaminated with the

human immunodeficiency virus (HIV). Through this sharing of

needles, it is believed that the vast majority of needle-using addicts

are at risk for contracting AIDS.

AIDS AND INTRAVENOUS DRUG USE

Currently, AIDS among intravenous drug abusers is largely confined

to the New York City/northern New Jersey metropolitan area, with

lesser concentrations in California, Florida, and Texas. The current

concentration of AIDS appears to be a temporal phenomenon—rates

are highest in those communities where AIDS was first detected.

Once introduced among intravenous drug abusers in a community,

infection spreads very rapidly. For example, the AIDS virus has been

detected in stored sera. First recognized among intravenous drug

abusers in New York City in 1978, infection rates were established at

40 percent in 1980 from stored blood and 60 percent in the latter

part of 1986. Rates of infection appear to be low in most of the

country, yet significant rates of infection are beginning to emerge in

some areas. With time, AIDS prevalence among intravenous drug

abusers is expected to increase rapidly in cities across the United

States.

The Public Health Service and the National Institute on Drug Abuse

(NIDA) have identified intravenous drug abusers as a major source for

the spread of AIDS to the heterosexual population. While data on

heterosexual AIDS transmission is incomplete, there is some indication

that transmission may occur fairly readily, at least among regular

sexual partners of persons with AIDS. Since many intravenous drug

abusers are sexually active, and since many female abusers resort to

prostitution to support their drug habits, the potential for the spread

2
of AIDS from intravenous drug abusers to the general population is

considerable, especially as HIV infection becomes more widespread

among intravenous drug abusers. This potential is of serious concern

for health-care delivery and drug abuse treatment programs, and for

the criminal justice system as well.

TREATMENT EFFECTIVENESS FOR INTRAVENOUS DRUG USERS

NIDA has sponsored research that suggests that treatment for drug

abuse is effective (Tims 1981; Tims and Ludford 1984). Clients

entering drug-free outpatient (counseling) programs, drug-free

residential (therapeutic community) treatment, and methadone

maintenance treatment generally experience dramatic reductions in

drug use and associated criminality. Many studies also show improvement in employment status and other behavioral outcomes among

treated drug abusers, The question of which treatment is superior

becomes clouded by the prevailing pattern for clients who have

multiple treatment experiences, often in more than one type of

program, before becoming abstinent from their principal drug of

abuse. This pattern of multiple treatments is reflected in a study by

Simpson and Sells (1982), in which opioid addicts were followed over

a 6-year period after admission to treatment. By the sixth year, 61

percent of these addicts were opioid abstinent and had been so for at

least 1 year. Treatment figured prominently in the attainment of

stable abstinence patterns, with about 80 percent of those abstinent

having achieved this status directly in connection with a treatment

episode. In addition to the 61 percent who were abstinent, 18

percent had given up daily opioid use but had other problems such as

occasional opioid use, heavy use of nonopioids or alcohol, or longterm incarceration. Thus, even though a significant number of clients

had other problems, only one-fifth of those treated continued their

pretreatment levels of opioid use at 6 years after leaving treatment.

Relapse prevention is an important component of treatment programming, and is the subject of ongoing research (Marlatt and George

1984; Tims and Leukefeld 1986). The greatest risk of relapse after

leaving treatment occurs during the first 90 days, at a time when

clients are exposed to drug-related stimuli, without the support of a

structured program to help resolve their conflicts. For this reason,

aftercare programs have been developed to follow up individuals in

the community, and to provide a resource to assist in maintaining the

client’s commitment to abstinence. Aftercare models include self-help

groups, such as Narcotics Anonymous, and approaches that stress the

development of coping skills through professionally guided self-help

3
training groups. Also, cognitive-behavioral models such as those

developed by Brownell et al. (1986) include coping strategies and

development of more effective perspectives on drug use “slips” and

relapse. Civil commitment programs also include a lengthy aftercare

component.

THE ROLE OF CIVIL COMMITMENT IN TREATMENT AND AIDS

CONTAINMENT

Recognizing that about 25 States have an existing civil commitment

statute, a panel of drug abuse treatment researchers met in January

1987 to examine the demand-reduction potential, clinical and therapeutic value, as well as costs/benefits associated with civil commitment for drug abusers from a public health perspective. The review

was to be the first meeting. After identifying the scientific base

during this meeting, additional efforts might focus on the pre- and

postadjudicatory mechanisms for mandatory treatment as well as on

national policy implications of compulsory treatment and civil

commitment.

The initial review was organized into five parts. Dr. Douglas Anglin

reviews data from several evaluations he completed on the California

Civil Addict Program. Dr. James Maddux, a former medical officer in

charge of the U.S. Public Health Service Fort Worth Narcotic

Hospital, reviews followup studies that compare compulsory followup

treatment and voluntary treatment of addicts released from the Public

Health Service hospitals in Fort Worth, TX and Lexington, KY. It

was suggested that emphasis be placed on what has been learned from

existing studies. Three major issues suggested for inclusion were:

(1) When is legal coercion therapeutically useful?

(2) What is legal coercion’s value in reducing the “contagious”

aspects of the drug-using lifestyle?

(3) Where and how has compulsory treatment and civil

commitment/legal coercion been used in the past?

It was also suggested that emphasis be placed on background,

overview, settings, and specific methodologies that are available for

better understanding compulsory treatment and civil commitment.

4
The first section, or group of papers, sets the stage with an overview

of compulsory treatment, civil commitment, court referral, and other

forms of legal coercion for drug abuse treatment.

The second section reviews long-term treatment evaluation studies by

focusing on the influence of judicial status—including probation,

parole, and mandatory release—on drug abuse, criminal behavior, and

related outcomes during and after treatment. Presentations included

longitudinal study results pertinent to compulsory treatment. A

description of the rationale, strengths, limitations, and generalizability

of findings is also incorporated. Dr. Robert Hubbard provides an

examination of clients involved in the Treatment Outcome Prospective

Study (TOPS), which confirms previous studies related to retention in

treatment and motivation by clients referred from the criminal justice

system and, more specifically, by Treatment Alternatives to Street

Crime (TASC). Dr. D. Dwayne Simpson reports on the influence of

pretreatment legal status 12 years after treatment for a group of

male addicts.

The third section reviews efficacy studies that focus on civil commitment, legal coercion, and court referral and highlights research

results and findings. The impact of civil commitment on treatment

outcomes and retention in treatment is stressed. Ms. Beth Weinman

describes TASC and discusses several evaluations of TASC.

Dr. Herman Joseph presents an historical perspective which focuses

on probation activities and diversion programs in New York City.

Dr. James lnciardi recalls his personal experiences as a staff member

in the New York Narcotics Addiction Control Commission, which had

responsibility for implementing the New York State Civil Commitment

Program. Dr. Eric Wish describes four approaches for identifying

drug abuse in the criminal justice system. Dr. George De Leon

reports on the linkage of therapeutic communities with the criminal

justice system and reviews data related to the effectiveness of

therapeutic communities. Dr. John Ball completes the presentations in

this group of papers by providing information from his study of

methadone maintenance programs.

The fourth section focuses on the costs and potential benefits from

civil commitment studies and related research. Dr. Barry Brown

examines civil commitment from the international perspective and

reports that little is known about costs and related benefits for civil

commitment internationally. He reviews the status of civil commitment in 43 countries. Dr. Henrick Harwood presents cost-benefit

5
information focused on TASC and other criminal justice system

programs.

Finally, the last section includes consensus statements of current

knowledge. In addition, the final section includes areas for future

research, which were developed during the consensus process.

Consensus development used the following issues as a frame of

reference:

Based upon the literature, how can the civil commitment process

be improved? Are there viable alternative models to civil

commitment which might be more productive/efficient from a

clinical/public health perspective?

What major research questions, strategies, and design features

should be incorporated into evaluative studies of compulsory

treatment and, more specifically, civil commitment?

What is the potential of compulsory treatment and civil

commitment for curbing the spread of AIDS?

REFERENCES

Brownell, K.D.; Marlatt, G.A.; Lichtenstein, E.; and Wilson, G.T.

Understanding and preventing relapse. Am Psychol 42:765-782,

1986.

Marlatt, G.A., and George, W.M. Relapse prevention: Introduction

and overview of the model. Br J Addict 79:261-273, 1984.

Nurco, D. Drug addiction and crime: A complicated issue. Br J

Addict 82:7-9, 1986.

Simpson, D.D., and Sells, S.B. Effectiveness of treatment for drug

abuse: An overview of the DARP research program. Adv Alcohol

Subst Abuse 2(1):7-29, 1982.

Tims, F.M. Effectiveness of Drug Abuse Treatment Programs.

National Institute on Drug Abuse Treatment Research Report.

DHHS Pub. No. (ADM) 84-1143. Washington, DC: Supt. of Docs.,

U.S. Govt. Print. Off., 1981. 181 pp.

Tims, F.M., and Leukefeld, C.G., eds. Relapse and Recovery in Drug

Abuse. National Institute on Drug Abuse Research Monograph 72.

DHHS Pub. No. (ADM) 86-1473. Washington, DC: U.S. Govt. Print.

Off., 1986. 197 pp.

6
Tims, F.M., and Ludford, J. Drug Abuse Treatment Evaluation:

Strategies, Progress, and Prospects. National Institute on Drug

Abuse Research Monograph 51. DHHS Pub. No. (ADM) 84-1329.

Washington, DC: U.S. Govt. Print. Off., 1984. 180 pp.

AUTHORS

Carl G. Leukefeld, D.S.W.

Frank M. Tims, Ph.D.

National Institute on Drug Abuse

National Institutes of Health

Parklawn Building, Room 10-A-38

5600 Fishers Lane

Rockville, MD 20857

7
The Efficacy of Civil Commitment

in Treating Narcotic Addiction

M. Douglas Anglin

INTRODUCTION

Civil commitment approaches to the control of narcotics addiction are

not new. The United States Public Health Service (USPHS) hospitals

in Fort Worth and Lexington represented an early attempt at

enforced treatment. Findings from the USPHS efforts in this respect

are reviewed by Maddux in this volume.

Before renewed consideration can be given to the compulsory commitment of drug addicts for treatment, it is crucial to determine whether

such treatment can be effective in reducing addiction, or at least in

minimizing the adverse social consequences of addiction. There have

been only a few studies that have addressed this question, and the

empirical evidence derived from most of them has been equivocal.

Most commitment programs implemented over the last 20 years were

based more on the hope that treatment would be effective than on

consistent and objective demonstration of efficacy.

In order to demonstrate conclusively whether enforced, or compulsory, treatment is effective, William H. McGlothlin and I conducted

an evaluation of the California Civil Addict Program (CAP), the first

true civil commitment program implemented in the United States

(McGlothlin et al. 1977).

BACKGROUND

The initial study was performed during 1974, 1975, and 1976. Nearly

1,000 individuals admitted to the California CAP from 1962 to 1964

for a 7-year period of commitment were selected for followup. For a

full description of the California CAP, see McGlothlin et al. 1977.

8
For other research results, see Anglin and McGlothlin 1984 and

Anglin, in press. Subsequently, in 1978, the combined effects of civil

commitment and methadone maintenance on another sample of

approximately 300 CAP admissions were studied (Anglin et al. 1981).

The first CAP study took advantage of a natural experiment that was

inadvertently created during the initial years of the program. The

laws creating the CAP were passed in 1961, and the program actually

began late in 1962. However, judges and other officials involved in

the initial implementation of the program were not very clear about

commitment procedures and thus made many procedural mistakes. In

the first 18 months of the program, therefore, nearly half the

individuals admitted were released on a writ of habeas corpus after

minimal exposure to the inpatient component.

This group thus encompassed people who were eligible for the

program and who had the same characteristics as others admitted to

the program, but who, because of what was apparently a semirandom process, were released after only a short time because of

procedural errors.

To take advantage of these circumstances, a treatment sample of

individuals was selected. These individuals had stayed in the program

for at least one inpatient stay and a subsequent release to supervised

community release, or outpatient status (OPS), and were matched with

individuals from among the group who had writted out. A time series

approach was used to study the data obtained from following up these

two groups.

OVERALL OUTCOMES OF CML COMMITMENT

Figure 1 is a time series graph from the original study. The

dependent variable was the percentage of time during each year that

narcotics were used on a daily basis. The solid line represents the

group that was admitted to the California Rehabilitation Center,

which is the inpatient facility for the CAP. The treatment sample

consisted of those who achieved at least one outpatient release.

Many of these, in fact, remained in the program for the full term.

The broken line represents those admissions who writted out after

minimal exposure to the program. They comprised the comparison

group. The break in the lines corresponds to the admission date to

the CAP. Eight years of preadmission data and 11 to 13 years of

postadmission data were obtained during the followup interviews.

9
FIGURE 1. Percent of nonincarcerated time using narcotics daily: CAP treatment and comparison samples
For part of the preadmission period, the treatment group reported

somewhat less daily narcotic use than did the comparison group. On

the whole, members of the treatment group spent an average of a

little over 40 percent of their time using narcotics daily before the 2

years immediately preceding commitment, compared to an average of

slightly less than 50 percent for the comparison group. For the 2

years before admission to the CAP, however, addiction levels for both

groups were “out of control,” and there was a sharp and converging

rise in the daily use of narcotics.

In the first year after release from treatment (either by writ or by

release to OPS), there was a sharp separation between the two

groups, with the comparison group using narcotics daily at a much

higher rate. Among the treatment group, an immediate and dramatic

drop occurred in daily narcotic use, which was sustained over the 5-

year period when most of the group were under supervision in the

CAP. After year 5, a time-related attenuation was evident, which

was associated with other social interventions and with maturing out

(Winick 1962). The comparison group showed a time-related attenuation over the entire postadmission period, eventually converging

toward the treatment group level by year 5.

Years 6, 7, and 8 show increased daily use levels by both groups.

Chronologically, that period occurred during a heroin epidemic in the

United States in the early 1970s. This concomitant increase in levels

of daily use by both CAP groups provides strong evidence that

consumption of heroin is directly related to availability of the drug.

Based on this time series data, it is clear that civil commitment has

an important and dramatic effect on suppressing daily heroin use by

narcotics addicts. However, the program was not just concerned with

narcotic use per se; it was also intended to affect addiction-related

behaviors, particularly those with adverse social consequences.

Figure 2 is a graph showing the reported percentage of time each

group engaged in property crime activities. Prior to admission, both

groups spent comparable amounts of time involved in the commission

of property crime. As before, a sharp and sustained reduction was

observed after admission for the treatment group, whereas the

comparison group shows only a time-related attenuation.

The differences observed in figures 1 and 2 must be considered as

minimal measures of the effects of civil commitment. In many

11
FIGURE 2. Percent of nonincarcerated time involved in property crime; CAP treatment and comparison samples
cases, individuals in the comparison group were not totally free of

legal supervision. Some were on parole or probation or were subject

to other types of supervision that also suppressed their narcotic use

and criminal behavior. Had this not been the case, their use levels

and crime rate would undoubtedly have been higher. Thus, the

difference between the curves gives only a minimum estimate of the

effectiveness of civil commitment.

Table 1 presents a complete set of dependent variables for both

groups, including employment, time spent dealing drugs, and so forth.

All these measures show similar effects to those observed in figures 1

and 2 for daily narcotics use and for property crime involvement.

However, as the behavior or measure becomes more prosocial, the

effect becomes less dramatic. Statistically significant increases in

employment were observed, for example, but the change was not

nearly as large as were reductions in antisocial behavior.

Table 1 shows the difference between the precommitment to postcommitment change in status and behavior for the treatment group and

the corresponding change for the comparison group. These data take

into account the initial precommitment levels of the variables and

determine the net difference in change scores for the two samples,

i.e., [comparison group postcommitment minus comparison group

precommitment] minus [treatment group postcommitment minus

treatment group precommitment].

Three periods are considered. Period I is the interval from time of

first narcotic use (N1) to civil commitment admission (A). Period II

is the 7 years after commitment, A to (A + 7), corresponding to the

full commitment term. Period Ill is the interval from A + 7 to the

interview (I), when, except for extended commitments, most of the

treatment group had been discharged from the CAP.

It must be noted that period II is defined on a purely chronological

basis, so that it represents the intended period of legal commitment.

Such a definition again gives a minimal estimate of the efficacy of

civil commitment, because a large minority of the treatment group

was released from CAP supervision before the imposed commitment

period expired. Reasons for early release included a determination as

unfit for treatment, incarceration for criminal offenses, and, less

often, graduation in good standing.

To test the sample differences for statistical significance, the data

are expressed in terms of the means of the individual measures. The

13
TABLE 1. Summary of mean precommitment and postcommitment status and behavior for comparison (C) and

treatment (T) samples
TABLE 1. (Continued)

1Data on arrests, self-reported crimes, and income from crime are rates per nonincarcerated person-year. Crime income does not include

drug dealing, gambling. etc.

2Heavy alcohol use is defined as drinking a six-pack of beer, or a bottle of wine, or seven drinks of liquor over a 6-hour period two or

more times per week.

NOTE: Period I=First narcotic use (N1) to civil commitment (A); Period II=A to (A + 7 years). the legislated period of commitment; Period

Ill=(A + 7 years) to time of interview (I). The percentages in this table are the mean of individual percentages for the

respective periods. not the percentage of the overall parson-months.

SOURCE: McGlothlin et al. 1977.
right half table 1 shows the difference between the change scores

and the corresponding t-ratio. For example, the difference between

drug arrest change scores between periods I and II is:

(TII-TI)-(CII-CI)=(.53-0.83)(-0.95-1.06)=-0.19.

Thus, the decrease in the drug arrest rate from preadmission, period

I, to postadmission, period II, for the treatment group was about 19

percent more than the corresponding change for the comparison

group. There was also a 40 percent greater reduction in nondrug

arrests. There was, however, an expected increase in parole violations (34 percent larger), because members of the treatment group

were on a lengthy supervised outpatient status and so were at risk

for administrative violation more often than the comparison group. It

should be noted that the violation increase did not even reach the

level of decrease in nondrug arrests, and certainly not the decrease

in the nondrug and drug arrests combined. Clearly, the CAP

benefited other agencies in the CJS by reducing criminal activity and

by handling individuals under civil commitment authority internally

rather than by instituting new and costly legal proceedings.

In general, members of the treatment group spent about 2 percent

more time incarcerated during the aftercare period, a negligible

difference. They spent 29 percent more time under legal supervision,

an expected difference because supervised community aftercare is a

strong component of the CAP. Their daily narcotic use was down 15

percent more. Their criminal activities were down by 12 percent

more if percent of time involved in property crime was the measure,

but were down 36 percent more when the number of crimes committed was the measure, and down 32 percent more when mean

income from crime was the measure. Their dealing was down 5

percent more, their employment was up by 7 percent more, and their

alcohol abuse was down 3 percent more (not statistically significant).

For a composite score—the percentage of time alive, not incarcerated,

and not using drugs daily—the change in the treatment group was 7

percent higher than the comparison group. Except for the daily

narcotic use and crime reductions, these changes were moderate for

the most part.

EFFECTIVE ELEMENTS OF CIVIL COMMITMENT

What is the component of civil commitment that produces the

greatest effect? While some period of inpatient care may be

necessary in the majority of cases, it is apparently the close

16
community supervision, with objective narcotics testing, that is most

important. To test the assumption that the level of legal supervision makes a critical difference in daily narcotic use, the data was

aggregated into periods when the subjects were under different types

of supervision. Figure 3 presents the results for daily narcotic use.

Before 1960, only data for no supervision and various legal supervisions (e.g., probation or parole) without drug testing was available

for our subjects. The graphs for these two conditions are very

similar. After 1960, sufficient data were available to construct

graphs for legal supervision with testing and for abscondence from

supervised conditions. After 1964, OPS data became available. OPS

differed from other legal supervisions with testing because of

specially trained parole officers, smaller case loads, and more

frequent drug testing.

It is clear that the level of supervision exemplified by OPS produced

the best results in reducing daily narcotic use for each of the 2-year

intervals for which data were available. The next most effective

approach over all the periods, although it fluctuated somewhat more,

was legal supervision with testing. The least effective, as might be

expected, was absconded status. In this condition, individuals under

supervision either rejected the degree of control exercised by their

parole officers, or got out of control in their drug use or other

behavior, and fled rather than wait for violation to occur.

Data from absconded periods are important because addicts in

abscondence represent a failure of the CJS to maintain control.

Absconding also becomes more common as controls become stricter.

Thus, it is necessary to balance the level of constraint that supervision places on addicts against the likelihood that they will abscond

if the control becomes too severe.

In its initial 6 to 8 years, the CAP was a very stringent program.

Addicts spent an average of 18 months incarcerated in the inpatient

phase. They were then released to the aftercare, or outpatient,

phase where they were closely and severely monitored to induce them

to remain drug free. The popular expression of parole agents was

“You use, you lose.” Outpatients who were detected in any narcotic

use violations were usually returned to the institution for another

incarceration period.

17
FIGURE 3. Percent of nonincarcerated time using narcotics daily as a function of legal supervisory status; total

CAP sample
In the 1970s, the program became more liberal, in both its inpatient

and outpatient requirements. The initial inpatient stays became

shorter and addicts who used drugs or otherwise violated parole

conditions were reincarcerated for a limited placement of 36 to 60

days. In the OPS phase, some infrequent drug use was tolerated if

the overall behavioral pattern of the addict was acceptable.

Although not presented here, our research findings for a 1970 CAP

treatment sample showed poorer outcomes resulting from these policy

changes (McGlothlin et al. 1977). Nevertheless, after the increasing

popularity of methadone maintenance (MM) in the 1970s, this later

CAP treatment sample performed as well as the earlier CAP treatment

group because a substantial minority entered MM.

While the more frequent and consistent OPS monitoring of the earlier

period was also more effective, for both program periods it was clear

that rigid application of policies that routinely returned individuals to

inpatient care could result in poorer outcomes for some (Jamison and

McGlothlin, in press). The best approach appeared to be a flexible

relationship between the parole officer and the parolee, in which the

parole officer had some sort of leverage to “bargain” for better

behavior. It became something of a therapeutic conspiracy between

some parole officers and their wards, “Well, you’ve been dirty once.

Now if you don’t give me another dirty, I won’t report it to my

superiors.” Some parole supervisors would accept this arrangement

and would tolerate occasional narcotic use as long as agents were

effective in preventing rearrest or a relapse to addiction. This sort

of bargaining seemed to work better than the parole officer who said,

“lf I find you dirty once, you’re going back in. If you hang around

with some of your old friends, you’re going back in.” That sort of

rigid application of policy often resulted in parolees absconding and

subsequently relapsing to high levels of addiction, dealing, and crime.

SUMMARY OF FINDINGS

Based on the data presented here and on other data, the most

effective civil commitment approach for narcotic addicts is to place

them on long-term parole, 5 to 10 years, so that their drug use and

other behavior can be closely monitored. While an inpatient period

may often be required initially, a few months should suffice to

stabilize the addict; inpatient time should be protracted only if the

addict needs vocational or educational training or for other reasons

unrelated to their addiction.

19
Once released to the community, frequent and careful monitoring is

required, using urine assays or other objective tests. lf relapse to

narcotic use, property crime, or dealing becomes apparent, only a

short return to the inpatient facility, at most 30 to 90 days, is

required to detoxify addicts and ready them for release again.

It is important to remember that the measure of recidivism often

used by the CJS for evaluation is not a particularly useful one in

assessing treatment outcomes for narcotic addicts. When dealing with

something of such a chronic relapsing nature as addiction, different

measures are more appropriate. The same perspective should be

applied to narcotic addiction control as many mental health professionals take toward intervention with the chronically mentally ill:

such intervention requires a lengthy, if not lifetime, management

program. lt is unrealistic to expect a cure, e.g., successfully

maintained abstinence, in the majority of addicts who frequently come

into contact with the CJS (Anglin and McGlothlin 1985). Instead, to

evaluate interventions properly, it is important to use such measures

as how much less time is spent incarcerated, how many fewer

relapses occur, and how much less time after the intervention is

spent using at an addicted level.

It would appear that an assessment of the CAP treatment and

comparison groups for recidivism or relapse rate alone would have

shown few differences between them. Nearly everyone in each group

became readdicted at some point after intervention, but the treatment

group had fewer such multiple instances, and when they did occur,

they were of shorter duration. There were also longer nonaddicted

periods of controlled use, or even abstinent periods, separating their

relapses.

Such realistic expectations should structure the major goals of civil

commitment. Although a small number of addicts do mature out of

their addiction every year, social policy efforts must be directed

toward long-term management programs using the CJS and treatment

to effectively minimize the adverse individual and social consequences

of addiction.

MM AND CIVIL COMMITMENT

Because long-term followup information was obtained on the addiction

career, the study was able to examine the effects of MM for some

who had been civilly committed. As noted earlier, the CAP program

began in 1962. MM did not become generally available in California

20
until after 1970. Subjects were interviewed in 1974 and 1975, about 3

years of followup data were available for those among the civil addict

sample who subsequently entered MM.

For analysis purposes, MM participation included any MM program

that our subjects encountered, however administered in their local

area. Subjects were divided into three groups depending on their

narcotic use and treatment status during the 3 years before the

interview. The “inactive” group included subjects who had shown

minimal daily (addicted) narcotic use in the 3 years before the

interview and were not in treatment. The “active” group comprised

subjects who showed considerable daily narcotic use in the 3 years

before the interview but had not entered treatment. The “methadone”

group had entered treatment at some time during the 3-year period.

The activities of each group were traced backwards using the actual

MM admission date as a reference point for the methadone group.

The median admission date for the methadone group was used as the

reference point for the inactive and active groups. The results for

daily use of narcotics are shown in figure 4. (The reference point is

indicated by an “M” on the abscissa).

Ten years before the MM admission date, just before most of the

subjects entered the CAP, there was little difference among the

groups. The CAP period started about years 8 and 9 before admission

and continued until about year 4. Over this 5- to 6-year period,

there is a dramatic separation in the level of daily narcotic use for

the groups. Those designated as active reduced their daily narcotics

use only minimally over the period of CAP supervision. (This period

of supervision is marked by dashes along the abscissa.) As soon as

supervision ended, there was a “bounce-back” effect in which actives

actually exceeded their precommitment daily narcotics use. Part of

this increase, however, was due to a heroin epidemic in the United

States (marked by asterisks along the abscissa).

The methadone group apparently was comprised of subjects who

responded reasonably well to the CAP by decreasing their addicted

level of narcotic use, but who also rebounded on discharge to a level

similar to that observed for the pre-CAP period. After MM entry,

this group demonstrated a dramatic decrease in daily use that

continued during the 3 years of followup. The inactive group, which

apparently matured out of addiction over time, responded ideally to

the CAP intent. These civil commitments reduced their daily narcotic

21
FIGURE 4. Percent of nonincarcerated time using narcotics daily; CAP inactive, active, and methadone

subsamples
use to a considerable degree over the prescribed commitment period.

By the time they were released, sufficient gains had been achieved

and stabilized so that these improvements could be independently

sustained in the community.

The important point these findings demonstrate for civil commitment

is that, no matter what the behavioral characteristics of the group or

their addiction career patterns, civil commitment produced desirable

effects to some degree for all types of admissions. Apparently, the

approach is a type of control that is differentially effective even on

the most recalcitrant of offenders.

Figure 5 is structured in the same manner as figure 4, only the

measure displayed is property crime involvement. The pattern of

change over the course of the CAP and MM is very similar to that

seen for daily narcotic use. For the same three groups, similar

suppression occurs during the CAP, with the same rebound effects for

the first two groups, after discharge, and the sustained low criminality for the inactive group. These results are further compelling

evidence that civil commitment and MM are generally efficacious

interventions and each has an appropriate application.

The findings presented above have occasionally been criticized on the

grounds that the data about the civil commitment program are

“contaminated” because some of the subjects have been on MM. That

is not the case, however.

First, the data points in the time series before 1971 are uncontaminated by MM, and one sees strong effects due solely to CAP

intervention (figures 1 and 2). Second, the addicts on MM were

segregated into a separate group in figures 4 and 5, and the effects

remain for the two groups that had never been involved with MM.

Despite the observed efficacy of the California CAP, these studies

have revealed several shortcomings that limited its overall utility.

Interviews with Hispanics in the program, for example, indicated that

they did not like the large group therapy format that required

discussion of personal thoughts, feelings, and behavior with others,

particularly with individuals of other ethnic groups. Therapy for

Hispanics might be more effective if they were assigned to a group

of their own, or if individual counseling were employed more often.

Such an approach could, however, lead to charges of racism, which

might dilute the comprehensive effectiveness of the program.

23
FIGURE 5. Percent of nonincarcerated time involved in property crime: CAP inactive, active, and methadone

subsamples
Furthermore, since 1980, the length of the commitment period has

been shortened from 7 years to a much shorter period that is set by

the California determinant sentence law. Although there is no

explicit evidence about the effect of this change, previous research

and experience indicate that the success of treatment is directly

related to the length of participation in the program. Therefore,

shortening the total length of the treatment program has likely

reduced its effectiveness. Determining the effects of this change

would be an appropriate subject for future research.

OTHER CIVIL COMMITMENT EFFORTS

Three major civil commitment programs have been tried in the United

States; each is discussed in this volume. The first of these was the

California CAP. Because of its relative success, New York began a

civil commitment program (Inciardi, this volume), and the Federal

Government passed the Narcotics Addiction Rehabilitation Act (NARA)

(Maddux, this volume), which also created a civil commitment

program. On the whole, the laws creating the new programs were

not very different from the California law. In general, the same

procedures were mandated: a diversion during criminal adjudication

from incarceration in jail or prison to a narcotic treatment facility or

program. There was also provision for the involuntary commitment of

addicted individuals who did not have any criminal charges against

them. This provision, however, was used relatively infrequently in

the California program, and is not used at all today, except in rare

instances. Involuntary commitment without criminal charges was also

infrequently used in the New York and NARA programs.

The general consensus of several authors is that the New York

program was pretty much a failure. James lnciardi presents this

conclusion elsewhere in this volume. Also, Titles I and Ill of the

Federal NARA did not fare well upon evaluation (Lindblad and

Besteman, in press). But Title II, administered by the Federal Bureau

of Prisons, was more efficacious (Kitchener and Teitelbaum, in press).

Most researchers in the field agree that implementation strategies

produced the outcome differences for the various civil commitment

programs reviewed in this volume. While it is possible to develop

reasonable social intervention policies that achieve good behavioral

outcomes when properly applied, how the policies are implemented can

ensure or sabotage success.

25
New York’s program was not particularly successful partly because it

was implemented through the State’s social welfare agency, rather

than through an established agency with experience in dealing with

addicts and addicted behavior. The Federal NARA program had

minimal results for Title I and Ill commitments for similar reasons.

In contrast, California’s and NARA’s Title II programs were implemented through the CJS, specifically the California Department of

Corrections and the Federal Bureau of Prisons, and both worked

reasonably well, or as well as any other type of intervention has

worked for the narcotic addict.

BEYOND CIVIL COMMITMENT

Many of the basic drug treatment programs now in the community did

not become established nationwide until after the NARA was passed;

in fact, NARA funding provided seed money for getting many

community programs started. It was not until the mid-1970s that a

broadly based infrastructure for community treatment was developed.

In the ensuing years, a “shotgun” marriage occurred between the

treatment community and the CJS, with many individuals referred to

drug treatment by the courts, probation, or parole. In essence, there

has developed a kind of de facto coercive structure in court,

probation, and parole referrals to drug treatment that is similar to

compulsory treatment efforts, albeit somewhat more haphazard and

less coordinated. Because of this development, some recent research

conducted at UCLA has not involved civil commitment per se, but

instead has studied CJS referrals to treatment in California.

LEGAL COERCION INTO COMMUNITY TREATMENT

Subjects from two studies of MM clients were asked why they had

entered MM or therapeutic community treatment programs. Two

cohorts were established: a Southern California cohort of 1971 to

1973 admissions to MM and a 1976 to 1978 cross-section cohort of

clients in MM treatment (Anglin and McGlothlin 1985; Anglin et al.,

in press). For each cohort, the total number of treatment entries for

MM and therapeutic communities and the self-reported reasons for

entry were determined. The results are shown in table 2.

In the admission cohort, 46 percent of those entering MM gave a

legal reason that motivated their entry. These reasons could be

subdivided into pressure from police, pressure from probation or

parole, pressure from the courts, and indirect pressure (“The cop on

26
TABLE 2. Major self-reported reasons for treatment entries for southern California programs (percent)

NOTE: MM=Methadone Maintenance: TC=Therapeutic Commmunity; P.O.=Probation or Parole officer.
the beat said he would bust me if I didn’t get some help,” or “I was

so well-known in the community that it was just a matter of time..”).

All of these situations represented some level of legal coercion into

treatment.

Among those from the admissions cohort who entered therapeutic

communities (which represent a less desirable situation for the addicts

because they are, in effect, restricted to a residential facility for a

period of time), 73 percent reported legal coercion as the main

reason for their entry into the program. Simply put, the threshold

level of coercion for motivating someone to enter treatment is higher

for therapeutic communities than for MM programs.

The same pattern was observed for the cross-section sample and for

both sexes. In this cohort, for MM entries, 36 percent of the men

and 21 percent of the women reported legal coercion. For those

entering therapeutic communities, 66 percent of the men and 54

percent of the women reported legal coercion.

Other reasons for entering treatment were more indeterminate, and

some of the classifications represent our best coding of open-ended

types of answers. The answers may have been as vague as a desire

to use less heroin. As is clear from the table, after legal reasons,

the most important reasons are either attempts to lower heroin use

or they reflect “burn out” with the addict lifestyle.

EFFECTS OF LEGAL COERCION INTO TREATMENT

Because there is a common belief that people entering treatment

under legal coercion do not do as well as volunteer admissions, this

presumption was tested by subdividing the admissions cohort into

three smaller groups: those who came in under moderate legal

coercion, those who came in under high legal coercion, and those

who reported no legal coercion and thus entered for “more voluntary

reasons.” High legal coercion was defined as having an active legal

supervision, with urine monitoring at entry and/or a self-perceived

legal coercion. Moderate legal supervision did not require either the

testing condition or the self-perception of coercion. Approximately

half of these combined categories contained individuals under

supervision by the CAP.

Possible differences in performance among these groups during their

first MM treatment episode were examined. Table 3 presents

behavioral variables under the three levels of legal coercion. As can

28
TABLE 3. During treatment behavior of MM admissions entering under no, moderate, and high legal coercion*

No Coercion Moderate Coercion High Coercion F-value

(n=84) (n=101) (n=111)

#Months MI-MD

CJS Legal Supervision

3 1

8 3

Criminal Activities

Property Crime

Number Crimes/Month

Crime Income/Month

Dealing

Dealing Income/Week

Drug Involvement

Daily Narcotic Use

lrregular Narcotic Use

No Use

Heavy Alcohol Use

Daily Marijuana Use

30

5

15.76 18.40 16.64

2.59 3.71 2.69

151.72 360.39 205.29

25.93 23.13 26.48

50.93 52.13 40.37

11.36 14.96 14.20 0.01

40.91 37.42 36.76 0.16

47.71 47.61 47.02 0.01

39.27 40.61 41.08 0.04

14.66 7.10 12.66 1.63

27 0.42

67 331.21**

0.19

0.58

2.48

0.48

0.11
TABLE 3. (Continued)

No Coercion Moderate Coercion

(n=84) (n=101)

High Coercion

(n=111)

F-value

Social Activities

Working

Work Income/Week

Married

Common-Law Relationship

56.59 57.67 54.50 0.15

93.77 101.61 91.74 0.34

40.89 42.63 35.31 0.69

33.61 35.92 44.46 1.59

*Unless otherwise noted, all measures represent percent of nonincarcerated time in the indicated status.

**p<.001

Ml=Methadone Intake

MD=Methadone Discharge
be seen, no significant differences occur for the period after entry

into treatment and treatment discharge, other than for percent of

time under CJS supervision.

The difference with respect to supervision level is to be expected

because it is an artifact of the way we have defined legal coercion.

However, criminal activities, drug involvement, and social activities of

these groups are essentially the same. These groups cannot be

distinguished in terms of their behaviors.

Since these three groups cannot be differentiated other than on the

level of coercion used to bring them into treatment, the findings

have very important social policy implications. The results provide a

powerful argument for a general social policy of using CJS coercion

to bring into treatment as many people as possible by whatever legal

means available. After all, until addicts are exposed to an environment where intervention can occur and are retained for a sufficient

period to produce and maintain positive outcomes, change cannot be

expected.

The advent of AIDS, where treatment seems to act as a buffer

against the probability of infection, is an added incentive for

following this policy. Based on the cumulative findings presented

above, civil commitment and other forms of legal coercion, when

properly implemented, work and seem to work for a majority of

addicts. Such efforts should be considered for much stronger

implementation, both in isolation, for addict offenders reluctant to

enter community treatment programs, and in cooperation with

treatment, as in the Federal TASC program (Hubbard, this volume).

CONCLUSIONS

The general conclusion from studies of the California CAP is that

civil commitment and other drug treatment initiatives, particularly

MM, are effective ways to reduce narcotics addiction and to minimize

the adverse social effects associated with it. How an individual is

exposed to treatment seems to be irrelevant. What is important is

that the narcotics addict must be brought into an environment where

intervention can occur over time. Civil commitment and other legally

coercive measures are useful and proven strategies to get people into

a treatment program when they will not enter voluntarily. The use

of such measures, in a better coordinated and expanded fashion, could

produce significant individual and social benefits.

31
While this conclusion is amply supported by research findings, given

the current state of treatment availability in the United States, it is

one that should not necessarily be immediately implemented until

other changes have been made in the treatment delivery system.

Funding for drug abuse treatment, particularly programs for narcotic

addiction, has been reduced during the last decade to a point where

relatively long waiting lists exist for most publicly funded programs.

Unless funding is provided to create new programs or to expand

existing ones, the coercion or commitment of individuals into drug

treatment will only exacerbate the current situation.

Further, little or no widespread outreach efforts exist to induce drug

abusers to enter treatment voluntarily. Such efforts would certainly

increase the population in treatment at a lesser implementation cost.

Without these two changes, civil commitment then would be appropriate only for a limited number of addicts who are unlikely to

enter treatment otherwise, and who are sufficiently problematic in

their behavior to warrant commitment.

Several features characterize an effective civil commitment program.

Inpatient care should be an option, and close monitoring with regular

urine testing of parolees in the community is essential. Despite the

need for testing, supervision of parolees should not be so strict that

they abscond rather than remain in the program. Parole officers

should have the flexibility to allow parolees to remain on the streets

if they test positive in only a few instances, or at widely spaced

intervals. As a useful adjunct for the CJS effort, MM is an

extremely valuable tool for limiting narcotics use, and its availability

should be expanded.

The general processes related to the cessation of narcotics use, or

maturing out (Winick 1962; Anglin et al. 1966; and Brecht et al. 1987),

are probabilistic and time-related ones. A small but accumulating

percentage of identified addicts will stop using narcotics on an

addicted basis in each year after intervention. Some parameters that

differentially influence that percentage can be specified, but their

effect is not very large in the short term. The chronic relapsing

nature of narcotic addiction, requires a long-term monitoring effort

like civil commitment, in combination with community treatment, so

that the percentage ceasing addicted use in any year can be maximized, and the duration of individual addiction careers—and their

cost to society—can be minimized.

32
REFERENCES

Anglin, M.D. Civil commitment as a model for reducing drug demand.

Perspectives on Drug Abuse, in press.

Anglin, M.D.; Brecht, M.D.; Woodward, J.A.; and Bonett, D.G. An

empirical study of maturing out: Conditional factors. Int J Addict

21:233-246, 1986.

Anglin, M.D.; McGlothlin, W.H.; and Speckart, G. Effect of parole on

methadone patient behavior. Am J Drug Alcohol Abuse 8:153-170,

1981.

Anglin, M.D., and McGlothlin, W.H. Outcome of narcotic addict

treatment in California. In: Tims, F., and Ludford, J., eds. Drug

Abuse Treatment Evaluation: Strategies, Progress, and Prospects.

National Institute on Drug Abuse Research Monograph 51. DHHS

Pub. No. (ADM) 84-1349. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1984. pp. 106-128.

Anglin, M.D., and McGlothlin, W.H. Methadone maintenance in

California: A decade’s experience. In: Brill, L., and Winick, C.,

eds. The Yearbook Of Substance Use and Abuse. Vol. III. New

York: Human Sciences Press, Inc., 1985. pp. 219-280.

Anglin, M.D.; McGlothlin, W.H.; Speckart, G.; Ryan, T.; and Booth, M.

Consequences and costs of shutting off methadone. Perspectives on

Drug Abuse, in press.

Brecht, M.L.; Anglin, M.D.; Woodward, J.A.; and Bonett, D.G.

Conditional factors of maturing out: Personal resources and

preaddiction sociopathy. Int J Addict 22(1):55-69, 1987.

Jamison, K.R., and McGlothlin, W.H. California Civil Addict Program

parole: Addicts and agents: Same rules, different games. In:

McGlothlin, W.H., and Anglin, M.D., eds. The Compulsory Treatment of Opiate Dependence, in press.

Kitchener, H.L., and Teitelbaum, H.E. A review of research on

implementation of NARA Title II in the Federal Bureau of Prisons.

In: McGlothlin, W.H., and Anglin, M.D., eds. The Compulsory

Treatment of Opiate Dependence, in press.

Lindblad, R.A., and Besteman, K.J. A national civil commitment

program for treatment of drug addiction. In: McGlothlin, W.H.,

and Anglin, M.D., eds. The Compulsory Treatment of Opiate

Dependence, in press.

McGlothlin, W.H.; Anglin, M.D.; and Wilson, B.D. An Evaluation of

the California Civil Addict Program. National Institute on Drug

Abuse Services Research Monograph Series. DHEW Pub. No. (ADM)

78-558. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1977. 102 pp.

33
Winick, C. Maturing out of narcotic addiction. Bull Narc 14:1-7,

1962.

ACKNOWLEDGMENTS

Preparation of this article was supported by NIH Grant number

86-IJ-CX-0069, National Institute on Drug Abuse Grant numbers

DA03425 and DA03541, and contract D-0053-5 from the California

Department of Alcohol and Drug Programs.

AUTHOR

M. Douglas Anglin, Ph.D.

UCLA Drug Abuse Research Group

1100 Glendon Avenue, Suite 763

Los Angeles, CA 90024-3511

34
Clinical Experience With Civil

Commitment

James F. Maddux

INTRODUCTlON

Unfortunately, many compulsive users of psychoactive substances

enter treatment only when under legal coercion. Even those who

enter voluntarily often do so under some form of social or pharmacological coercion, such as pressure from family or friends, perceived

imminent arrest, loss of regular drug seller, or inability to pay the

cost of an increasing daily dosage. With or without external

coercion, nearly all seem to have an ambivalent attitude toward their

substance dependence. They want to free themselves of the burden

and consequences of substance dependence, but they also want the

effects of the substance. In an individual at different times, one

desire or the other becomes dominant. Among contemporary opioid

users, two other personality attributes often adversely affect engagement in treatment. The first, variously labeled psychopathy, psychopathic deviance, sociopathy, antisocial behavior, or antisocial attitude,

has often been reported as a noteworthy personality feature of opioid

users. The other, variously labeled impulsivity, low frustration

tolerance, or inability to delay gratification, has also been frequently

reported among opioid users (Maddux et al. 1986). An ambivalent

attitude toward the drug dependence, together with an antisocial

attitude and a low tolerance for distress, create a conflicted and

unstable motivation for treatment. This unstable motivation has

represented a major problem in the treatment of opioid dependence.

In this chapter, clinical experience with opioid addicts in treatment

voluntarily under varied criminal law coercions and under civil commitment is reviewed. Experience at the two former Public Health

Service (PHS) hospitals at Lexington, KY, and Fort Worth, TX, is

35
described. The effect of varied treatment and correctional interactions on long-term outcomes is estimated.

PREMATURE DEPARTURE OF VOLUNTARY PATIENTS

In 1936, the first annual report of the PHS hospital at Lexington

stated that treatment of voluntary patients had not been very

effective because most of them left before treatment was completed.

Although the Lexington PHS hospital and its sister hospital (opened

in 1938 at Fort Worth) were established primarily to care for narcotics addicts convicted of Federal law violations, the two hospitals

were also authorized to admit and treat voluntary patients. Most

admissions to both hospitals were voluntary from 1935 until 1968,

when admission of voluntary patients ceased. Approximately 70

percent of the voluntary patients signed out against medical advice

before completing treatment (Rasor and Maddux 1966). Most of those

who remained to complete treatment had the legal pressure of probation from a State court (Levine and Monroe 1964).

The hospital programs were designed to treat not only withdrawal

illness but also the drug-using habit and associated mental and social

problemS as well. The treatment programs included four fairly

distinct elements: drug withdrawal, residence in a drug-free environment, psychotherapy, and supervised activities (Kolb 1939; Kolb

and Himmelsbach 1938; Kolb and Ossenfort 1938). The recommended

duration of hospital treatment was 6 months, but this was later

reduced to 4 months. The supervised activities came to include work,

vocational training, remedial education, and recreational activities.

Medical care, dental care, social work service, and religious services

were provided.

Nearly all of the professional staff viewed drug withdrawal as a

preliminary or minor aspect of treatment, with the important therapeutic work to come later. Consequently, the departure of most

voluntary patients during or shortly after withdrawal became a source

of continuing frustration for the staff. Usually the voluntary

patients signed out silently, but some gave reasons for leaving, such

as: I came only to reduce my habit; I’m not getting enough methadone; I want to go to work; I need to take care of family problems

(Maddux et al. 1971). Whatever the reasons, most voluntary patients

would not or could not stay to complete the treatment program.

36
In 1946, the “Blue Grass” admission was initiated at the Lexington

hospital to reduce premature departures (Kay 1974). The Commonwealth of Kentucky made habitual narcotics use a misdemeanor, with

punishment of up to 1 year in jail. Patients who left against advice

were readmitted only if they pleaded guilty to narcotic use in a

Kentucky court. The consequent sentence was then suspended on

condition that the person stay at the Lexington hospital until

treatment was completed. If the patient attempted to leave prematurely, the local sheriff was notified. The Blue Grass procedure

came into disfavor because patients were required to obtain a

criminal conviction as a condition of admission to the hospital, and

was discontinued about 1956. During the 1950s hospital staff

members recommended enactment of a Federal civil commitment law

for narcotic addicts, but legal counsel in the Department of Health,

Education, and Welfare considered such a law unconstitutional.

EARLY FOLLOWUP STUDIES

Several followup studies from 1943 into the 1960s indicated that

addicts treated under legal coercion had better outcomes than others.

Pescor’s (1943) followup study suggested that paroled prisoners and

probationers had better outcomes than voluntary patients (table 1).

However, prisoners without compulsory posthospital supervision did no

better than the voluntary patients. The Hunt and Odoroff study

(1962) showed that nonvoluntary patients did better than voluntary

TABLE 1. Percentage of opioid addicts continuously abstinent for 6

months or longer after discharge from Lexington PHS

hospital, by hospital status

Hospital Status Percentage Abstinent

Voluntary (n=1206) 13

Probation (n=491) 27

Paroled Prisoner (n=110) 31

Other Prisoner (n=2895) 10

SOURCE: Pescor 1943.

37
TABLE 2. Percentage of opioid addicts found continuously abstinent 1

to 4 1/2 years after discharge from Lexington PHS

hospital, by hospital status

Hospital Status Percentage Abstinent

Voluntary (n=1503) 6

Nonvoluntary (n=378) 11

SOURCE: Hunt and Odoroff 1962.

patients (table 2). Duvall et al. (1963) reported, however, that

voluntary black males had better outcomes than black male prisoners

(table 3). All of these studies had methodological problems, and, in

the case of the Duvall study, the small number of prisoners creates a

problem in interpretation. An increase of one abstinent prisoner

would increase the percentage abstinent from 4 to 8 percent.

Vaillant’s (1966a; Vaillant 1966b) 12-year followup study tended to

confirm Pescor’s finding of two decades earlier with respect to the

importance of postinstitution parole. Table 4 shows that only 4

percent of voluntary hospitalizations, but 67 percent of prison/parole

combinations were followed by postinstitution abstinence for 1 year.

These data also present a problem in interpretation because only 100

subjects were followed, and what is included in the table are episodes

of institutionalization of subjects over a 12-year period. The

episodes are not mutually independent.

TABLE 3. Percentage of black male addicts abstinent 6 months after

discharge from Lexington PHS hospital, by hospital status

Hospital Status Percentage Abstinent

Voluntary (n=38) 11

Prisoner (n=24) 4

SOURCE: Duvall et al. 1963.

38
TABLE 4. Percentage of institutionalizations followed by 1 year of

abstinence during 12-year followup

Type of Institutionalization Percentage Abstinent

Voluntary Hospitalization (n=270) 4

Prison<9 Months (n=279) 4

Prison>8 Months With No Significant

Parole (n=46) 13

Prison>8 Months With Parole>1 Year

(n=30) 67

SOURCE: Vaillant 1966b.

As I have noted, some “voluntary” patients were admitted to both the

Lexington and Fort Worth PHS hospitals under legal pressure of probation from a State court. A followup study in the 1960s at the Fort

Worth PHS hospital showed that voluntary patients with legal pressure had better outcomes than those with no legal pressure (table 5)

(Maddux et al. 1971). Patients with legal pressure not only had

hospitalization with legal pressure, but they also had compulsory

posthospital supervision.

TABLE 5. Percentage of opioid addicts abstinent during 1 year after

discharge from Fort Worth PHS hospital, by hospital

status

Hospital Status Percentage Abstinent

Voluntary With Legal Pressure

(n=61) 20

Voluntary With No Legal Pressure

(n=120) 7

SOURCE: Maddux et al. 1971.

39
While these studies generally found better outcomes of treatment with

legal coercion, the outcomes were not markedly better than those

after treatment with no legal coercion. With the exception of the

Vaillant (1966b) followup study, the studies found that only 4 to 31

percent of patients treated under legal coercion remained abstinent

for 6 months or longer after release from the institution. Even after

treatment with legal coercion, most patients resumed opioid use.

FEDERAL CIVIL COMMITMENT LAW

At the White House Conference on Narcotic and Drug Abuse, convened by President Kennedy in 1962, one of the major topics was

treatment under civil commitment (White House Conference on

Narcotic and Drug Abuse 1963). Nearly all the speakers approved

civil commitment or some form of compulsory treatment, although

little clinical experience with civil commitment was described. At

that time, most States had laws that permitted civil commitment of

narcotic addicts, but those laws had been infrequently used (Harney

1962). California, in 1961, and New York, in 1962, enacted legislation

that provided for the development of large rehabilitation programs

based on civil commitment. Civil commitment was advocated as

having two main purposes: protection of society and rehabilitation of

the individual. Some cautionary comments were made about the

possibility of “commitment” becoming another name for incarceration.

Following the White House Conference, the President’s Advisory

Commission on Narcotic and Drug Abuse recommended that a civil

commitment statute be enacted to provide an alternative method of

handling the federally convicted offender who was a confirmed

narcotic or marijuana abuser (President’s Advisory Commission on

Narcotic and Drug Abuse 1963).

When Congress enacted the Narcotic Addict Rehabilitation Act

(NARA) (Public Law 69-793) in 1966, the statute provided not only

for civil commitment of convicted offenders as recommended by the

Advisory Commission but also of persons charged, but not convicted,

and of persons not charged with any offense. The act consisted of

four titles.

Title 1 authorized civil commitment for treatment of eligible addicts

charged with a Federal offense who chose to be committed instead of

prosecuted. After examination, addicts considered suitable for

rehabilitation could be committed to the Surgeon General for 36

months of institutional treatment and supervised aftercare.

40
Title II authorized civil commitment of eligible addicts convicted of a

Federal offense. After examination, addicts considered suitable could

be committed to the Attorney General for a period not to exceed 10

years of institutional treatment and aftercare.

Title Ill authorized civil commitment of addicts not charged with any

criminal offense. Any addict or individual related to an addict could

petition the U.S. Attorney in the district in which he or she resided

for commitment to treatment. As under Title I and Title II, examination was required prior to commitment to determine if the person

was an addict who was likely to be rehabilitated. Addicts considered suitable could then be committed to treatment in a hospital

for a period not to exceed 6 months. Following hospital treatment,

the court could place the person under the custody of the Surgeon

General for posthospital treatment for 36 months. During this period

the person could be recommitted for another 6 months of hospital

care.

Title IV authorized financial assistance to States and localities for

treatment programs for narcotic addicts. Grants to States and communities for drug abuse were later administered under amendments to

the Community Mental Health Centers Act until 1980, when drug

abuse, alcoholism, and mental health grants were consolidated into a

block grant. In 1986, the Anti-Drug Act (Public Law 99-570) provided for additional funds in the block grant for treatment and

prevention of drug abuse.

NARA PROGRAM

The NARA authorized the Surgeon General to enter into contracts

with any public or private agency to provide examination or treatment of committed addicts; but, in order to develop the NARA

program quickly, it was decided to use the Lexington and Fort Worth

PHS hospitals for examination and institutional treatment. In 1967,

the PHS renamed the two hospitals “clinical research centers.”

However, under the NARA, their clinical missions continued, and they

are referred to as “hospitals” throughout this chapter.

Admission of NARA patients to the Lexington and Fort Worth

hospitals began in 1967. Admission of Federal prisoners ceased in

1967, and admission of voluntary patients ceased in 1988. From 1967

through 1973, 10,153 NARA patients were admitted to the two hospitals. Five percent were admitted under Title I, 2 percent under Title

II, and 93 percent under Title Ill. In 1968, admission of Title II

41
patients ceased because the Bureau of Prisons had developed rehabilitation programs for addicts and began to accept Title II patients.

Patients who entered hospitals with NARA commitment did not seem

to differ noticeably from those previously admitted with voluntary or

prisoner status. In 1962, 84 percent of admissions to the two centers

were men; from 1967 through 1973, 85 percent of the NARA admissions were men. In 1962, admissions had the following ethnic

distribution: white, 48 percent; black, 36 percent; and Hispanic, 16

percent (Maddux 1965). During the years 1970 through 1973, 5,931

NARA admissions had the following ethnic distribution: white, 43

percent; black, 47 percent; and Hispanic, 10 percent. Clinically, the

NARA patients seemed to resemble their predecessors: most were

undereducated, most had erratic work histories, and all had become

handicapped by their drug dependence. Antisocial attitudes and low

tolerance for distress seemed prominent.

ATTRITION OF NARA PATIENTS

To the dismay of court officials, many of the NARA patients sent to

hospitals for examination were found not suitable for treatment.

Through 1968, the Fort Worth hospital found 38 percent of the NARA

admissions not suitable for treatment. Through 1971 the Lexington

hospital found 51 percent not suitable for admission. The patients

coming to the two hospitals may have differed in suitability, or the

professional staffs may have differed in their judgments of suitability.

Nearly all the “not suitable” patients were found to be narcotic

addicts, but they were considered too antagonistic, disruptive, or

dangerous to participate in the institution treatment program. Many

entered the NARA program under Title Ill as a condition of probation

after conviction in a State court. Having entered the NARA program,

patients had in many instances complied with the State court

requirement, and some acted to get themselves labeled unsuitable:

they refused to get out of bed; would not come to interviews;

remained silent in group therapy; refused to shower; and some

threatened violence against staff members or other patients. The

professional staff worked hard to draw these patients into therapeutic

interaction before they reported them as not suitable (Maddux 1978).

Some NARA patients expressed contradictory attitudes to court

officials and hospital staff. For example, a heroin user would apply

for commitment and tell the judge that he wanted treatment in the

NARA program; the judge would send him for examination to one of

the hospitals. There he would insist that he did not want treatment

42
and intended to resume heroin use as soon as possible; for approximately 3 weeks he would refuse to take part in the treatment

program; when returned to the court as “not suitable,” he would tell

the judge that he did not understand why the hospital rejected him,

for he wanted treatment in the NARA program.

Thus, many NARA patients, who previously would have entered the

hospitals voluntarily and then signed out against advice, now entered

the examination phase of the NARA program but avoided commitment

by adverse conduct. Furthermore, some patients committed for 6

months of institutional care under Title Ill became so antagonistic

during hospitalization that they were discharged and the court

commitment terminated. Mandell and Amsell (1973) found that only

35 percent of 7,353 NARA patients admitted for examination were

discharged to aftercare. The attrition continued after discharge to

aftercare. Langenauer and Bowden (1971) reported that only 38

percent of 252 NARA patients released remained in aftercare 6

months after discharge. Patients were lost from aftercare by

recommitment for institutional care, conviction, incarceration, death,

and disappearance.

The NARA provided penalties for escape from institutional commitment under Title Ill, but no one was prosecuted. Some judges

questioned the constitutionality of the law. Only a small number of

patients committed under Title Ill escaped from institutional custody.

Patients did not have to escape to get out: they could obtain their

release by adverse behavior.

Release from the hospitals for adverse behavior was not new under

the NARA. The two hospitals had always discharged patients

considered disruptive or dangerous in the hospital environment.

Disruptive prisoner patients were transferred to prisons, and disruptive voluntary patients were discharged involuntarily. From 1938

through 1969, approximately 30 percent of prisoner addicts admitted

to the Fort Worth hospital were subsequently transferred to prisons

(Maddux, unpublished). These patients seemed to have intense

chronic anger, manifested by episodic outbursts of fury, or by

persisting antagonistic behavior. They probably used heroin as

attempted self-medication for their anger.

DEVELOPMENT OF HOSPITAL PROGRAMS

Although the NARA program required new and different procedures,

the fundamental treatment programs of hospitals did not change very

43
much in direct response to the NARA. Evaluation reports had to be

prepared and sent to courts, patients had to be transported between

courts and the hospitals, and reports had to be sent to community

agencies providing posthospital service.

During the 1950s and 1960s, treatment programs changed in response

to changes in the theory and practice of American psychiatry. The

main changes consisted of (1) the advent of a psychoanalytic orientation in diagnosis and psychotherapy: (2) introduction of group

therapy; and (3) development of sociotherapy (Lowry 1956; Lewis and

Osberg 1958; Maddux 1965).

While individual psychotherapy became psychoanalytically oriented,

only a small number of patients entered psychotherapy. Few staff

members were available, and few patients seemed ready to explore

their personal problems in individual psychotherapy sessions. Group

therapy seemed more suitable for most patients, and by the end of

the 1960s most patients were in some form of group therapy or group

counseling.

The recognition that the social milieu of the mental patient could be

either therapeutic or noxious became widespread in the United States

after World War II. The hospitals attempted to create a therapeutic

milieu. This effort was influenced initially by the therapeutic

community developed in England by Jones (1953) and later by the

Synanon treatment program (Yablonsky and Dederich 1965).

At the Fort Worth hospital during the years 1964 to 1966, Hughes et

al. (1970) attempted to develop a rehabilitation-oriented community of

addict patients by implementing intensive group work and by enlisting

patient collaboration in the treatment program. This unit was based

partly on the Synanon model. During the late 1960s, the Lexington

program was reorganized into five relatively autonomous treatment

units, each based on the therapeutic community concept and each

having about 100 patients (Conrad 1977). All units emphasized daily

therapeutic interaction among staff and patients using confrontation

as a major technique, with emphasis on current behavior. Emotional

disorders also received attention, especially the depression that often

emerged as a person became engaged in treatment.

One of the units, directed by ex-addicts, resembled Synanon more

than the other units. This unit was in operation for 2 years.

Toward the end of the second year the ex-addict leaders regrettably

began to behave in an irresponsible manner, which required

44
termination of the unit. Partially self-governing units had existed at

the Lexington and Fort Worth hospitals in the years preceding NARA.

Most of these units eventually became corrupted by antisocial

behavior, with consequent disillusion and anger among staff. Synanon

itself degenerated in the 1970s (Deitch and Zweben 1981).

Grants to States and communities under Title IV of the NARA and

under other legislative authority led to closure of the Fort Worth and

Lexington hospitals in the early 1970s. The increasing local services

for drug abuse treatment led to decreasing Title Ill commitments.

Addicts could be committed legally under Title Ill only if appropriate

State or other facilities were not available. Consequently, the

hospitals lost their clinical mission, and their research mission was

terminated.

NARA FOLLOWUP STUDIES

Two followup studies of NARA patients were completed. Langenauer

and Bowden (1971) reported that 86 percent of 97 patients remaining

in aftercare in the sixth month had used an opioid drug at some time

during the 6 months. Stephens and Cottrell (1972) reported that 87

percent of 200 NARA patients used an opioid drug at some time

during the first 6 months after release from the hospital, but only 65

percent became readdicted. The two studies found that 13 to 14

percent remained abstinent for 6 months. Thus, with respect to

duration of abstinence, the NARA program seemed to lead to somewhat better results than did voluntary hospitalization. Moreover,

some of the previous studies may have overestimated abstinence. In

the NARA posthospital service, counselors observed subjects

repeatedly during the followup period, and regular urine testing was

done. In our study of the addiction careers of 246 opioid users, we

found that repeated observation tended to reveal more opioid use

(Desmond and Maddux 1977; Maddux and Desmond 1981).

Followup studies of voluntary, prisoner, and civil commitment patients

from the PHS hospitals gave an unduly pessimistic picture of treatment outcomes. They emphasized a severe outcome measure of

success, namely, continuous abstinence during 6-month to 4 1/2-year

periods after discharge. Both the Drug Abuse Reporting Program

(DARP) and the Treatment Outcome Prospective Study (TOPS) used a

more advanced design to estimate treatment effectiveness, namely,

before and after measures (Simpson and Sells 1982; Hubbard et al.

1984). Since nearly all opioid users are using daily before entering

treatment, a before and after comparison will nearly always show

45
improvement after treatment. The early followups concentrated on

opioid use, while the DARP and the TOPS followups measured not

only opiold use but also other substance use and other behaviors.

LEGAL COERCION AND LONG-TERM OUTCOMES

While short-term outcomes seem better with legal coercion during and

after institutional treatment, hardly any research exists on the

effects of coercion on long-term outcomes. Zahn and Ball (1972)

found that length of hospital stay was associated with 3-year cure

among Puerto Rican addicts who had been treated at the Lexington

hospital. Since those with a longer stay were predominately

prisoners, the findings point to a better outcome after nonvoluntary

treatment. However, the subjects had a mean age of only 33 at the

time of the followup interview.

In his 20-year followup of Lexington patients, Vaillant (1973) reported

that addicts who achieved stable abstinence of 3 years or longer

received more imprisonments with parole than did subjects who died.

His group would have had a mean age of 45 at the time of followup,

if all were alive. O’Donnell (1969) did not analyze the possible

different outcomes from voluntary and nonvoluntary hospitalization in

his long-term followup of Kentucky addicts. In their 12-year

followup study, Simpson et al. (1986) found that treatment patterns

over time were too varied and confounded with other influences to

permit comparisons for long-term outcomes. However, 57 percent of

the subjects abstinent in the 12th year reported that fear of being

jailed was a reason for quitting addiction.

In 1984, 18 years after our study of addiction careers began, 22 (9

percent) of the subjects were found in stable abstinence, that is, for

3 years or longer they had abstained from opioid drugs, they had not

been alcoholic, they had worked regularly, and they had no felony

arrests (Maddux and Desmond 1981). The treatment and correctional

experience of this group varied widely. One subject had one

voluntary hospitalization lasting 11 days and then entered stable

abstinence, which endured for 20 years (through 1984). Residence

relocation away from San Antonio and intense religious activity

probably facilitated his abstinence. Another subject voluntarily

entered methadone maintenance while he was on probation for 10

years after a criminal conviction. Treatment was not required as a

condition of probation. During 8 years on methadone, he repeatedly

expressed fear of prison. He had never been in prison, but he had

spent 2 months in jail. He withdrew from methadone and entered

46
stable abstinence, which continued for 7 years (through 1986). His

enduring fear of prison probably facilitated his abstinence. Another

subject had seven treatment and correctional interactions before

entering stable abstinence. The last two immediately preceded his

abstinence. He was convicted of a drug law violation and placed on

probation, with the requirement that he apply for treatment under

the NARA. While in residential treatment under a Title Ill commitment, he seemed to undergo marked changes in attitude. On completion of treatment, he was employed as a drug abuse counselor. His

stable abstinence continued for 12 years (through 1984). His employment as a drug abuse counselor probably facilitated his abstinence.

These three vignettes illustrate the variations in treatment modes, in

numbers of treatment and correctional interactions, and in legal

coercions, which can lead to stable abstinence. Although the treatment and correctional interactions varied, 20 (92 percent) of the 22

subjects in stable abstinence had one or more treatment or correctional interactions during the year preceding the onset of stable

abstinence. Thus, a treatment or correctional interaction may have

sewed as a critical experience that enabled the person to begin

stable abstinence. The vignettes also suggest the importance for

continued stable abstinence of the motivational state and of posttreatment activities such as residence relocation, religious activity,

and employment in a drug abuse treatment agency.

The long-term pattern of treatment admissions and correctional

interactions of the 22 subjects in stable abstinence was compared

with that of 22 subjects who did not achieve stable abstinence by

1964. Each subject in stable abstinence was matched with a subject

not in stable abstinence, by age and calendar year of first opioid use.

Then, for each member of each pair, the number of voluntary

treatment admissions, nonvoluntary treatment admissions, and

correctional interactions was counted for the same period of time,

namely, the years from first use to onset of stable abstinence in the

member in stable abstinence of each pair. The mean age of first

opioid use of the subjects in stable abstinence was 18; as a consequence of selection, the mean age of first opioid use was the same

for the comparison group. The mean number of years from first use

to onset of stable abstinence in the stably abstinent group was 18.

Table 6 shows a similar pattern of treatment admissions and correctional interactions in both groups. None of the small differences

between groups were statistically significant. Nonvoluntary treatment

did not appear associated with achievement of stable abstinence.

47
TABLE 6. Treatment admissions and correctional interactions during

mean period of 18 years of subjects in stable abstinence

and those not in stable abstinence

Stable

abstinence

(n=22)

Not in

Stable

abstinence

(n=22)

Mean Voluntary Treatment

Admissions 3.3 3.7

Mean Nonvoluntary Treatment

Admissionsa2.4 2.1

Mean Correctional lnteractionsb3.1 4.0

aNonvoluntary Treatment Admission=treatment while on probation or parole, awaiting

prosecution, in prisoner status, or under civil commitment.

bCorrectional Interaction=probation, prison, or jail 1 week or longer.

ILLICIT OPIOID USERS NOT IN TREATMENT

At a conference in 1969, a colleague assured this author that the

problem of heroin addiction in the United States would disappear

within 2 years, because all the heroin addicts would be maintained on

methadone. Since that time, many studies have demonstrated that

while patients remain in methadone maintenance treatment their

heroin use and criminal behavior diminish and their legitimate

employment increases (Cooper et al. 1983). A review of 113 studies

indicated that approximately 15 to 35 percent of methadone patients

dropped out during the first year of treatment (McLellan 1983). The

dropout rate for methadone maintenance seems much lower than that

for drug-free treatment in either voluntary status or Title Ill

commitment.

Since our study of addiction careers began before and continued after

methadone maintenance became available to large numbers of opioid

users in San Antonio in 1970, we can estimate how methadone

maintenance affected the study group. During the 16-year period

48
from 1970 through 1986, 62 percent of the subjects alive in 1970

entered methadone maintenance; due to dropouts, much smaller

percentages were found on methadone in any specified year. In 1984,

only 12 percent were maintained on methadone during most of the

year (table 7). However, if we exclude deceased subjects and those

in prison or jail, thereby restricting the denominator to the 155

subjects alive and in the community, then 19 percent were maintained

on methadone. Only 10 percent were known to be using heroin. If,

as before, we restrict the denominator to those alive and in the

community, then 16 percent were using heroin. Some of the subjects

TABLE 7. Status of 248 San Antonio opioid users in 1984

Status Number Percent

Using Heroin Daily

Using Heroin Occasionally

Deceased

Jail or Prison

Maintained on Methadone

Social Recoverya

Partial Social Recovery

Abstinent From Opioids

Stableb

Not Stable

Alcoholic

Other

Partial Information Indicating

Abstinence

Partial Information Indicating

Substance Abuse or Other

Related Problems

Unknown

4

8

TOTAL 248 100

16 6

9 4

53 21

40 16

7

22

22 9

29 12

16 6

4

10

2 1

3

9

2

aSocial recovery=3 or more years continuous maintenance, not alcoholic, regular

work, negative urines, and no felony arrest.

bStable=3 or more years continuous abstinence, not alcoholic, regular work, and no

felony arrest.

49
with unknown status were probably using heroin. lf all the unknowns

were using heroin, the total using heroin would be 19 percent, or 30

percent of those alive and in the community.

Although the problem of heroin addiction did not disappear, methadone maintenance has undoubtedly reduced the pool of illicit opioid

users in the community. Nonetheless, a noteworthy segment of our

study subjects, between 16 and 30 percent of those alive and in the

community, were using an illicit opioid drug in 1964. All of our

subjects were men, and 87 percent had a Mexican-American background. In these respects, they differed from the U.S. population of

illicit opioid users, but we have no reason to believe that they

differed in severity of opioid dependence. Our data suggest that

many chronic opioid users are not in treatment and are not incarcerated.

CIVIL COMMITMENT IN AN ARRAY OF COERCIONS

The unstable motivation for treatment described at the beginning of

this chapter varies among individuals and, with time, in a given

individual. Some opioid users enter and stay in treatment with a

minimum of external coercion, such as pressure from family members.

Some enter and stay in treatment in response to the threat of loss of

a job or loss of a license to practice a profession. Some stay in

treatment after civil commitment with no criminal coercion. Some

stay in treatment after criminal conviction and probation, as an

alternative preferred over prison; some stay in treatment only after

criminal conviction and sentencing to an institution having a treatment program.

Within this array of pressures and coercions, civil commitment,

without criminal law coercion, can probably bring some opioid users

into treatment who would not enter voluntarily and who have not

incurred any criminal law coercion. Thereby, it would reduce

somewhat the pool of opioid users in the community who are not in

treatment. The experience of the PHS hospitals suggests that civil

commitment, without any Federal criminal law coercion (the Title Ill

commitment), will hold only about one-third of the admissions

through 8 months of institutional care. Some of these, as noted,

were under coercion of probation from a State court. None of the

Title Ill patients were prosecuted for escape from institutional

treatment. In general, law enforcement agencies do not seem to

pursue persons who escape from civil commitment, whether for

50
substance abuse or other forms of mental illness, as vigorously as

they pursue persons who escape from criminal custody.

For persons with criminal convictions, civil commitment in lieu of

sentencing seems to have no special advantage if the correctional

system has treatment programs, or if community programs are available and can be utilized. The criminal conviction itself provides

strong coercion.

LIMITATIONS OF CIVIL COMMITMENT

Civil commitment has three serious limitations. First, civil commitment cannot overcome deficits in services. Few States with civil

commitment laws for drug users appear to have treatment programs

for committed persons. Furthermore, in 1987, insufficient treatment

services, especially methadone maintenance, existed in the United

States for opioid users who voluntarily applied for treatment.

Second, coercion can bring a person into treatment, but it cannot

make him or her participate in the treatment. Until the 1950s, a

prisoner patient could serve his time quietly at one of the PHS

hospitals, without psychotherapy or counseling, and with minimum or

no participation in vocational training or remedial education. The

staff knew of these passive patients, but hoped that residence in a

drug-free environment would help to extinguish the drug-using habit.

After 1950, with the advent of group therapy and the therapeutic

community concept, it became increasingly difficult for patients to

remain aloof from psychosocial interaction with staff and other

patients. Even into the 1970s, however, some patients passively

participated in group therapy or other activities. Patients called this

“going along with the program.” Some Title Ill patients probably left

the program because of the discomfort created by confrontations from

staff and other patients. Most modem institutional treatment

programs are based on some form of the therapeutic community.

They cannot treat all the opioid users. Secure custodial care only is

required for some.

Third, civil commitment operates within constitutional guarantees of

individual liberty. This is a controversial area. Under what circumstances and to what extent should society curtail the liberty of a

compulsive drug user? Szasz (1972), a psychiatrist, developed the

argument that in a free society all drugs should be legalized. He

proposed that it should be none of the government’s business what

drug a man puts into his body. Newman (London 1972; Newman

51
1974), director of the New York City methadone maintenance program, vigorously opposed civil commitment. He was concerned about

curtailment of civil liberty but also about insufficient voluntary

treatment services, especially methadone maintenance.

The problem becomes further complicated because nonvoluntary

treatment, whether civil or criminal commitment, usually has dual

goals: first, to help the individuai; and second, to protect the

community. Civil commitment of the mentally ill has always served

these two purposes. During the 1970s, the criteria for civil commitment of mentally ill persons changed from mentally ill and in need of

treatment to mentally ill and dangerous to self or others (Stromberg

1982). This emphasis on dangerousness has allegedly increased the

number of homeless, mentally ill persons wandering the streets.

Statutes related to civil commitment of substance abusers have

probably followed the trend toward a criterion of dangerous to self

or others. A study is needed of current State statutes for civil

commitment of substance abusers, and the extent to which they are

used.

SUMMARY

The unstable motivation of the addicted person has represented a

major problem in the treatment of opioid dependence. Only a

minority of voluntary patients remained in the two PHS hospitals for

treatment beyond withdrawal. Early followup studies at the two

hospitals indicated that treatment under legal coercion, especially

when combined with compulsory posthospital care, had better

outcomes, but not markedly better, than did voluntary treatment.

A large proportion, one-third to one-half, of the patients admitted to

the hospitals for examination prior to civil commitment were found

not suitable for treatment, mainly due to their disruptive or dangerous behavior. Due to attrition after examination and during 6 months

of hospital treatment under commitment, only about one-third of the

civil commitment patients admitted were discharged to aftercare. The

high attrition rate may have been partly due to intensive psychosocial

treatment. Patients who absconded from treatment were not prosecuted; consequently, civil commitment provided only a weak coercion

to treatment. Two followup studies suggested that the short-term

outcomes of the civil commitment patients were somewhat better than

those of voluntary patients.

52
Limited and inconclusive research exists on the relation of coercion

to long-term stable abstinence.

Methadone maintenance is accompanied by improved social adjustment,

but it retains in treatment only a minority of opioid drug users. One

study suggests that 16 to 30 percent of the population of chronic

opioid users in the community is not in treatment.

Civil commitment, as one of an array of social and legal coercions,

can probably bring some opioid users into treatment who would not

voluntarily enter. It has several limitations. Civil commitment

cannot overcome deficits in treatment services. Civil commitment, or

any other kind of external coercion, can bring drug users into

treatment but cannot assure that patients will participate in treatment. Finally, civil commitment is restricted by constitutional

guarantees of individual liberty.

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Cooper, J.R.; Aitman, F.; Brown, B.S.; and Czechowicz, D., eds.

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55
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ACKNOWLEDGMENT

This work was supported, in part, by the Public Health Service Grant

number DA 00083 from the National Institute on Drug Abuse.

D.P. Desmond, MSW, helped with the collection and the analysis of

data.

AUTHOR

James F. Maddux, M.D.

Department of Psychiatry

The University of Texas

Health Science Center

7703 Floyd Curl Drive

San Antonio, TX 78284-7792

56
The Criminal Justice Client in

Drug Abuse Treatment

Robert L. Hubbard, James J. Collins,

J. Valley Rachal, and Elizabeth R. Cavanaugh

INTRODUCTlON

The assumed relationships between drug use and crime (Ball et al.

1981; Gandossy et al. 1980; Panel on Drug Use and Criminal Behavior

1976), the finding that successful drug abuse treatment reduces crime

(Simpson et al. 1978; McGlothlin et al. 1977; Nash 1976), and

criticisms of traditional criminal justice approaches to dealing with

drug-abusing offenders (Lipton et al. 1975; Carter and Klein 1976) led

to the development of programs to refer drug abusers in the criminal

justice system to treatment. Clients referred from the criminal

justice system have been shown to stay in treatment longer than

other clients (Collins et al., in press). Their longer retention leads

to an expectation that these criminal justice system clients will have

better treatment outcomes than other clients. The literature has not

provided consistent results to support this expectation.

Legal involvement alone may motivate some drug abusers to seek

treatment as a way to reduce sentences. There are various formal

and informal mechanisms to identify and refer drug abusers in the

criminal justice system to treatment. The major model is the

Treatment Alternatives to Street Crime (TASC) program. TASC programs have been developed with Federal funds under local administration and were intended to become institutionalized under State or

local auspices at the expiration of their Federal grants. The goals of

the TASC programs have been to identify drug abusers who come into

contact with the criminal justice system, to refer those who are

eligible to appropriate treatment, to monitor clients’ progress, and to

return violators to the criminal justice system. Through TASC and

other types of formal or informal referral mechanisms, linkages

between the criminal justice system and the drug treatment system

57
have been developed in many cities to assist criminally involved drug

abusers to obtain treatment.

This chapter summarizes the findings from the Treatment Outcome

Prospective Study (TOPS) to examine the question of whether or not

referral to drug abuse treatment through the criminal justice system

benefits the client and society. Because of the crime reduction

impact of drug abuse treatment (Harwood et al., this volume),

treatment of drug abusers in the criminal justice system is thought to

have more positive cost benefits for society than treatment of clients

with no legal involvement.

Formal referral programs such as TASC may increase the number of

drug abusers in the criminal justice system who are treated. Drug

abusers in the criminal justice system are thought to be more unlikely than other drug abusers to seek treatment of their own accord.

Nonvolunteer clients, however, may be more difficult to treat than

clients who seek treatment on their own. Empirical evidence is

needed to determine if, and how, criminal justice system referral

contributes to treatment outcomes of clients compared to self-referral

and other sources of referral.

Clients who entered treatment through TASC or who were otherwise

involved in the criminal justice system are the principal focus of the

analyses presented in this chapter. Four important questions need

to be considered to assess the effectiveness of TASC programs and

other types of criminal justice system involvement compared with

clients with no legal involvement.

How do clients involved with the criminal justice system differ

from other clients entering treatment in terms of drug abuse

treatment history and treatment needs?

How successful are programs in retaining clients involved with the

criminal justice system?

Do TASC and non-TASC criminal justice system clients differ from

other clients in services received and satisfaction with treatment?

Do drug use and criminal behavior of clients involved with the

criminal justice system decrease during and after treatment?

58
METHODOLOGY

TOPS is a large-scale prospective study of clients in 10 cities who

entered 41 publicly funded outpatient methadone, residential, and outpatient drug-free drug abuse treatment programs from 1979 to 1981.

TOPS established baseline data on drug use, criminal behavior, and

other behavior in the year before treatment; gathered data on events

during treatment; and reinterviewed samples of clients at 3 months or

1, 2, or 3 to 5 years after they left treatment. A major purpose of

TOPS is to determine the key factors that affect treatment outcomes,

including involvement with the criminal justice system.

As described in previous monographs, the characteristics and

behaviors of clients entering each modality differed greatly (Hubbard

et al. 1986). as did the nature of treatment received in each modality

(Allison et al. 1985). Table 1 illustrates major differences among the

modalities in the proportion of clients involved with the criminal

justice system. About one-third of the clients in residential and

outpatient drug-free programs were referred to treatment through the

criminal justice system. Less than 3 percent of the methadone

clients were referred by the criminal justice system. Because

relatively few methadone clients were referred to treatment through

the criminal justice system, and only about one in six reported any

involvement with the criminal justice system at admission, the

subsequent analyses were conducted only for residential and

outpatient drug-free clients.

The analyses for the residential and outpatient drug-free modalities

were conducted separately, because each modality treats very different client populations and has a different approach to treatment.

Furthermore, the analyses were limited to clients in the five cities

that had TASC programs. The analyses of intake data compare with

those referred to treatment through TASC programs (n=502), those

involved with the criminal justice system but not TASC at admission

to treatment (n=855), and clients without any current involvement

with the criminal justice system or TASC (n=1,078).

No direct self-report measure of a client’s perception of legal pressure is included in the TOPS data. Clients with various types of

involvement with the criminal justice system were distinguished using

self-report questionnaire items on TASC supervision, current legal

status, and source of referral. The responses to these items were

59
TABLE 1. Referral source by modality

Referral

Source

Outpatient Outpatient

Methadone Drug-Free Residential

Percent Percent Percent

Self-referral 47.7 19.4 24.2

Family/Friends 31.2 20.6 19.0

TASC or Other

Criminal Justice System 2.6 30.9 31.2

Other 18.5 29.1 25.6

100.0 100.0 100.0

n= 4,184 2.914 2.991

SOURCE: Data are from entire TOPS population, 1979-1981,

examined to develop definitions of (1) TASC clients; (2) other (nonTASC) criminal justice system clients; and (3) clients with no legal

involvement.

TASC clients were defined as those who reported being under TASC

supervision at admission to a treatment program. Non-TASC criminal

justice system clients were those who did not report being under

TASC supervision but reported a current legal status of probation,

parole, on bail, in jail or prison, or identified their principal source

of referral to treatment as an agent of the criminal justice system,

such as an attorney, judge, or probation or parole officer. Clients

not classified as TASC or non-TASC criminal justice clients were

assumed to have no legal involvement at admission to treatment.

These comparison groups facilitate the differentiation of TASC effects

from the effects of other criminal justice system involvement on

client behaviors during and after treatment. Data are drawn from

four periods: the year before treatment, the first 3 months in

treatment, the second 3 months in treatment, and the first year after

treatment.

All TASC clients who were admitted to one of the outpatient drugfree and residential programs in 1979 and 1980 and who completed an

intake interview were selected into the followup samples. Clients

involved with the criminal justice system other than through TASC

60
and those who currently were not involved with the criminal justice

system were randomly selected at rates that satisfied the sampling

precision requirements for the overall TOPS followup samples.

Samples of 603 of 1,281 outpatient drug-free and 496 of 1,154

residential clients were interviewed 1 year after leaving treatment.

Descriptive analyses comparing TASC, non-TASC criminal justice, and

no legal involvement clients on legal status and prior treatment are

presented. More detailed comparisons of sociodemographic characteristics, drug use, and other behaviors reported in Collins et al. (in

press) are summarized.

Multivariate analyses were also conducted to identify the influence of

TASC or other criminal justice system involvement on retention and

outcomes during and after treatment, particularly predatory illegal

acts. Prior research has found that all crime decreases after treatment, and that crimes that are directly drug related, most particularly

drug sales, decrease much more than other crimes (Ball et al. 1981).

For that reason, analyses of crime were restricted to the predatory

illegal acts that victimize members of the general population (assault,

robbery, burglary, theft, forgery, fraud, embezzlement, and dealing in

stolen property).

CHARACTERlSTlCS OF CLIENTS DIFFERING IN CRIMINAL JUSTlCE

SYSTEM INVOLVEMENT

Systematic differences in legal status were found between the three

categories of clients entering treatment in the outpatient drug-free

and residential modalities. About one-half of TASC clients in

residential programs and non-TASC criminal justice clients in both

outpatient drug-free programs and residential programs were on probation at the time of admission to drug abuse treatment (table 2).

Half of the TASC clients in outpatient drug-free programs were on

bail, indicating pretrial or presentencing diversion. These findings

indicate that TASC and non-TASC criminal justice clients were

referred to the two drug abuse treatment modalities at different

stages of the legal process.

The criminal justice system clients, especially TASC clients (85

percent), were disproportionately male, compared with no legal

involvement clients (57 percent). Probably, because they were not

considered eligible, few clients under 18 were in TASC. TASC and

other criminal justice clients in residential and outpatient drug-free

modalities were younger (average age 25) than were no legal

61
TABLE 2. Legal status at intake by criminal justice system

involvement

Outpatient Dtua-Free Residential

Legal Status TASC

Non-TASC

Criminal

Justice TASC

Non-TASC

Criminal

Justice

No Legal Status

Probation

Parole

On Bail

In Jail

Other

n=

Percent Percent Percent Percent

9.1 6.0 5.1 2.5

20.3 57.8 57.0 48.8

8.1 13.2 5.7 8.8

51.3 12.0 6.3 17.2

5.9 3.7 23.4 19.7

5.3 7.3 2.5 3.0

100.0 100.0 100.0 100.0

328 338 174 519

SOURCE: 1979 and 1980 TOPS Admission Cohorts.

involvement clients (average age 27). Despite their lower average

ages, far more outpatient drug-free clients in each legal involvement

category had at least a high school diploma, compared with their

counterparts in residential treatment. No major differences in druguse patterns were noted.

The treatment histories of clients in different legal involvement categories in each modality appeared to be very similar (see table 3).

Residential clients were far more likely than outpatient drug-free

clients to have had previous drug abuse treatment experience (about

50 percent in each criminal justice system involvement category) and

three or more previous treatment episodes (21 to 25 percent). Within

modalities, there was little difference in the prior treatment histories

of the three categories of clients.

These descriptive analyses suggest the hypothesis that there are few

major differences between criminal justice system clients and clients

with no legal involvement. To examine this hypothesis further,

multivariate analyses were conducted to identify factors that were

significantly associated with self-reported referral through TASC or

another criminal justice mechanism. The characteristics of 30 percent

62
TABLE 3. Prior drug treatment by TASC/criminal justice system involvement

Number of

Prior Admissions TASC

Outpatient Drug Free Residential

Non-TASC Non-TASC

Criminal No Legal Criminal No Legal

Justice Involvement TASC Justice Involvement

Percent Percent Percent Percent Percent percent

None 71.6 62.6 70.5 50.0 45.2 49.5

One 12.3 15.3 11.6 18.5 18.1 17.6

Two 4.2 7.1 6.1 10.3 11.4 11.3

Three or More 11.9 14.9 11.8 21.2 25.3 21.6

100.0 100.0 100.0 100.0 100.0 100.0

n= 328 336 617 174 519 461

SOURCE: 1979 and 1980 TOPS Admission Cohorts.
of the clients who reported the criminal justice system as the

primary source of referral are contrasted with the other 70 percent

of the clients, who reported other sources. This procedure more

directly tests the basic hypothesis by focusing on the effect of active

referral by the criminal justice system. Odds ratios for sex, age,

race, drug-use pattern, and prior treatment were calculated by

logistic regression procedures.

Table 4 presents the comparisons where significant differences were

found. In general, males, clients aged 21 to 25, and clients with no

prior treatment were more likely to be involved with the criminal

justice system. Marijuana or alcohol users were more likely to be

referred than heroin users, especially in outpatient drug-free programs. Clients who reported no use or less than weekly use of

alcohol or drugs in the year before treatment (minimal users) had the

highest relative likelihood of referral. The high rate of criminal

justice referral of marijuana/alcohol users and minimal users may be

attributable to the fact that criminal justice system clients are likely

to be referred to treatment early in their drug-use careers, or that

many criminal justice clients (especially those in residential programs)

had recently been in jail or prison and were unlikely to be more than

minimal users of any drug. A second multivariate analysis, comparing

all criminal justice system clients with those with no legal

involvement, yielded similar results.

BEHAVlOR BEFORE AND DURING TREATMENT

Given the high rate of illegal activity of criminal justice clients

before treatment, reductions during treatment have societal benefits,

even if the reductions are not maintained after the clients leave

treatment. Table 5 displays percentages of primary problem drug use,

depression symptoms, predatory illegal acts, and full-time

employment reported by outpatient drug-free clients in the year

before treatment and during the first 6 months of treatment.

Outpatient drug-free TASC clients reported improvement during treatment for each outcome measure of table 5; clients with lower percentages reported regular use of their primary problem drug, fewer

reported depression symptoms, only a few reported predatory illegal

acts, and more reported working full time most of the time. The

other outpatient drug-free criminal justice clients also improved after

entering treatment. Primary problem drug use and depression symptoms decreased, and fewer reported predatory illegal acts. There was

little or no improvement in full-time work during the first 6 months

64
TABLE 4. Effects of demographic characteristics and pretreatment

behaviors on the odds of criminal justice system referral

for outpatient drug-free and residential clients

Risk Factors

Outpatient

Drug Free

(n=1,281)

Residential

(n=1,154)

Male vs. Female

White vs. Other Race

Age 21-25 vs. 31 and Over

No Prior Treatment vs. Three

or More Prior Treatments

Minimal Users vs. Alcohol/

Marijuana

Heroin vs. Alcohol/Marijuana

2.51*** 1.65***

.74** 1.43***

2.07*** 1.62***

1.38* 1.60**

1.26 2.57***

.53*** .87

*p<.05.

**p<.01.

***p<.001.

SOURCE: 1979 and 1980 TOPS Admission Cohorts.

in treatment for other criminal justice clients. The outpatient drugfree clients with no legal involvement also showed improvement in

each outcome category. Their improvements, however, were not as

marked as those of one or both of the legally involved client groups

for each outcome measure. The results of these findings during

treatment must be cautiously interpreted, however, because the

numbers of cases were small, and other factors such as opportunity

to use drugs, work or commit crimes were not integrated into the

analysis. Despite these limitations, the findings are promising; results

indicate improvement in almost every treatment-outcome measure.

Data for residential clients are not shown in a table because clients

who are monitored 24 hours a day have virtually no drug use or illegal activity and usually are not allowed to work outside the program, at least in the early stages of treatment. TASC clients and

other criminal justice clients reported less reduction in depression

symptoms during treatment, however, than did similar clients in outpatient drug-free programs or clients who are not legally involved in

either residential or outpatient drug-free programs.

65
TABLE 5. Outpatient drug-free clients who reported weekly or daily use of their primary problem drug,

depression symptoms, predatory illegal acts, and full-time employment 75 percent of the time for

pretreatment and intreatment periods

Weekly or

Daily Use

of Primary

Drug

Depression

Symptoms

Predatory 75 Percent

Illegal Full-Time

Acts Work

Year Before Treatment

First 3 Months in Treatment

3 to 6 Months in Treatment

n=

Year Before Treatment

First 3 Months in Treatment

3 to 6 Months in Treatment

n=

TASC

65.1 44.2 63.2 29.5

15.0 25.0 4.9 46.5

12.5 16.3 2.3 59.1

41 43 40 43

Non-TASC Criminal Justice

54.8 36.7 40.0 25.0

17.9 6.5 17.2 22.6

14.3 12.9 11.5 26.6

29 31 26 30
TABLE 5. (Continued)

Weekly or

Daily Use

of Primary

Drug

Depression

Symptoms

Predatory 75 Percent

Illegal Full-Time

Acts work

No Leqal Involvement

Year Before Treatment 76.4 72.5 34.9 41.2

First 3 Months in Treatment 29.4 45.1 6.5 52.0

3 to 6 Months in Treatment 21.6 39.2 6.9 49.0

n= 50 50 50 50

NOTE: Only clients who remained in treatment at least 6 months are included in this table.

SOURCE: 1979 and 1980 TOPS Admission Cohorts.
TREATMENT RETENTION

Treatment retention is an important contributor to treatment effectiveness (Simpson 1981; Hubbard et al. 1988). If an individual leaves

treatment within a few days, it is unlikely that treatment has

permanently changed the characteristics or conditions that are

related to his or her drug problem. Treatment lengths of 6 or more

months were found necessary to produce significant reductions in

drug use (Hubbard et al. 1988). Furthermore, as seen in the preceding table, criminal behavior is reduced while individuals are in

treatment (Demaree and Neman 1976; Long and Demaree 1975;

Harwood et al., this volume).

Analyses described in Collins et al. (in press) showed that more TASC

clients stayed in outpatient drug-free and residential treatment at

least 3 months (48 percent and 57 percent) than did other criminal

justice clients (35 percent and 51 percent) and clients with no legal

involvement (30 percent and 41 percent). The differences between

TASC and other criminal justice clients were not statistically significant beyond the .05 probability level. The differences between TASC

clients and clients with no legal involvement were statistically

significant beyond the .05 level in both modalities. All differences

were statistically significant when TASC and other criminal justice

categories were combined into a single category and compared to the

no legal involvement groups within each modality. These results

suggest that both TASC and non-TASC criminal justice involvement

contributed to longer retention in treatment.

As described previously, there are systematic differences in the

characteristics and behaviors of clients in the three legal involvement

categories. These differences, not the TASC programs or criminal

justice involvement, may explain the differential retention findings.

Regression analyses were conducted to address the effects of legal

pressure on treatment retention more fully.

The multiple regression model included variables controlling for sex,

age, race, number of prior treatment admissions, and drug-use pattern

in the year before treatment. Both involvement with the criminal

justice system and TASC referral were associated with longer retention. Table 6 shows that TASC referral to the outpatient drug-free

modality was associated with longer retention than other criminal

justice involvement, although both variables predicted longer retention. After controlling for the other variables in the regression

model, outpatient drug-free TASC clients stayed 45 days longer and

68
TABLE 6. Estimated effect on retention in treatment of criminal

justice referral

Category of

Criminal Justice

Involvement

Outpatient Drug free Residential

n=1,281 (n=1,154)

Additional Days Additional Days

TASC vs. No Legal Involvemant 44.6*** 50.1**

Non-TAX Criminal Justice vs.

No Legal lnvolvement 16.7* 51.0***

*=F ratio significant>.05.

**=F ratio significant>.01.

***=F ratio significant>.001.

SOURCE: 1979 and 1980 TOPS Admission Cohorts.

other criminal justice clients stayed 17 days longer than clients with

no legal involvement.

TASC and other criminal justice residential clients stayed longer

than clients with no legal involvement. After controlling for the

other variables in the regression model, TASC clients stayed 50 days

longer and other criminal justice clients stayed 51 days longer than

clients with no legal involvement. Based on the magnitude of the

unstandardized regression estimates, the effect of TASC on treatment

retention was stronger in the residential than in the outpatient drugfree modality.

SERVICES RECEIVED AND TREATMENT SATISFACTION

Clients entering treatment from the criminal justice system may have

a unique set of treatment needs that require more intense and

different types of services. Furthermore, the degree of coercion

used to get them to enter and remain in treatment may affect their

treatment responses. There are clear differences between the outpatient drug-free and residential modalities in the number (see table

7) and type (see table 8) of services delivered to each client group

during the first 3 months of treatment.

Outpatient drug-free clients with no legal involvement were twice as

likely to receive three or more types of services (29 percent) as

69
were TASC referrals (15 percent) or other criminal justice clients

(17 percent). Over a third of the TASC clients and almost 3 out of

10 other criminal justice clients in outpatient drug-free programs did

not report receiving any of the 7 types of services. This pattern of

lower service delivery to TASC and other criminal justice clients was

also found for medical, psychological, and family services. TASC

clients (37 percent) were also less likely to receive psychological

services than other criminal justice clients (53 percent). Program

directors and counselors may have assumed that TASC clients needed

fewer services than other clients, because TASC clients had less

extreme drug-use patterns. The high reports of drug-related problems

by TASC clients entering outpatient drug-free programs make such an

assumption questionable.

There were no major differences by criminal justice involvement in

the number of service types or the specific services delivered in

residential programs. In some cases, TASC clients reported receiving

more services. The similar level of services across all legal involvement categories is consistent with the uniform therapy process for

every client in a residential program.

Three measures of satisfaction were included during intreatment

interviews in TOPS: help in reducing drug use; help with other problems; and general satisfaction with treatment. Clients with no legal

involvement were more likely to be very satisfied with their treatment than TASC and other criminal justice clients. In general, both

outpatient drug-free and residential TASC clients seemed somewhat

less satisfied with all aspects of treatment. About half the TASC

clients and other criminal justice clients were very satisfied (see

table 9) and felt treatment had helped them reduce their drug use

and had helped them with other problems.

POSTTREATMENT CRIMINAL BEHAVIOR AND OTHER OUTCOMES

The analyses in this section focus on predatory illegal acts before

and after treatment. The effects of criminal justice system involvement on other outcomes including drug use are also summarized.

lnvolvement in Predatory Illegal Acts

Multivariate analyses were conducted to compare the impact of TASC

and other criminal justice system involvement on the number of

predatory illegal acts in the year after treatment. Regression

models were developed which included sex, age, race/ethnicity,

70
TABLE 7. Number of types of services by TASC/criminal justice system involvement

Number

of Types

of Service TASC

Outpatient Drug Free

Non-TASC

Criminal

Justice

No Legal

lnvolvement TASC

Residential

Non-TASC

Criminal

Justice

No Legal

lnvolvement

Percent Percent Percent Percent Percent Percent Percent

None 35.4 27.6 16.1 4.4 10.4 7.2

1-2 49.5 55.1 54.6 46.1 43.5 43.9

3 or More 15.1 17.3 29.1 55.5 46.1 48.9

100.0 100.0 100.0 100.0 100.0 100.0

n = 156 117 164 99 264 166

NOTE: Only clients who remained in treatment at least 3 months are included in this table.

SOURCE: 1979 and 1980 TOPS Admission Cohorts.
TABLE 8. Types of services by TASC/criminal justice system involvement

Types of

Service TASC

Outpatient Drug Free Residential

Non-TASC Non-TASC

Criminal No Legal Criminal No Legal

Justice Involvement TASC Justice Involvement

Medical

Psychological

Family

Legal

Education

Employment

Financial

n =

percent Percent

16.5 27.5

37.2 52.6

26.6 23.2

5.5 9.7

10.7 18.1

14.4 9.7

9.8 3.2

156 117

Percent Percent Percent Percent

35.8 83.1 86.6 83.8

72.7 61.2 56.4 50.8

51.5 36.9 29.7 43.0

1.2 26.2 32.0 4.7

12.4 41.2 44.3 45.2

13.4 16.0 14.7 26.6

6.2 22.8 9.2 12.2

Muitiple Response

184 99 264 188

NOTE: Only clients who remained in treatment at least 3 months are induded in this table.

SOURCE: 1979 and 1980 TOPS Admission Cohorts.
TABLE 9. General satisfaction with treatment by TASC/criminal justice system involvement

Level of

Satisfaction

Outoatient Drug Free Residential

Non-TASC Non-TASC

Criminal No Legal Criminal No Legal

TASC Justice Involvement TASC Justice Involvement

Very Satisfied

Somewhat

Satisfied

Not At All

Satisfied

n =

Percent

46.2

40.2

3.6

100.0

156

Percent

40.7

46.7

2.6

100.0

117

Percent

60.0

36.2

1.8

100.0

164

Percent

49.1

45.1

5.8

100.0

99

Percent

46.9

51.3

1.8

100.0

264

Percent

54.1

44.5

1.4

100.0

166

NOTE: Only clients who remained in treatment at least 3 months are included in this table.

SOURCE: 1979 and 1980 TOPS Admission Cohorts.
pretreatment drug-use patterns, previous treatment admissions, TASC

referral or other criminal justice involvement, length of time in

treatment, and drug abuse treatment after the TOPS treatment experience. In addition, reports of predatory illegal acts in the year

before treatment were subject to comparative multivariate analysis

along with regression model data.

The regression results in table 10 show how particular characteristics

are associated with posttreatment predatory illegal acts. A risk

factor greater than one indicates that an individual with a particular

characteristic is more likely to commit predatory illegal acts than

similar individuals without that characteristic. A risk factor less

than one indicates an individual with that characteristic is less likely

to commit predatory illegal acts posttreatment.

The former clients were categorized as committing one or more predatory illegal acts in the year after leaving treatment or as not

committing any such act. Table 10 shows the effects of comparative

risk for the four major variables of interest in this analysis: prior

treatment, pretreatment predatory illegal acts, retention in treatment, and criminal justice system involvement.

Outpatient drug-free clients who had been in drug abuse treatment

before TOPS were 1.67 times (p<.05) more likely to commit predatory

illegal acts after TOPS treatment than those who had not been in

drug abuse treatment previously. An opposite (though not statistically significant) relationship was found for residential clients;

those with prior treatment were .73 times (p=<.20) as likely to commit

predatory illegal acts in the year after treatment. This suggests that

the risk of posttreatment predatory illegal acts is somewhat higher

when the first treatment admission is to a residential program

through the criminal justice system. On the other hand, clients

with prior treatment experiences may be more successful in

residential treatment.

Short retention was strongly related to higher posttreatment involvement in predatory illegal acts. Both outpatient drug-free and

residential clients staying in treatment 4 weeks or less almost doubled

their chances of committing predatory illegal acts compared with

those staying in treatment more than 3 months (p<.05). A stay in

treatment between 4 and 13 weeks increased the risk of committing

predatory illegal acts 1.25 times (p=.42) for outpatient drug-free

clients and 2.43 times (p<.001) for residential clients.

74
TABLE 10. Effects of treatment and criminal justice system involvement on the odds of committing predatory illegal acts in

the year after treatment

Risk Factors

Outpatient Drug Free

(n=603)

Residential

(n=498)

Prior Treatment

Prior Treatment for Drug Abuse

vs. No Prior Treatment

Predatory lllegal Acts

1.67* .73

1-10 Predatory Acts Before

Treatment vs. No Acts

11 or More Predatory Acts

Before Treatment vs. No Acts

Retention in Treatment

2.59*** 1.58

4.33*** 2.26**

4 Weeks or Less vs. 3 Months or More

4-13 Weeks vs. 3 Months or More

Criminal Justice System Involvement

TASC vs. No Legal Involvement

Non-TASC Criminal Justice System Other

1.91**

1.25

1.10

1.83*

2.46***

1.22

than TASC vs. No Legal Involvement 1.54 .72

*p<.05.

**p<.01.

***p<.001.

SOURCE: 1979 and 1980 TOPS Admission Cohorts.

The TASC and criminal justice involvement variables did not predict

significant variation in the likelihood of posttreatment predatory

illegal acts when the other factors in the models were controlled.

Similar findings were obtained when time-at-risk corrected measures

of number of predatory illegal acts were used as the dependent

variables (Marsden et al. 1986). Longer retention is associated with

lower numbers of predatory illegal acts so, by increasing retention,

75
criminal justice referrals may have a greater impact on posttreatment

predatory illegal acts than is indicated in the regression analysis.

Other Outcomes

Criminal justice system involvement may affect drug use, depression,

employment, and other client behaviors. The effect of a legal source

of referral rather than self-referral for other behaviors in the year

after treatment was examined in a multivariate model. The results

indicated that a legal source of referral significantly affected weekly

or daily use of the primary problem drug but not the use of other

drugs, depression, criminal behavior, or employment. After treatment,

criminal justice system-referred residential clients were .62 times

(p<.05) less likely and outpatient drug-free clients were .61 times

(p<.10) less likely to use their primary problem drug weekly or more

often than their self-referred counterparts. These results suggest that

a more elaborate model of the direct and indirect effects of criminal

justice involvement is needed to better delineate the overall impact

of criminal justice system involvement.

CONCLUSIONS

The results of the analyses support the basic belief that criminal

justice clients do as well or better than other clients in drug abuse

treatment. TASC programs and other formal or informal criminal

justice system mechanisms appear to refer individuals who had not

previously been treated and many who were not yet heavily involved

in drug use. This early interruption of the criminal and drug-use

careers may have important long-term benefits in reducing both crime

and drug use among treated offenders. Criminal justice system

involvement also helps retain clients in treatment. The estimated 6

to 7 additional weeks of retention for TASC referrals provided programs with considerably more time for rehabilitation efforts. There

also seemed to be more substantial changes in behavior during treatment for other criminal justice clients. These findings support

efforts to continue and expand criminal justice programs such as

TASC. Other results suggest the need for careful assessment of how

TASC and other criminal justice programs might be improved.

TASC programs have a broad mandate to identify and refer drug

abusers in the criminal justice system to treatment. It is clear,

however, that a large number of individuals entering drug abuse

treatment are involved with the criminal justice system but not a

TASC program. Whether these individuals were not identified by

76
TASC program. Whether these individuals were not identified by

TASC; were not considered to be eligible by TASC; were not allowed

to enroll for other reasons, such as the decision of a judge or

prosecutor; or chose not to participate in TASC needs to be studied.

The TOPS data do not indicate the structure and process of formal

criminal justice programs and referral processes other than TASC.

Further, studies are needed to identify these mechanisms and to

determine how they complement the TASC programs.

One major finding in this research is that few TASC clients and

other criminal justice clients enter outpatient methadone programs.

The reasons for the low numbers in methadone programs need to be

explored. There appear to be many heroin addicts in the criminal

justice system who could benefit from methadone treatment to reduce

their criminal behavior.

A second finding is that TASC and other criminal justice system

clients in outpatient drug-free programs received fewer services than

other clients in the same program. Although TASC and other criminal justice system clients reported fewer drug-related problems than

clients with no legal involvement, they still reported a wide array of

problems. Differential service delivery for clients from various

referral sources should be carefully examined.

A third finding is that, although treatment itself reduced crime, those

referred by TASC or involved with the criminal justice system did

not report fewer predatory illegal acts after treatment than those

who were not currently involved with the criminal justice system.

The analyses described in this report may not fully identify the

positive effects of TASC and other criminal justice system involvement on criminal behavior. Retention, which was positively related

to reduction in risk of predatory illegal acts and arrest, was

controlled in the multivariate analyses. Thus, the indirect effect of

TASC and other criminal justice system involvement through increased

retention was not estimated. A more complex model such as path

analysis would be a more appropriate way to demonstrate the overall

impact of TASC and other criminal justice involvement. lt should be

noted that TASC and other criminal justice clients appeared to be at

earlier stages of their drug-use and criminal careers. lt is reasonable

to expect that drug abuse treatment moderates the increasing seriousness of drug use and criminal behavior for younger TASC and

other criminal justice clients. More intensive aftercare services may

be needed to maintain the reduction in drug abuse and crime achieved

during treatment. An appropriate new role for TASC might be the

77
provision or coordination of long-term aftercare services to help

reinforce the behavior changes achieved during treatment.

TASC programs have been shown to identify and refer more individuals than would be expected from a less formal, nonprogrammatic

referral system. Furthermore, some potential differential outcomes of

TASC clients and other clients involved in the criminal justice system

may be obscured by differences in clients’ motivation for treatment

which were not included in the analyses for this chapter. The

evidence of the efficacy of criminal justice referral demonstrated in

the TOPS data support the belief that a formal and comprehensive

program such as TASC should produce benefits that far outweigh

their costs.

REFERENCES

Allison, M.; Hubbard, R.L; and Rachal, J.V. Treatment Process in

Methadone Residential and OPDF Programs (TOPS). National

Institute on Drug Abuse Treatment Research Monograph Series.

DHHS Pub. No. (ADM) 85-1388. Washington, DC: Supt. of Docs.,

U.S. Govt. Print. Off., 1985. 89 pp.

Ball, J.C.; Rosen, L; Flueck, J.A.; and Nurco, D.N. The criminality of

heroin addicts when addicted and when off opiates. In: Inciardi,

J., ed. Drugs-Crime Connection. Beverly Hills, CA: Sage

Publications, 1981. pp. 39-65.

Carter, R.M., and Klein, M.W., eds. Back on the Street. Englewood

Cliffs, NJ: Prentice-Hall, 1976.

Collins, J.J.; Hubbard, R.L; Rachal, J.V.; and Cavanaugh, E.R. Drug

Abuse Treatment Clients in the Criminal Justice System. 1979-1980

TOPS Admission Cohorts. National Institute on Drug Abuse

Treatment Research Monograph Series. Rockville, MD: the

Institute, in press.

Demaree, R.G., and Neman, J.F. Criminality indicators before, during

and after treatment for drug abuse. DARP research findings 1976.

In: Drug Use and Crime: Report of the Panel on Drug Use and

Criminal Behavior (Appendix). Research Triangle Park, NC:

Research Triangle Institute, 1976. pp. 457-487.

Gandossy, R.P.; Williams, J.R.; Cohen, J.; and Harwood, H.J. Drugs

and Crime. A Survey and Analysis of the Literature. U.S.

Department of Justice, National Institute of Justice. Washington,

DC: Supt. of Docs., U.S. Govt. Print. Off., 1980. 173 pp.

78
Hubbard, R.L.; Cavanaugh, E.R.; Craddock, S.G.; Bray, R.M.; Rachal,

J.V.; Collins, J.J.; and Allison, M. Drug Abuse Treatment Client

Characteristics and Pretreatment Behaviors 1979-1981 TOPS

Admission Cohorts. National Institute on Drug Abuse Treatment

Research Monograph. DHHS Pub. No. (ADM) 86-1480. Rockville,

MD: the Institute, 1986. 76 pp.

Hubbard, R.L; Marsden, M.E.; Cavanaugh, E.R.; Rachal, J.V.; and

Ginzburg, H.M. The role of drug abuse treatment in limiting the

spread of AIDS. Rev Infect Dis 10(2):377-384, 1988.

Lipton, D.; Martinson, R.; and Wilkes, J. The Effectiveness of

Correctional Treatment: A Survey of Treatment Evaluation Studies.

London: Praeger, 1975.

Long, G.L., and Demaree, D.G. Indicators of criminality during

treatment for drug abuse. Am J Drug Alcohol Abuse 2(1):123-126,

1975.

Marsden, M.E.; Collins, J.J.; and Hubbard, R.L. Effects of Adjusting

Individual Offense Rates for Time at Risk Among Drug Abuse

Treatment of Clients. Revised. Paper presented at the 1985

meeting of the American Society of Criminology, 1986.

McGlothlin, W.H.; Anglin, M.D.; and Wilson, B.D. A followup of

admissions to the California Civil Addict program. Am J Drug

Alcohol Abuse 4(2):197-199, 1977.

Nash, G. An analysis of twelve studies of the impact of drug abuse

treatment upon criminality. In: Drug Use and Crime. Report of

the Panel on Drug Use and Criminal Behavior (Appendix). Research

Triangle Park, NC: Research Triangle Institute, 1976. pp. 231-271.

Panel on Drug Use and Criminal Behavior. Drug Use and Crime.

NTIS No. PB 259-167/5. Research Triangle Park, NC: Research

Triangle Institute, 1976. 112 pp.

Simpson, D.D. Treatment for drug abuse: Followup outcomes and

length of time spent. Arch Gen Psychiatry 38(6):875-880, 1981.

Simpson, D.D.; Savage, L.J.; Lloyd, M.R.; and Sells, S.B. Evaluation of

Drug Abuse Treatments. DHEW Pub. No. (ADM) 78-701.

Rockville, MD: National Institute on Drug Abuse, 1978. 108 pp.

AUTHORS

Robert L. Hubbard, Ph.D.

James J. Collins, Ph.D.

J. Valley Rachal, M.S.

Elizabeth R. Cavanaugh, M.A.

79
Research Triangle Institute

Box 12194

Research Triangle Park, NC 27709

80
Legal Status and Long-Term

Outcomes for Addicts in the

DARP Followup Project

D. Dwayne Simpson and H. Jed Friend

INTRODUCTlON

From 1969 to 1973 approximately 44,090 drug abusers were admitted

to 52 federally funded and community-based treatment agencies in the

Drug Abuse Reporting Program (DARP). Over the course of several

years, a series of during-treatment studies were conducted on this

treatment population (Sells 1974; Sells and Simpson 1976), and samples

of these drug abusers were later followed up at about 6 years and

again at 12 years after admission to treatment (Simpson and Sells

1982; Simpson et al. 1986a; Simpson et al. 1986b). This chapter

examines these longitudinal data concerning the influence of judicial

status on client performance during and after treatment.

Previous findings from DARP during-treatment evaluations and

followup research data relevant to legal status are reviewed, and new

analyses are presented that focus specifically on pretreatment judicial

status in relation to treatment retention and long-term behavioral

outcomes, including opioid use, criminality, and employment. However, the DARP data did not emanate from civil commitment agencies,

and there were differences among agencies, with regard to the role

legal status played in treatment referrals. Overall, 40 percent of the

DARP treatment population were admitted with some form of legal

status, such as probation, awaiting trial, or parole, but the client’s

legal classification was not necessarily reflected in the source of

referral. Some of the legally involved clients reported being referred

to DARP treatment from courts, parole/probation officers, and police

but others did not. Thus, client motivations recorded retrospectively

in the 12-year followup as major reasons for entering drug abuse

treatments were also examined in relation to treatment history and

long-term outcomes.

81
DESCRlPTlON OF THE SAMPLE

Data are presented below for black and white male daily opioid users,

which is the subsample most representative of the DARP population.

For instance, among the almost 44,000 admissions to the DARP, 75

percent were male, 81 percent were either black or white, and 64

percent had used opioid drugs (heroin, illegal methadone, or other

opiates) daily during the P-month pretreatment period. Male addicts

were also the major focus of the 12-year foilowup study, even though

a subsample of female addicts was studied in detail by Marsh and

Simpson (1986). In the present study, therefore, the research sample

was limited to male daily opioid users. This limitation reduces the

confounding of results on drug use, criminality, and employment

outcomes by avoiding baserate differences involving males/females and

addicts/nonaddicts.

Out of the nearly 44,000 original DARP admissions, 27,460 subsequently entered treatment with acceptable data and were studied in

the DARP during-treatment research phase (Sells 1974; Sells and

Simpson 1976). Table 1 shows that among the subgroup of 11,920

black and white male addicts in this population, 5,704 were treated in

methadone maintenance (MM) programs, 1,767 were treated in therapeutic communities (TC), 1,232 were treated in outpatient drug-free

(DF) programs, and 3,217 were treated in outpatient detoxification

(DT). This treatment sample is described in table 1 with regard to

race, age, legal status at admission, source of referral, days spent in

treatment before termination, and reasons for discharge.

Followup Samples

The 12-year longitudinal data were obtained from a cohort sample of

opioid addicts admitted to DARP treatment programs during the

period of June 1969 through May 1972. However, the first wave of

(6-year) followup interviews was conducted with a stratified random

sample of 4,107 addicts and nonaddicts from 25 different DARP

agencies located across the United States (Simpson and Joe 1977); 87

percent of the cases were located, and successful interviews were

completed with 3,131 respondents. The 6-year DARP foilowup studies

(Simpson and Sells 1982) focused on evaluation of posttreatment

outcomes. Sample stratification factors for this followup study

included DARP treatment classification, time in treatment, race/ethnic

group, sex, age, and treatment agency or clinic. Clients were

selected to represent MM, TC, DF, and DT programs, as well as an

intake only (IO) group, whose members completed intake and

82
TABLE 1. Description of black and white male daily opioid users admitted to DARP during 1969-1973

MM

Type of DARP Treatment

(percent)

TC DF DT

Total

(percent)

Race:

Black

White

80

20

53

47

60 66 70

40 34 30

Age:

Under 18 1

18-20 11

21-25 35

26-30 17

Over 30 36

Legal Status of Admission:

None 66

Probation 16

Parole 5

Awaiting Trial 12

7 8 4 4

26 22 19 16

40 43 45 39

10 12 13 15

17 15 19 26

34 48 55 57

35 23 22 21

9 9 8 7

22 20 15 15
TABLE 1. (Continued)

MM

Type of DARP Treatment

(percent)

TC DF DT

Total

(percent)

Source of Referral:

Legal/Court 7

Family/Friends 38

Other 56

Days in Treatment:

1-30

31-90

91-365

Over 365

5 26 25 44 21

10 24 30 40 22

36 32 36 15 30

49 18 7 1 27

Reason for Treatment Discharge:

Completed 28

Quit/Expelled 49

Jailed 6

Other 17

Sample Sizes: 5,704 1,767 1,232 3,217 11,920

31 22 10 13

24 26 30 32

45 52 60 55

20 13 21 23

71 77 73 61

2 4 3 5

7 6 3 11
admission procedures but did not return for treatment in the DARP.

The IO group in this study was viewed as an important comparison

group but not as a control group, since treatment samples were not

formed through random assignment.

From the completed 6-year interviews, a second wave of 697 DARP

admissions was selected for a 12-year followup study of opioid

addiction careers. Sample selection was based on pre-DARP drug use

history, treatment classification, race/ethnic group, sex, and treatment agency or clinic. Only clients who were daily opioid users at

the time of DARP admission were included in the 12-year study (this

sampling restriction was made, in part, because of funding limitations). The sample targeted equal numbers of black and white males

from all five treatment groups; black and white females were included

only in the MM treatment group due to sampling limitations in other

treatments. The final sample was drawn from 18 different treatment

agencies, as explained in more detail by Simpson (1984a).

The fieldwork for the DARP followup studies, involving the location

and interviewing, was carried out under contract with the National

Opinion Research Center. For the 12-year study, 558 (80 percent) of

the target sample were located during 1982 and 1983,490 (70 percent)

were interviewed after granting informed consent, 52 (8 percent) were

deceased, and 13 (2 percent) refused to be interviewed. The

remaining 142 (20 percent) were not located before time and

resources for the fieldwork ran out. Analysis of intake and 6-year

followup data, however, revealed no evidence of systematic sampling

bias associated with these nonlocated cases (Simpson 1984a).

The 1 P-year followup interviews were conducted face-to-face with

trained interviewers who followed strict procedures to protect confidentiality. The average time for each interview was about 2 hours,

for which the respondent was paid $15. The interview focused on

behavioral changes and outcomes over time, as well as historical

assessments of psychological and social factors involved throughout

their addiction careers. The major treatment outcomes measured

were illicit drug use, drug abuse treatment, alcohol use, employment,

and criminality. Comparisons of self-reported information with

urinalysis results, criminal justice records of post-DARP incarcerations, and checks for internal consistency indicated a high level of

data reliability and validity (Simpson 1984b).

The final interviewed sample of 490 former opioid addicts included 18

percent females and 62 percent males and 51 percent blacks and 49

85
percent whites, with a median age of 34 at the time of the 12-year

followup interview (19 percent were over 40 years old). As previously noted, the present study includes only male addicts (n=405)

because females were fewer in number and because they differed

systematically from males on several behavioral measures, particularly

employment and criminality.

DARP TREATMENT ADMISSIONS AND PROGRAM PERFORMANCE

About 40 percent of the opioid addicts who entered treatment in the

DARP during 1999 to 1972 reported some form of legal involvement at

the time of admission; 17 percent were on probation, 14 percent were

awaiting trial, and 8 percent were on parole. There were large differences between treatment modalities, however. For instance, only

34 percent of admissions to MM were legally involved, compared to

66 percent for TC, 52 percent for DF, and 45 percent for DT. These

differences, especially between MM and TC programs, were further

illustrated by the sources of treatment referral that were reported by

clients at the time of their admission. For MM programs, 7 percent

of the admissions were court referred and 47 percent reported being

self-referred; for TC programs, these percentages were 31 percent

and 30 percent (Simpson et al. 1978).

Early DARP studies of retention in treatment conducted by Joe

(1974), Joe and Simpson (1978a), and Joe and Simpson (1978b) examined legal involvement at admission as a predictor variable. These

studies found that predictions of treatment tenure from legal status

were inconsistent across treatment categories and were usually statistically nonsignificant. Legal status was also unrelated to duringtreatment drug and alcohol use, employment, and criminality (Spiegel

and Sells 1974; Gorsuch et al. 1976a; Gorsuch et al. 1976b). Thus,

legal status at intake, as well as source of referral to treatment, was

not a useful predictor in the DARP during-treatment research.

Since these earlier studies of legal status were based on combined

samples of addicts and nonaddicts in a multiple regression analytic

model, the present study narrowed the focus to black and white male

addicts. In particular, treatment performance indicators (length of

time in treatment and reason for discharge) were compared between

clients who were legally involved when admitted to DARP (i.e., on

parole, probation, or awaiting trial) and those who had no legal

status. These comparisons answered the question of whether legal

86
pressure at the time of treatment admission was associated with (1)

the length of time the addict remained in treatment, and (2) the

addict’s reasons for leaving.

The findings are summarized for each treatment modality in the upper

portion of table 2. In short, legal status and treatment tenure

showed no significant relationship (using chi-square) in any of the

four treatment groups. Reason for discharge was also generally

unrelated to legal status. However, MM clients with legal status had

slightly lower treatment completion rates (25 percent vs. 30 percent

for those without legal status) and higher rates of termination due to

incarceration in jail (10 percent vs. 4 percent for those without legal

status); although these were statistically significant differences

(p<.01), they have small practical implications.

To test for the further possibility that legal status might be differentially important for certain age ranges, similar analyses were conducted separately within age categories (i.e., under 18, 18 to 25, and

over 25). Again, the results showed no evidence that pretreatment

legal pressures were related to retention and to cause of discharge.

POSTTREATMENT OUTCOMES

The first wave of DARP followup interviews was conducted about 6

years after treatment admission. The focus was on using posttreatment outcomes to assess treatment effectiveness, especially in

the first year after termination from DARP treatment. Simpson and

Sells (1982) reported that clients in the major treatment modalities

(MM, TC, and DF) had significantly better posttreatment outcomes on

opioid use, criminality, and employment than clients in DT and the

comparison group of IO clients. Longer retention in these treatments

was also predictive of better outcomes.

Client demographic and background measures used in the DARP provided small but statistically significant predictions of posttreatment

outcomes. Examination of pre-DARP legal status, in relation to

posttreatment outcomes, is summarized in the lower portion of table

2. In the MM, TC, and DF treatment groups, jail or prison was

significantly more likely in the first year after DARP among those

who were legally involved before admission. This relationship is not

surprising, since some of these incarcerations were probably the

direct result of pre-DARP legal problems. None of the other outcomes, however, in years 1 or 6, were significantly related to preDARP !egal status. In addition, analysis of variance comparing

87
TABLE 2. Treatment performance and outcome indicators by legal involvement at time of admission to DARP

treatments
TABLE 2. (Continued)

NOTE: “Some” legal involvement indicates the addict was on parole, probation, or awaiting trial when admitted to DARP.
posttreatment outcome scores between clients with specific types of

legal status (parole, probation, awaiting trial, and not legally involved) also indicated that there were no significant differences

associated with subcategories of legal status.

In year 12 after DARP treatment admission, the followup sample contained 39 percent who had used opioid drugs (including 26 percent

who had used opioids daily) in 1 or more months during that year.

Marijuana was used in year 12 by 61 percent, and other nonopioid

drugs (mostly cocaine) were used by 47 percent, while 31 percent had

spent time in drug abuse treatment during the year (Simpson et al.

1988).

With regard to other outcomes, 27 percent consumed an average of

over 4 ounces of 80-proof liquor equivalent per day, 29 percent spent

time in jail or prison, and 64 percent worked during 6 or more

months (28 percent had not worked at all in year 12). As reported

in more detail by Simpson et al. (1986), these outcome levels for year

12 changed very little from those in year 6, but this was not merely

a result of the long-term stability of outcomes over time. For instance, about one-half of the sample maintained the same level of

opioid use from year 6 to year 12 (42 percent were abstainers in both

years and 9 percent used opioids daily in both years), but one-fourth

increased their use and the remaining one-fourth decreased their use

across this time period.

Lehman and Simpson (1984) reported that long-term predictions of

12-year outcomes, that is, using predictors based on pre-DARP information, are generally poor. For instance, even the significant treatment group differences in behavioral outcomes found during the first

year following DARP “fade out” over time as other treatments and

life changing events accumulate. lt is not surprising, then, that most

of the year 12 outcome measures were also statistically unrelated to

pre-DARP legal status of black and white male addicts. These data

are summarized in table 3, and they show that year 12 opioid use and

employment rates did not differ due to pre-DARP legal status. However, it was found that addicts who were legally involved when they

entered DARP treatment did have a significantly higher incarceration

rate in year 12 (37 percent vs. 27 percent).

90
TABLE 3. Twelve-year followup outcomes for clients grouped by

pre-DARP legal status

With Pre-DARP Without Pre-DARP

Legal Status Legal Status

(Percent) (Percent)

Any Opioid Use in Year 12 35 33

Daily Opioid Use in Year 12 25 20

Any Jail in Year 12 37 27

Employed for 6 Months

in Year 12 46 47

Sample Sizes: 294 201

ADDICTION CAREERS

Longitudinal analyses of opioid use patterns over time illustrate the

long-term threat of addiction relapse (Simpson and Marsh 1966). For

instance, 65 percent of the DARP sample quit for a month or longer

during the 12-year followup, only to relapse to daily opioid use one

or more times. More encouraging, however, were the findings that 25

percent of these addicts never returned to daily opioid use over the

12-year followup period, and, by year 12, 63 percent had not used

opioids daily for at least 3 years. As expected, longer periods of

abstinence from opioid addiction were also associated with less

legal involvement as well as with more employment in year 12.

The DARP treatment evaluation studies have consistently indicated

that drug abuse treatment is effective in improving client posttreatment outcomes (Simpson and Sells 1962). Data from the 12-year

followup interviews give further support to this conclusion, since 56

percent of the sample that had quit opioid use by year 12 reported

being in a treatment program when they quit. A detailed treatmenthistory study of these addicts in the 12-year followup indicates the

complexity of treatment experience when viewed from a longitudinal

perspective (Marsh et al. 1965). The average length of time from the

first to the last daily opioid use was 10.5 years. This period of time

averaged 9 years for those who had quit before year 12, compared to

91
16 years for those who were still addicted. The average number of

drug abuse treatment episodes per client was 6.2. As expected,

addicts who were primarily treated in DT throughout their addiction

career had the highest average, with 9.9 treatment episodes, compared

to 5.1 for those usually treated in MM, 4.6 for TC, and 3.4 for DF.

Comparisons between these mutually exclusive groups classified by

lifetime treatment experiences, however, showed that they were not

significantly different in client sociodemographic characteristics (i.e.,

age, race, marital status, and educational levels), in reasons usually

given for entering treatment (discussed later), and in drug use or

criminal involvement in year 12. On the other hand, analysis of

addicts according to whether they had ever been treated in each separate treatment modality (using partial regression weights) showed

that those treated one or more times in a TC had the most favorable

year 12 outcomes on drug use, alcohol use, employment, and time in

jail (Marsh et al. 1985).

As part of the 12-year followup interview, DARP respondents were

asked to review their lifetime of treatment experiences and to rate

the overall importance of their reasons for entering treatment. Almost 9 out of 10 (89 percent) indicated that “deciding for self” was

important (i.e., “very” or “somewhat” important) for entering treatment. Family was an important reason for 73 percent, but only 28

percent remembered friends as being important. Legal reasons were

also considered important by about half the sample—49 percent

acknowledged “legal problems” and 41 percent “probation or parole”

(the four-point ratings of importance for these two items correlated

at 0.62). A smaller percent indicated that drug availability or quality

were important treatment motivations, that is, 32 percent for “poor

quality of drugs” and 20 percent for “unavailability.” Finally, only 16

percent said medical problems were important in making treatment

decisions.

Legal and family incentives for treatment were also statistically

associated with larger numbers of lifetime treatment episodes. For

example, 50 percent of those who reported parole/probation as important treatment motivations had five or more treatments, while only 37

percent of those who reported parole/probation as being unimportant

had as many treatments. Likewise, 48 percent of those who considered family reasons as important reported five or more treatment

experiences, compared to only 26 percent of those for whom family

reasons were unimportant. Thus, addicts who entered treatment more

92
frequently were subject to greater influence from legal pressures and

family concerns.

In table 4, the data show that addicts who were originally admitted

to DARP treatment with legal involvement also reported in year 12

that parole/probation and legal problems had previously been important treatment incentives. In addition, they were less likely to

report “decisions for self” as being important. None of the other

reasons for entering treatment were significantly related to pre-DARP

legal status. The total number of career treatment episodes was also

unrelated to pre-DARP legal status.

TABLE 4. Important reasons for treatments for clients grouped by

pre-DARP legal status

With Pre-DARP Without Pre-DARP

Legal Status Legal Status

(Percent) (Percent)

“Parole/Probation” Was

Important 53 29

“Legal Problems” Were

Important 63 35

“Decided for Self” Was

Important 84 95

Finally, analyses of relationships between reasons for entering

treatment and year 12 outcomes revealed only two statistically significant findings. First, year 12 incarcerations in jail or prison for

one or more months was more likely among those who rated probation or parole as important reasons for entering treatment (42 percent vs. 24 percent, p<0.01). Second, employment in year 12 (for 6

or more months) was less likely among addicts who reported medical

or physical problems as important reasons for entering treatment (27

percent vs. 47 percent, p<0.01).

93
CONCLUSIONS

The DARP research team has been asked many times during the past

15 years if reasons for admission to treatment (sometimes

characterized as “involuntary admissions,” “legal referrals,” or “civil

commitments”) are related to during-treatment behavior and to posttreatment outcomes. After several caveats, the answer has always

been a cautious “No, we can’t say they are!” These caveats emphasize that DARP samples and variables might not be generalizable to

other situations. The study reported here focuses on a reduced

sample of black and white male addicts who were examined at

different points in time throughout a 12-year followup period.

The simple question posed was “Does the pretreatment legal status of

addicts relate to length of stay in (DARP) treatment, to why they

left treatment, and to their behavioral performance after treatment?”

With few exceptions, pretreatment legal status did not predict sub

sequent outcomes. That is, within each separate treatment modality

(MM, TC, DF, and DT), the length of time in treatment, reasons for

discharge, and posttreatment outcomes were similar for addicts who

were legally involved and those who were not. Exceptions usually

involved outcome measures representing incarceration, which sometimes occurred as a direct consequence of the legal status (such as

awaiting trial). However, there were some long-range associations of

these criminality indicators that suggested habitual criminal involvement among some addicts.

Compared to more recent treatment populations, the DARP clientele

was usually younger, more opiate-dependent, more legally involved,

and had fewer prior treatment admissions (Hubbard et al. 1988).

Especially significant is the fact that over 80 percent of the addicts

admitted to DARP programs had one or more prior arrests, and over

half had already spent time in jail or prison. Thus, legal status at

the time of DARP admission may not have been a very discriminating

variable in this relatively homogeneous sample of primarily young,

inner-city, criminally active “street addicts.” Source of referral was,

therefore, examined in an extended effort to refine this definition of

legal pressure. Of special interest were addicts referred by court or

legal sources, which presumably carried more pressing legal implications. These clients were compared to those referred by family,

friends, self, and others. The results, however, were no different

from those using the original measure of legal status—in particular,

DARP treatment retention for court-referrals was not significantly

different from other referrals. Because these results were consistent

94
with others in this study focusing on legal status, these analyses

were not elaborated. It is possible, however, that this measure could

also have been too general or incomplete to reflect a high degree of

pending legal liabilities.

In spite of the negative findings of this study, there are still

unresolved questions about judicial pressures on treatment success.

Clinical judgments vary on this point. As Indicated above, there is a

lack of precision in the simple classification of “legal status.”

Indeed, legal status does not necessarily imply legal pressure; there

are important methodological distinctions in comparing clients “with”

and “without” legal status versus those who differ only in degree of

legal pressure. Ideally, effects of legal pressures might be tested

most appropriately using clients otherwise matched for criminal

history and legal status, even though this is not easy to achieve in

practice.

There is evidence from the DARP and other treatment evaluation

studies that treatment is effective in improving behavioral outcomes.

Treatment effects vary, however, and making accurate outcome

predictions on the basis of pretreatment data is difficult. Staying

longer in treatment tends to increase the chances for posttreatment

success, but legal pressures at DARP treatment entry did not seem

very important. More precise data concerning legal and other

environmental incentives, as well as the client motivations and

readiness for change, might help with these predictions, as suggested

by De Leon and Jainchill (1986).

lt is clear that future use of civil commitment will add more stress

to the drug abuse treatment resources available in this country. It

is, therefore, important to continue searching for ways to maximize

treatment impact by identifying those most likely to benefit from

various therapeutic efforts and then to define and improve the

critical elements of treatment process and aftercare supervision.

REFERENCES

De Leon, G., and Jainchill, N. Circumstance, motivation, readiness

and suitability as correlates of treatment tenure. J Psychoactive

Drugs 18(3):203-208, 1986.

95
Gorsuch, R.L.; Abbamonte, M.; and Sells, S.B. Evaluation of treatments for drug users in the DARP: 1971-1972 admissions. In:

Sells, S.B., ed. The Effectiveness of Drug Abuse Treatment. Vol.

IV (Part 1). Cambridge, MA: Ballinger Publishing Co., 1976a.

pp. 1-226.

Gorsuch, R.L.; Butler, M.C.; and Sells, S.B. Evaluation of treatment

for drug users in the DARP: 1972-1973 admissions. In: Sells, S.B.,

and Simpson, D.D., eds. The Effectiveness of Drug Abuse Treatment. Vol. V (Part 1). Cambridge, MA: Ballinger Publishing Co.,

1976b. pp. 1-167.

Hubbard, R.L.; Allison, M.; Bray, R.M.; Craddock, S.G.; Rachal, J.V.;

and Ginzburg, H.M. An overview of client characteristics, treatment services, and during-treatment outcomes for outpatient

methadone clinics in the Treatment Outcome Prospective Study

(TOPS). In: Cooper, J.R.; Altman, F.; Brown, B.S.; and Czechowicz,

D., eds. Research on the Treatment of Narcotic Addiction: State

of the Art. National Institute on Drug Abuse Research Monograph.

DHHS Pub. No. (ADM) 63-1281. Washington, DC: Supt. of Docs.,

U.S. Govt. Print. Off., 1963. pp. 714-751.

Joe, G.W. Studies of retention in treatment of drug users in the

DARP: 1969-1971 admissions. In: Sells, S.B., ed. The Effectiveness of Drug Abuse Treatment. Vol. 1 (Part IV). Cambridge, MA:

Ballinger Publishing Co., 1974. pp. 439-497.

Joe, G.W., and Simpson, D.D. Retention in treatment of drug users

admitted to treatment during 1971-1972. In: Sells, S.B., and

Simpson, D.D., eds. The Effectiveness of Drug Abuse Treatment.

Vol. IV (Part II). Cambridge, MA: Ballinger Publishing Co., 1976a.

pp. 253-324.

Joe, G.W., and Simpson, D.D. Treatment retention for drug users:

1972-1973 DARP admissions. In: Sells, S.B., and Simpson, D.D.,

eds. The Effectiveness of Drug Abuse Treatment. Vol. V (Part II).

Cambridge, MA: Ballinger Publishing Co., 1976b. pp. 167-228.

Lehman, W.E.K., and Simpson, D.D. Prediction of Long-Term Outcomes: 12-Year Followup of 1969-1972 Admissions to DARP Drug

Abuse Treatments. College Station, TX: Texas A&M University,

Behavioral Research Program, 1984. 43 pp. (Document is being

revised for a book in preparation.)

Marsh, K.L; Joe, G.W.; Lehman, W.E.K.; and Simpson, D.D. Treatment

History of Opioid Addicts: 12-Year followup of 1969-1972 Admissions to DARP Drug Abuse Treatments. College Station, TX: Texas

A&M University, Behavioral Research Program, 1985. 28 pp.

(Document is being revised for a book in preparation.)

96
Marsh, K.L, and Simpson, D.D. Sex differences in opioid addiction

careers. Am J Drug Alcohol Abuse 12(4):309-329, 1986.

Research Triangle Institute. Treatment Outcome Prospective Study:

lntreatment Data Book - 1981 Cohort. Research Triangle Park, NC:

Research Triangle Institute, 1983. 103 pp.

Sells, S.B., ed. The Effectiveness of Drug Abuse Treatment. Vol. I

and II. Cambridge, MA: Ballinger Publishing Co., 1974. Vol. I.

532 pp. Vol. II. 413 pp.

Sells, S.B., and Simpson, D.D., eds. The Effectiveness of Drug Abuse

Treatment. Vol. Ill, IV, and V. Cambridge, MA: Ballinger

Publishing Co., 1976.

Simpson, D.D. Research Design and Methods: 12-Year Followup of

1969-1972 Admissions to DARP Drug Use Treatments. College

Station, TX: Texas A&M University, Behavioral Program, 1984a.

22 pp. (Document is being revised for a book in preparation.)

Simpson, D.D. Reliability and Validity of Data: 12-Year Followup of

1969-1972 Admissions to DARP Drug Abuse Treatments. College

Station, TX: Texas A&M University, Behavioral Research Program,

1984b. 15 pp. (Document is being revised for a book in preparation.)

Simpson, D.D., and Joe, G.W. Sample Design and Data Collection:

National Followup Study of Admissions to Drug Abuse Treatment in

the DARP During 1969-1972. College Station, TX: Texas A&M

University, Behavioral Research Program, 1977. 43 pp.

Simpson, D.D.; Joe, G.W.; and Lehman, W.E.K. Addiction Careers:

Summary of Studies Based on the DARP 12-Year Followup.

National Institute on Drug Abuse Treatment Research Report.

DHHS Pub. No. (ADM) 86-1420. Washington, DC: Supt. of Docs.,

U.S. Govt. Print. Off., 1986a. 22 pp.

Simpson, D.D.; Joe, G.W.; Lehman, W.E.K.; and Sells, S.B. Addiction

careers: Etiology, treatment, and 12-year followup outcomes.

J Drug Issues 16(1):107-121, 1986b.

Simpson, D.D., and Marsh, K.L. Relapse and recovery among opioid

addicts 12 years after treatment. In: Tims, F.M., and Leukefeid,

C.G., eds. National Institute on Drug Abuse Research Monograph

72. DHHS Pub. No. (ADM) 86-1473. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., 1986. pp. 86-103.

Simpson, D.D.; McBride, A.A.; and Lehman, W.E.K. Data Book for

Questionnaire Responses: 12-Year Followup of 1969-1972 Admissions

to DARP Drug Abuse Treatments. College Station, TX: Texas A&M

University, Behavioral Research Program, 1988. 226 pp.

97
Simpson, D.D.; Savage, J.; Joe, G.W.; Demaree, R.G.; and Sells, S.B.

DARP Data Book: Statistics on Characteristics of Drug Users in

Treatment During 1969-1974. College Station, TX: Texas A&M

University, Behavioral Research Program, 1976. 285 pp.

Simpson, D.D., and Sells, S.B. Effectiveness of treatment for drug

abuse: An overview of the DARP research program. Adv Alcohol

Subst Abuse 2(1):7-29, 1982.

Spiegel, D.K, and Sells, S.B. Evaluation of treatments for drug users

in the DARP. In: Sells, S.B., ed. The Effectiveness of Drug

Abuse Treatment. Vol. I (Part I). Cambridge, MA: Ballinger

Publishing Co., 1974. pp. 3-222.

ACKNOWLEDGMENTS

This paper was supported by the National Institute on Drug Abuse

Grant number R01 DA03419.

The contributions of Drs. S.B. Sells, George W. Joe, Wayne E.K.

Lehman, and the National Opinion Research Center are acknowledged.

AUTHORS

D. Dwayne Simpson, Ph.D.

H. Jed Friend, M.S.

Behavioral Research Program

Department of Psychology

Texas A&M University

College Station, TX 77843

98
Treatment Alternatives to Street

Crime1

L. Foster Cook, Beth A. Weinman et al.2

lNTRODUCTlON

Treatment Alternatives to Street Crime (TASC) provides a bridge

between the criminal justice system, which employs legal sanctions

that reflect community concerns for public safety, and the treatment

community, which emphasizes therapeutic relationships as a means

for changing individual behavior and reducing substance abuse and

other problems. Under TASC auspices, community-based treatment is

made available to drug-dependent individuals who would otherwise

become involved with the criminal justice system.

TASC programs were initiated nearly 15 years ago in response to

recognized links between substance abuse and criminal behavior. The

mission of TASC is to participate in criminal justice processing, as

early in the continuum as acceptable to participating agencies. TASC

identifies, assesses, and refers appropriate drug- and/or alcoholdependent offenders accused or convicted of nonviolent crimes to

community-based substance abuse treatment, as an alternative or

supplement to existing criminal justice sanctions and procedures.

TASC then monitors the drug-dependent offender’s or client’s

compliance with individually tailored progress expectations for

abstinence, employment, and improved social/personal functioning.

TASC then takes responsibility for reporting treatment results back

to the referring justice system component. Clients who do not follow

or who violate conditions of their criminal justice mandate, TASC, or

treatment agreement are usually returned to the criminal justice

system for continued processing or for sanctions.

99
THE TASC MODEL

TASC combines the influence of legal sanctions for probable or

proven crimes with the appeal of such innovative dispositions as

deferred prosecution, creative community sentencing, diversion,

pretrial intervention, probation, and parole supervision: the goal is to

motivate treatment cooperation by the substance abuser. Through

treatment referral and closely supervised community reintegration,

TASC aims to permanently interrupt the vicious cycle of addiction,

criminality, arrest, prosecution, conviction, incarceration, release,

readdiction, criminality, and rearrest.

TASC programs encourage participants to improve their lifestyles

while retaining important community ties. TASC programs also

provide important incentives to other criminal justice and treatment

participants. TASC can reduce costs and relieve many substance

abuse-related processing burdens within the justice system through

assistance with such responsibilities as addiction-related medical

situations, pretrial screening, and posttrial supervision. The

treatment community also benefits from TASC’s legal focus, which

motivates and prolongs clients’ treatment cooperation and ensures

clear definition and observation of criteria for treatment dismissal or

completion. Public safety is also increased through TASC’s careful

supervision of criminally involved clients during their communitybased treatment.

In 1962, a landmark Supreme Court decision, Robinson v. California,

defined chemical addiction as an illness rather than a crime. It also

held that the State could force an addict to submit to treatment and

could impose criminal sanctions for failure to comply with the

treatment program. In the context of the times, when penal coercion

was disavowed as an effective rehabilitation incentive and communitybased treatment for substance abuse was only slowly gaining

acceptability and credibility, alternatives to routine criminal justice

system processing for drug-dependent offenders were initiated.

In the years following, several conceptual and strategic models were

developed to implement these new understandings. By the early

1970s a Presidential-appointed Special Study Commission on Drugs

established a definite link between drugs, particularly narcotics, and

crime. A small number of addicts were found to be responsible for a

large percentage of crimes, and a disproportionate share of criminal

justice system resources were being absorbed by their recidivism.

Discussions on how to link treatment with the judicial process and

100
how to interrupt the relationship between drugs and property crimes

took place among the Law Enforcement Assistance Administration

(LEAA), the Special Action Office for Drug Abuse Prevention

(SAODAP), and the National Institute of Mental Health’s Division of

Narcotic Addiction and Drug Abuse (DNADA)-predecessor to the

National Institute on Drug Abuse (NIDA). The resulting Federal

initiative, modeled after earlier experiments with diversion programs

and two demonstration projects in New York City and Washington,

DC, was funded by the Drug Abuse Office and Treatment Act of 1972,

and named TASC. The first TASC project opened in Wilmington, DE,

in August of that year, and provided pretrial diversion for opiate

addicts with nonviolent criminal charges who were identified in the

jail lockup by urine tests and interviews. After assessment of their

treatment suitability and needs, arrestees who volunteered for TASC

were referred and escorted to appropriate community-based treatment

and monitored for continued compliance with treatment requirements.

Successful completion usually resulted in dismissed charges.

LEAA issued program guidelines for replication of the TASC model,

which focused on pretrial diversion and sentencing alternatives for

drug-dependent offenders, and awarded “seed” grants, with the

understanding that successful demonstration projects would gain local

or State funding to continue the programs within a 3-year period. In

1972 to 1973, 13 TASC projects were initiated by local jurisdictions

in 11 States. By 1975, 19 more such projects had started, making a

total of 29 operational sites in 24 states. Before Federal funding was

withdrawn in 1982, TASC projects were developed at 130 sites in 39

states and Puerto Rico. TASC is currently operational in 18 states.

Many of these local programs also continued communications with

each other through a National TASC Consortium, which was reestablished in 1984.

LEAA made a special effort to fund TASC programs in a variety of

geographic areas and jurisdictions, including large metropolitan areas,

smaller cities, suburban and rural counties, regional conglomerations,

and statewide networks of sites. Original client participation criteria

were also expanded to include polydrug and alcohol abusers; juveniles;

and, in some places, domestic violence and mental health demonstration projects. TASC services to the alcohol- and drug-related traffic

offender were also evolving.

101
EVALUATION OF TASC PROGRAMS

All of the TASC programs funded by LEAA were required to conduct

independent evaluations. More than 40 of these local assessments

were completed over the 10-year period from 1972 to 1982. Although

a few evaluators found some TASC programs had overly optimistic

expectations for client success or were underutilized, the majority

concluded that local TASCs effectively:

intervened with clients to reduce drug abuse and criminal activity;

linked the criminal justice and treatment systems; and

identified previously untreated drug-dependent offenders.

During the same period, three national assessments of the TASC

program focused on the success of multiple sites in meeting general

TASC goals. Evaluators of five early TASC projects (System

Sciences, Inc. 1974) concluded that those sites included a substantial

proportion of repeat offenders with long histories of addiction,

initiated more than half of the identified clients (55 percent) into

their first treatment experience, and reduced criminal recidivism.

A 1976 study of 22 operational TASC sites (Lazar Institute 1976)

found several commonalities in the success of TASC programming,

which included: (1) the broad-based support of the justice system

gained by TASC; and (2) the support of the treatment system,

because TASC’s legally sanctioned referral mechanisms to treatment

were more effective than informal treatment initiations. TASC’s

monitoring function improved clients’ treatment performance, and

TASC involvement seemed to reduce rearrest rates. Only 8 percent

of clients in all sites were known to have been rearrested for new

offenses while in the TASC program. However, TASC had no solid

data base or data collection mechanism in place that would allow for

long-term evaluation and comparison of the program’s impact on

drug-related crime or on the processing burdens of the justice

system.

A subsequent evaluation of 12 TASC sites (System Sciences, Inc. 1978)

found that:

the TASC model offered a beneficial and cost-effective alternative

to the criminal justice system for drug-abusing offenders;

102
its major functions and procedures were effective;

a majority of clients were admitted to TASC prior to trial;

TASC’s threat of legal sanctions added a positive factor to the

treatment process;

TASC projects achieved remarkably progressive success rates with

clients (considering the seriousness of the crimes and the drugs

involved); and

staff quality was more important to program success than were

organizational and other factors.

Poor recordkeeping and information management, however, were

widespread among TASC programs.

A report from the National Institute on Drug Abuse’s Treatment

Outcome Prospective Study (TOPS) (Collins and Allison 1983)

examined the impact of TASC or similar programs for drug-dependent

offenders on clients’ intreatment and posttreatment behavior. This

study compared criminal justice-involved clients (in TASC and under

other justice system supervision) with voluntary controls on

demographic characteristics, treatment retention, treatment progress,

and predatory behaviors in the year following treatment termination.

The findings were that criminal justice-referred clients were more

likely to be male, nonwhite, and younger and to have had previous

justice system involvement in the year before treatment than their

volunteer counterparts. More important, TASC clients improved as

much with regard to drug use, employment, and criminal behavior as

other clients during the first 6 months of treatment. TASC clients

under legal coercion also tended to remain in both residential and

outpatient drug-free treatment modalities 6 to 7 weeks longer than

other criminal justice-referred or voluntary clients—a finding usually

associated with better treatment outcomes. The monitoring/case

management function of TASC seemed to encourage this longer

treatment participation. However, predatory crime and arrest before

treatment were still the most consistent predictors of criminal

reinvolvement, as measured by arrest records and self-reports in the

first posttreatment year.

103
SUMMARY

These studies point to TASC’s success and effectiveness in

programming through specific critical program elements. The specific

program elements shown to be successful through various studies

were: the establishment of the broad-based support by the criminal

justice and treatment systems; the use of an offender eligibility

criteria that assists in the early identification, assessment, and

referral of the previously unidentified drug-dependent offender, and a

comprehensive monitoring or case management system that holds the

client accountable and has proven to reduce client rearrest rates and

improve the treatment performance of the drug-dependent offender.

Conversely, these studies have also shown that the lack of data

collection and evaluation has hindered TASC programming.

FOOTNOTES

1. This is an abridged version of the TASC Program Brief published

by the Bureau of Justice Assistance, Office of Justice Programs,

U.S. Department of Justice, 1985. (The TASC Program Brief is

available directly from the Bureau of Justice Assistance or the

National Association of State Alcohol and Drug Abuse Directors.)

2. Over 300 authors from the National Association of State and

Drug Abuse Directors and the Bureau of Justice Assistance

contributed to this chapter.

REFERENCES

Collins, J.J., and Allison, M. Legal coercion and retention in drug

abuse treatment. Hosp Community Psychiatry 34(12):1145-1149,

1983.

Lazar Institute. Phase I Report, Treatment Alternatives to Street

Crime (TASC) National Evaluation Program. Washington, DC: Law

Enforcement Assistance Administration, 1976. NCJ #34057.

System Sciences, Inc. Final Report—Evaluation of TASC, Phase II.

Bethesda, MD: Law Enforcement Assistance Administration, 1978.

NCJ #51931.

ACKNOWLEDGMENTS

This work was supported by the TASC training and technical

assistance Grant number 86-FA-CX-K026 from the Bureau of Justice

Assistance, Office of Justice Programs, U.S. Department of Justice.

104
AUTHORS

L. Foster Cook

University of Alabama

TASC Program

3015 Seventh Avenue South

Birmingham, AL 35233

Beth A. Weinman

TASC Project Director

National Association of State Alcohol

and Drug Abuse Directors

444 North Capitol Street, NW

Suite 520

Washington, DC 20001

105
The Criminal Justice System

and Opiate Addiction:

A Historical Perspective

Herman Joseph

INTRODUCTION

Within the past 30 years, agencies affiliated with the criminal justice

system in New York City developed various programs to assist

arrested narcotic addicts. The existence of these programs offers

more than a historical record of attempts to solve a seemingly intractable problem. Historical experiences and available research

findings can provide guidelines for future planning.

In New York City, persons convicted of misdemeanors or felonies may

be sentenced to probation as an alternative incarceration. They are

supervised in the community by a probation officer and must adhere

to orders of probation approved by the sentencing judge (i.e., obtain

employment and contact the probation officer as directed). Parole is

similar except that individuals have served time in prison and are

released to the community under the supervision of a parole officer

for the remainder of their sentences. Parolees must adhere to conditions similar to the orders of probation, but mandated by the New

York State Board of Parole.

During the period of 1956 through 1965, the New York State Division

of Parole and the New York City Office of Probation established narcotics units with specially trained officers to supervise convicted

narcotic addicts. It was assumed that the authority of the court,

coupled with the intensive supervision and guidance of a trained

probation or parole officer, would be sufficient to assist addicts to

abstain from drugs, become employed, and lead crime-free lives.

Research from both agencies, however, showed the majority of addicts

supervised in these programs were unable to make acceptable adjustments in the community (Joseph and Dole 1970).

106
The Narcotic Offender Unit of the New York State Division of Parole

was established in 1956 for the purpose of supervising addicted

parolees (Diskind and Klonsky 1964). Of the 673 parolees who were

placed on parole in this unit between November 1, 1956, and December 31, 1961, 27 percent either completed parole successfully or were

considered to be in good standing. The remaining 73 percent either

relapsed to the use of drugs, were rearrested, or were reinstitutionalized on parole violations. A postparole followup study of 66 successfully terminated cases showed that after parole 30 individuals

were known to have relapsed and 34 amassed 99 rearrests. The postparole study was undertaken approximately 2 years and 9 months following the successful termination of the 66 parole cases. Therefore,

about 80 percent of the 673 parolees were unable to adjust in the

community during parole and the immediate postparole period. The

unit was terminated in 1961.

From 1963 through 1965, the New York City Office of Probation and

the Washington Heights Rehabilitation Center, a now-closed public

health agency that treated addicts, created a program to treat addicted probationers (Brill and Lieberman 1969). A team comprising probation officers, public health nurses, and social workers worked with

selected probationers. A drug-free counseling approach was employed

by the staff. Urine testing was administered to probationers participating in the program by their supervising probation officers in the

men’s room of the probation office or at the time of home visits.

The tests were analyzed by the Department of Health’s laboratory. If

urine tests were administered on field visits, the specimens were

delivered by the probation officers to local drug stores, which were

designated as pick-up stations for the Department of Health.

During the first year of treatment, about 78 percent of the 159 probationers reverted to heroin use in varying degrees, about 48 percent

were rearrested, and 25 percent were convicted. Although a group of

probationers did achieve abstinence from opiates for 45 percent of

the time they were enrolled in the program, about 50 percent of the

probationers had used heroin in varying degrees during any given

treatment month. In general, the rate of relapse paralleled the unsuccessful efforts of the New York Riverside Hospital to rehabilitate

addicts (Brill and Lieberman 1969). In summation, the overwhelming

majority of the probationers who participated in this program were

unable to achieve the goals of drug abstinence, employment, and a

law-abiding life. As with all programs, however, there are success

stories: the current Director of the New York State Division of

107
Substance Abuse Services, Julio Martinez, was a probationer in this

program for about 3 years.

In 1963, the probation office of the Kings County Supreme Court established Daytop Lodge, later known as Daytop Village, a drug-free

therapeutic community. Unfortunately, there are no followup studies

that would document the subsequent adjustments of the residents and

probationers who entered and left treatment at that time. However,

several narcotic addicts who entered Daytop during its formative

years subsequently became leaders in the therapeutic community

movement.

PROBATION CLINICS

As abstention programs appeared to fail for the majority of the addicted parolees and probationers in the 1950s and the 1960s, other

methods of treatment had to be considered. The New York City Probation Methadone Program was established in response to a need for

methadone maintenance treatment in New York City. In 1970, addicts

who applied for methadone maintenance had to watt from 8 to 12

months before being accepted for treatment. The Probation Department was unable to obtain adequate medical treatment for addicted

probationers from community sources and, therefore, under the direction of this writer, developed its own methadone maintenance program.

From 1970 to 1973, the New York City Office of Probation operated

five methadone maintenance clinics in Manhattan, the Bronx, Queens,

and Brooklyn (Joseph 1973). Medical institutions that cooperated with

Probation in this program were the Beth Israel Medical Center, the

Psychiatric Clinic of the Courts of New York City, the methadone

program of the Albert Einstein College of Medicine, and the New

York City Health Services Agency.

Four of the clinics were located within Probation offices. Medication

counters and examination rooms were set up and all aspects of methadone treatment were carried out in the probation office: intake interviews, physical examinations, stabilization on methadone, ongoing

treatment, administration of urine tests, counseling, and methadone

detoxification. However, the Manhattan Beth Israel Probation Unit

was housed in a satellite hospital clinic with two psychiatrists from

the Psychiatric Clinic of the Courts of New York serving as clinic

doctors. In all clinics, probation officers functioned as counselors.

The medical institutions provided doctors, nurses, medication, physical

examinations, and addiction specialists. The latter were successful

108
methadone patients who assisted the professional staff with counseling of clinic patients.

The program was open to addicted probationers over 18 years of age

with an addiction history of 2 or more years. In the 3 years of operation, close to 1,000 addicted probationers were treated in five probation clinics. About 18 percent of these patients were terminated

because they failed to cooperate with program regulations, continued

drug abuse, were incarcerated following conviction or rearrest, or

requested voluntary detoxification. Patients wishing to continue

treatment after completing probation were transferred to methadone

units operated by hospitals and physicians (Joseph 1973).

Unemployment was a major problem in the Probation Methadone Program. In November 1972, approximately 53 percent of the active

patients were unemployed, 33 percent were working, 7 percent were

in school or training, and 7 percent were homemakers. Most of the

probationers were high school dropouts with an estimated fifth-grade

reading level. They were unable to compete in a job market that

was changing from manufacturing to service and that demanded specific technical skills as well as advanced education. Referrals were

made with varying degrees of success to community agencies for job

placement. Eventually, it was necessary to obtain a governmental

grant with the Federation Employment and Guidance Service of New

York City to counsel, educate, and locate jobs for patients in the

Bronx Probation Clinic. This clinic served a particularly disadvantaged Hispanic and black probation population between the ages of 18

and 30. This particular program was in operation for about 4 years

but was discontinued due to cutbacks in funding.

Unemployment appeared to be related to the arrest rate. During 34

months of operation, 94 patients (10.4 percent of the first 900 admissions) were rearrested while in treatment. Approximately 77 percent

of the rearrested probationers were unemployed, as compared to an

overall unemployment rate of 53 percent for the program. Of the rearrested group, about 23 percent had jobs.

The New York City Probation Methadone Program’s policy was to administer daily methadone doses of 80 to 100 mg. At this level, the

tolerance to methadone diminishes or eliminates the euphoric effects

of heroin, relieves the yen or physical craving to compulsively use

heroin, and protects patients from overdose reactions if large amounts

of illegal or unprescribed opiates are ingested. Also, at 80 to 100 mg

per day, patients develop tolerance to the tranquilizing, euphoric, and

109
narcotizing properties of methadone. Thus, the patient is potentially

able to function in conventional society without incapacitating narcotic effects. When methadone maintenance is correctly prescribed,

the medication acts as a normalizer rather than a narcotic.

In 1973, methadone treatment became available citywide without a

long waiting period for admission. The probation clinics were eventually phased out, and patients were transferred to methadone treatment near their homes or jobs.

MANHATTAN PROBATION OFFlCE

The office of Probation in Manhattan operated two methadone clinics:

one was a satellite clinic of Beth Israel Medical Center and the

other, located in the Probation Office, was operated in conjunction

with the New York City Health Services Administration. A survey

administered by this writer to 1,414 misdemeanor probation cases

active at the Manhattan Probation Office during the first 2 weeks of

March 1973 identified current use of heroin and treatment-status

referrals. Use of heroin was verified by urine tests, the probationer’s reports, and official records. Approximately 83 percent of

the 1,414 cases surveyed were known to have had histories of heroin

abuse. The probationers, at the time of the survey, were all over

the age of 18. The majority (57 percent) were enrolled in methadone

maintenance treatment with the probation department program or with

other agencies (see table 1). However, methadone maintenance was

not the only treatment of choice: probationers were referred to therapeutic communities as well as to other drug-free programs. Also, a

small percentage of probationers appeared to abstain from heroin for

unknown periods of time, without treatment. Those probationers who

were known to be using heroin were referred to treatment. In summation, 85 percent of the probationers who had known histories of

heroin abuse were either in methadone treatment, in drug-free programs, or appeared to be abstaining without treatment.

COURT DIVERSION AND PRISON PROGRAMS

Another type of program diverted addicts from the criminal justice

system to treatment programs within the community. In the early

1970s, the New York City Commissioner of Corrections, Benjamin

Malcolm, asked Dr. Vincent P. Dole of The Rockefeller University to

set up a medical unit in the New York City jails to detoxify heroin

addicts. In 1974, the Montefiore Medical Center in the Bronx assumed responsibility for the Department of Correction’s detoxification

110
TABLE 1. Treatment status of addicted probationers in Manhattan

Status

Probation Methadone Clinics 225 26

Other Methadone Clinics 274 31

Drug-Free Programs 126 14

Abstain No Program 124 14

Using No Program 66 7

Questionable Use 17 2

Bench Warrant Status 40 5

Jail 14 1

Total

Number Percent

886 100

program and established wards at the correctional facility on Rikers

Island. The program is still in operation and has been expanded to

include the initial stages of long-term methadone treatment. Between

1985 and 1986, there were 15,828 admissions to this opiate detoxification program (New York State Division of Substance Abuse Services

1986).

As a result of his experiences working within the jails, Dr. Dole originated the idea of screening incarcerated addicts for treatment in the

community. Arrangements were made with the judges and community

methadone programs to enroll arrested addicts in outpatient treatment. The idea proved to be so successful that the now defunct New

York City Addiction Services Agency received a grant in 1972 from

the Federal Law Enforcement Assistance Administration to develop

the first Court Referral Project.

Arrested addicts were then diverted from the court system to treatment. Referrals were made to outpatient drug-free programs, therapeutic communities, methadone maintenance, and the commitment

facilities of the New York State Drug Abuse Control Commission.

Retention data for 12 months in treatment for the years 1973 and

1974 showed methadone programs retained between 50 percent and

60 percent of those diverted to treatment; therapeutic communities,

between 12 percent and 18 percent; and ambulatory drug-free programs, between 12 percent and 32 percent (figures 1, 2, and 3)

(Addiction Services Agency 1974). The commitment facilities discharged their referrals at various points in time from lockup centers.

111
Therefore, the retention rate did not reflect voluntary behavior. In

1978, the State of New York assumed financial responsibility for the

treatment of drug addicts, and the Court Referral Project was

subsequently terminated.

FIGURE 1. Methadone maintenance-clients placed in 1973 and 1974

SOURCE: 1974 Report of the Court Referral Project of the New York City Addiction

Services Agency.

In 1974, after the closing of the probation clinics, the current State

agency, now known as the Division of Substance Abuse Services

(DSAS), in conjunction with the New York City Office of Probation

and the New York State Court System, developed a referral service to

community programs for addicted probationers. This was the MultiPurpose Outreach Program. Units were initially set up in probation

offices in New York City. By 1978, almost 50,000 persons known to

the courts and probation were interviewed throughout New York State

and about 30,000 were referred to treatment. This program, involving

a staff of over 100 workers, was phased out because of budget

considerations in 1978. Today a small unit works in the New York

112
FIGURE 2. Therapeutic communities—clients placed in 1973 and 1974

SOURCE: 1974 Report of the Court Referral Project of the New York Cty Addiction

Services Agency.

City courts and probation offices; however, in 1986 State workers

were assigned to the New York State Parole Office in Manhattan to

interview, evaluate, and refer drug-abusing parolees to communitytreatment facilities. This program, known as ACCESS, is based on

procedures and concepts developed in the Multi-Purpose Outreach

Program and will soon be expanded.

About 10 years ago, the “Stay’N Out” program was implemented at

the Arthur Kill Correctional Facility on Staten Island under the

direction of Mr. Ron Williams. This program utilizes the model and

concepts of a therapeutic community, Phoenix House, to assist

prisoners in resolving substance abuse and personal problems that

lead to relapse and criminal activities. The program is operated by

the New York State Department of Corrections and the New York

Therapeutic Communities and is evaluated through a National Institute

on Drug Abuse grant by Narcotic and Drug Research, Inc. The “Stay’N

Out” program is hierarchical in structure—namely, the resident

113
FIGURE 3. Ambulatory drug-free programs—clients placed in 1973 and

1974

SOURCE: 1974 Report of the Court Referral Project of the New York City Addiction

Services Agency.

assumes greater responsibility within the program as improvements in

outlook and behavior become evident. Techniques to foster change

include individual counseling, encounter groups, and seminars. Upon

release from prison, parolees are encouraged to seek further treatment in therapeutic communities. The results show that for those

who participated in the prison program from 9 months to 1 year,

there were lower recidivism rates and a higher proportion of positive

discharges from parole when compared to the parole outcomes of

participants in other drug-free-oriented counseling methods available

in prisons (Wexler et al. 1985).

Another example of a diversion project was developed in 1986 and

1987 by Charles Laporte, Assistant Director of the New York State

Division of Substance Abuse Services and Director of the agency’s

Bureau of Chemotherapy Services. This program, known as KEEP

(Key Extended Entry Process), was implemented to facilitate the

114
entry of untreated heroin addicts into long-term treatment. Patients

are recruited from three major sources: walk-in applicants from the

streets who come to methadone programs in search of treatment; the

waiting list for methadone maintenance programs; and inmates incarcerated at the New York Correctional Facility at Rikers Island.

Patients who enter the KEEP program are initially stabilized on

methadone and placed on a detoxification schedule of up to 180 days.

During this period, patients are evaluated for placement in an appropriate long-term program—methadone maintenance, therapeutic communities, etc. A decision about the patient’s long-term treatment

placement is based on the results of a medical examination; the duration of the patient’s addiction; the patient’s preferences; and an

evaluation of the patient’s adjustment, behavior, and needs.

KEEP programs in the community are affiliated with methadone treatment programs. Most patients enrolled in methadone treatment either

curtail or stop criminal activities and their use of needles for the

injection of illicit drugs. Therefore, it is anticipated that problems

associated with addiction—criminality and the spread of infectious

diseases such as acquired immunodeficiency syndrome (AIDS) or hepatitis—may be reduced or brought under some control with the implementation of this program.

Patients recruited for KEEP from the detoxification wards at Rikers

Island are voluntarily maintained on either 30 or 40 mg per day of

methadone while in jail. This phase of the program is known as PreKEEP, and was initially developed by Mr. Laporte’s staff in the

different correctional facilities located on Riker’s Island. The Montefiore Medical Center in the Bronx, which operates the detoxification

service for the New York City Department of Corrections, currently

administers the medical and referral aspects of the KEEP program.

Inmates are on methadone when discharged to the community and are

instructed to report to specific community KEEP methadone programs

within 24 hours. The goals, therefore, of the Rikers Island program

are to prevent inmate relapse to drug abuse upon release from the

correctional facility; to reduce criminal recidivism; to limit the spread

of infectious disease, namely AIDS; and to initiate long-term treatment. These goals are accomplished by linking the methadone treatment received at Rikers Island to the methadone treatment received

in the community program. Preliminary program results are encouraging. Notwithstanding serious problems related to unemployment and

homelessness, over 70 percent of the inmates reported to the

programs when released.

115
A diversion program was developed by ADAPT (Association for Drug

Abuse Prevention and Treatment) in 1986 to serve AIDS and AIDSrelated complex (ARC) patients at Rikers Island. Originally formed in

the late 1970s to merge the varying philosophies and approaches to

drug treatment, ADAPT was reconstituted as a voluntary organization

in 1985 to educate drug abusers about AIDS and to develop programs

to meet the AIDS epidemic. The organization, under the leadership

of its president, Yolanda Serrano, a counselor in a methadone clinic,

consists of persons employed in drug-treatment programs, recovered

and recovering addicts, health-care professionals, and other interested

parties.

Within the past year, ADAPT interviewed about 100 patients on the

Rikers Island Hospital AIDS ward. Patients were helped with legal

problems, family matters, grievances concerning conditions on the

ward, and, upon their release from jail, were referred for medical

treatment and social services. ADAPT is developing models for the

delivery of services to AIDS and ARC patients with addiction histories. These models can be adopted by other cities and countries.

As of this writing, an ADAPT branch in Australia is being organized

based on the experiences and programs developed by the New York

City ADAPT (Serrano, personal communication 1987).

There are controversies concerning the effectiveness of civil commitment. The New York State Civil Commitment Program operated from

1987 to 1979. The program was discontinued because it was not cost

effective, there were problems concerning the civil liberties of those

committed, and there were high relapse rates in the predominantly

drug-free outpatient components of the programs. In 1989, at a

hearing before senate and assembly committees of the state legislature, former Commissioner Pierce indicated that approximately 56

percent of the 1,893 persons known to the New York State Civil

Commitment Aftercare Division for a 21-month period either

absconded or relapsed. The rest (44 percent) were being supervised

and appeared to be abstaining from drugs for Unspecified periods of

time (New York State Legislative Hearings 1969).

The California Civil Addict Program is still operating, but in a modified and reduced form, because judges have been reluctant to use

civil commitment. Furthermore, findings from studies in the 1960s

differ from the results of recent long-term followup studies. For

example, of 456 persons known to the outpatient parole division of

the California Civil Addict Program in the 1960s, 16 percent remained

in good standing for 3 years; 81 percent either absconded, relapsed,

116
or were recommitted or rearrested; and 3 percent were removed from

the program either by a writ of habeas corpus or by death (Kramer

et al. 1968). These findings are in contrast to the long-term results

of civil commitment described by Anglin (this volume). lt appears

that individuals who were supervised in the aftercare parole division

of the California program, When reinterviewed between 11 and 13

years after commitment, showed reductions in daily drug use and

Criminal activity. These results were found in three groups: active

users, minimal users prior to commitment, and those maintained on

methadone. Anglin (this volume) has reported that urine testing,

while an addict was under supervision to the parole division, was a

significant factor in these outcomes. However, alcohol problems

appear to be developing within the abstinent group (Anglin, this

volume; Anglin, personal communication 1987).

THE EFFECT OF LARGE SCALE METHADONE PROGRAMS ON

CRIME AND HEALTH STATISTICS

In New York City during the years 1971 through 1973, there was an

increase in the methadone census of about 19,900 cases, bringing the

number of patients in methadone treatment to over 34,000. Within

the same period there were dramatic decreases in the number of drug

arrests (-24,900) and complaints to the police department for crimes

usually associated with addiction—burglary, robbery, and grand

larceny (-77,000) (figure 4). Similar results were evident in 1976

When methadone maintenance was introduced on a large scale in Hong

Kong. Approximately 8,000 addicts were admitted to a network of

citywide clinics. For the period 1976 through 1980, there was a

sharp decline in the number of addicts admitted to prisons in Hong

Kong for drug offenses and other crimes (figure 5). Despite differences in culture and the periods of time involved, the phenomenon of

reduction in addict-related crime was evident in Hong Kong and New

York City when large-scale methadone treatment was implemented.

Also, in New York City during the period 1971 to 1973, there was a

substantial decrease in the number of reported cases of serum

hepatitis (-1,500) (figure 6) (Dole et al. 1981).

In a 1974 to 1976 followup study of over 1,500 active and discharged

methadone patients, Dr. Dole and this writer reported that arrest

rates were dramatically reduced after entry into methadone treatment.

There was a 60 percent decrease in arrest rates for patients who

remained in treatment for less than 1 year and an 63 percent

decrease for patients who remained in treatment for over 1 year.

However, it should be noted that patients who left during the first

117
FIGURE 4. Relation between increase in number of addicts treated in

methadone clinics and reduction in criminal activity in

New York City

NOTE: Data from New York City Police Department.

year of treatment had higher pretreatment arrest rates than those

who remained in treatment for longer periods (Dole et al. 1981)

(figure 7).

118
FIGURE 5. Reduction in number of narcotic addicts entering prison in

Hong Kong since introduction of methadone maintenance

program.

NOTE: Data provided by Peter E.I. Lee, Commissioner for Narcotics, Hong Kong.

Analysis of stored blood samples in New York City revealed the

presence of human immunodeficiency virus (HIV) antibodies in samples

from as far back as 1978. In 1984, 163 male heterosexual methadone

maintenance patients were tested for the presence of HIV antibodies.

For the 68 patients who entered continuous treatment prior to 1977,

31 percent tested seropositive, as compared to 51 percent of the 95

seropositive patients who entered continuous treatment after January

1, 1977. However, in another study, about 10 percent of 35 patients

enrolled in methadone treatment prior to 1978 tested seropositive.

Patients with positive reactions had continued intravenous drug abuse

while in treatment. In contrast to this finding, about 58 percent of

88 intravenous drug users studied in New York City were found to be

seropositive (Novick et al. 1986; Novick, personal communication

1987). Also, a recent study of risk behaviors that can result in the

transmission of the AIDS virus by methadone patients found that both

the frequency of drug injection and the frequency of injection in

119
FIGURE 6. Relation between increase in number of addicts treated in

methadone clinics and reduction in serum hepatitis

NOTE: Data on hepatitis from Health, Education, and Welfare and New York State and

City Departments of Health.

shooting galleries are significantly reduced over time (Abdul-Quader

et al. 1987). lt appears, therefore, that prompt entry into methadone

maintenance treatment may play an important role in helping to

reduce the spread of the AIDS virus. Since methadone is orally

administered, most patients will eventually curtail or eliminate use of

needles. Therefore, over time, the majority of patients in methadone

treatment should be removed from, or participate less frequently in,

the network of transmitting AIDS through the use of shared needles,

syringes, and cookers.

120
FIGURE 7. Drug and other arrest rates

121
DISCUSSION

Available historical studies of the 1950s, 1960s, and 1970s in New

York City show that methadone maintenance may be the most costeffective outpatient treatment for the majority of arrested opiate

addicts under probation and parole supervision who remain in the

community and do not enter residential facilities. These early studies

show that addicted probationers who stay in methadone treatment

have lower arrest rates and remain in treatment longer than convicted addicts who are supervised in special narcotics units without

chemotherapy. However, methadone maintenance should not be the

only method of treatment available, since some opiate addicts respond

to a variety of drug-free approaches, including residential treatment

as well as individual and group therapy. Ideally, a choice of

treatment methods should be available to probationers and parolees

with the provision that programs undergo evaluation and monitoring

to determine cost-effective treatment approaches.

Many patients maintained on methadone have serious cocaine and

alcohol problems. Programs that use therapeutic community, Alcoholics Anonymous, or Narcotics Anonymous approaches and that would

also allow patients or residents to remain on methadone should be

implemented and evaluated. One such program developed in New

York City by Charles LaPorte is called Short Stay. This therapeutic

community permits methadone patients to receive their prescribed

dose of methadone while resolving behavior, alcohol, and nonopiate

chemical-dependency problems. After a period of treatment from 3 to

6 months, residents are transferred back to their methadone programs

for continued treatment.

Addicts should not be coerced into a particular type of treatment. A

general condition of probation or parole to enter drug treatment is

more suitable than a condition to enter a specific therapeutic community or methadone maintenance program. The authority and judgment

of the physician would be compromised if a judge or parole panel

ordered methadone treatment. Thus, with a general order of probation or parole, addicts and their supervising officers have a certain

amount of flexibility and leeway. In other words, if one program

does not work for the probationer or parolee, another type of treatment can be used without jeopardizing the probationer’s or parolee’s

legal standing. Rigid conditions of probation or parole specifying

treatment may further disrupt lives and exacerbate the social problems that these agencies address. Court authorities should recognize

that methadone maintenance can help reduce crime that is related to

122
drug abuse, but it cannot eliminate crimes, committed by patients,

that may be related to homelessness, poverty, and unemployment.

There has been concern in some quarters about the “moral issues” of

high-dose methadone and the duration of methadone treatment. For

hard-core addicts, high-dose methadone (80 to 100 mg/day) may be

more beneficial, especially during the first few years of treatment. A

goal of the former probation clinics in New York City was to help

convicted addicts obtain education and employment and desist from

street activities related to drug abuse. Low-dose methadone was not

efficient in that context since addicts could inject heroin and experience its euphoric effect. A primary concern for persons caught up

in the spiral of addiction, crime, and incarceration was to accelerate

social rehabilitation. This could be more effectively achieved on a

daily dose of methadone in the range of 80 to 106 mg than on a lowdose regimen. After rehabilitation is achieved, when the patient no

longer abuses drugs, stops criminal activity, and is productively

employed, the dose of methadone may either be reduced or kept at a

high level. In either case, the dose can be kept constant over an

indefinite period of time without impairing the patient’s health or

behavior.

A New York City followup study, conducted from 1974 through 1976,

found that only 8 percent of the 846 discharged patients were alive

and doing well (i.e., not in jail or rearrested, abstaining from

narcotics use and the excessive use of nonopiate drugs and alcohol).

About 34 percent of the 167 patients who left in good standing

appeared to be free of the problems associated with drug addiction

and alcoholism. Furthermore, those who were described as well after

discharge had shorter periods of addiction and longer periods of

treatment than those who experienced problems after termination

from methadone treatment. Therefore, to expect a high rate of

abstinence after 3 or more years of treatment is unrealistic for the

addicts with histories of 2 or more years of addiction. Many

methadone patients may have to be maintained for longer periods or

for the duration of their lives in order to prevent relapse to illicit

narcotics (Dole and Joseph 1978).

Methadone maintenance, if correctly implemented, can have a number

of cost-effective benefits. For addicts who enter programs, treatment

can help curtail or bring under control pathological problems associated with addiction (i.e., crime, unemployment, drug and alcohol

abuse, high death rates, AIDS, and hepatitis). Methadone maintenance, however, is not a panacea. It will not eliminate the problem

123
of illicit opiate addiction, which is partially determined by the

availability of illicit opiates. New heroin addicts are constantly

created from the thousands of susceptible individuals found in all

societies. Also, there is a group of heroin addicts who do not enter

treatment. Therefore, the implementation of a well conceived range

of treatment programs including methadone maintenance, drug-free

programs, and combinations of approaches can be a humane, costeffective measure that will benefit both the addict and the larger

society.

REFERENCES

Abdul-Quader, A.S.; Friedman, S.; Des Jarlais, D.; Marmor, M.;

Maslansky, R; and Bertelme, S. Behavior by Intravenous Drug

Users That Can Transmit HlV and How Methadone Maintenance

Affects This Behavior. Poster presented at the Third International

AIDS Conference, Washington, DC, June 1987. (Available at

Division of Substance Abuse Services, Bureau of Research and

Evaluation, 55 West 125th Street, 10th floor, New York, NY

10027.)

Anglin, M.D. Personal communication, 1987.

Addiction Services Agency of the City of New York. Annual Report

of the Court Referral Project, 1974.

Brill, L, and Lieberman, L. Authority and Addiction. Boston: Little

Brown and Company, 1989. 318 pp.

Diskind, M.H., and Klonsky, G. Recent Developments in the Treatment of Paroled Offenders Addicted to Narcotic Drugs - Parts I &

II. New York: State Division of Parole, 1984.

Dole, V.P., and Joseph, H. Long-term outcome of patients treated

with methadone maintenance. Ann NY Acad Sci 311:181-189, 1978.

Dole, V.P.; Joseph H.; and Des Jarlais, D. Costs and Benefits of

Treating Chronic Users of Heroin with Methadone Maintenance.

Internal Report of the New York State Division of Substance Abuse

Services, Bureau of Research, 1981.

Friedman, S.; Des Jarlais, D.; and Sotheran, J. Personal communication, Department of Substance Abuse Services, Bureau of Research

and Evaluation, 55 West 125th Street, 10th floor, New York, NY

10027.

Joseph, H. Methadone maintenance treatment in probation. In:

Proceedings of the Fourth Methadone Conference, 1972. pp. 91-93.

Joseph, H. A probation department treats heroin addicts. Fed

Probation 37:35-39, 1973.

Joseph, H., and Dole, V.P. Methadone patients on probation and

parole. Fed Probation 34:42-46, 1970.

124
Kramer, J.C.; Bass, A.; and Berecochea, J.E. Civil commitment for

addicts: California program. Am J Psychiatry 125:816-824, 1968.

New York State Division of Substance Abuse Services. Bureau of

Research and Evaluation. Heroin Update. December, 1986.

New York State Legislature. Minutes of the Proceedings of a Public

Hearing of the Senate Finance Committee and the Assembly Ways

and Means Committee of Budget Requests of the Narcotic Addiction

Control Commission. February 26, 1969.

Novick, D.M. Personal communication, Beth Israel Medical Center,

New York, NY 10003, 1987.

Novick, D.M.; Khan, I.; and Kreek, M.J. Acquired immunodeficiency

syndrome and infection with hepatitis viruses in individuals abusing

drugs by injection. UN Bull Narc 38(1,2):15-25, 1986.

Serrano, Y. Personal communication, 1987.

Wexler, H.K.; Lipton, D.S.; and Foster, K. Outcome evaluation of a

prison therapeutic community for substance abuse treatment:

Preliminary results. Paper presented at the American Society for

Criminology, 1985. (Available from Narcotic and Drug Research,

Inc., 55 West 125 Street, New York, NY 10027.)

AUTHOR

Herman Joseph

Research Scientist

New York State Division of

Substance Abuse Services

Bureau of Research and Evaluation

55 West 125th Street - 10th floor

New York, NY 10025

125
Some Considerations on the Clinical

Efficacy of Compulsory Treatment:

Reviewing the New York Experience

James A. Inciardi

INTRODUCTION

The philosophical basis of civil commitment and other forms of

compulsory treatment for drug abuse seems to have considerable logic.

The theory of civil commitment holds that, of the numerous types of

heroin and other substance abusers, some are motivated for treatment, but most are not. Therefore, there must be some lever for

structuring treatment for those who ordinarily do not seek assistance

on a voluntary basis. This lever has often been referred to in the

literature as “rational authority” (Brill and Lieberman 1989; Melselas

and Brill 1974)—a late 1960s euphemism for not necessarily punitive

but, nevertheless, mandatory treatment.

Compulsory treatment is not a new concept, having been proposed for

the first time in the United States shortly after the passage of the

Harrison Act of 1914. As early as 1919, the Narcotics Unit of the

Treasury Department urged Congress to set up a chain of Federal

“narcotics farms” where heroin users could be incarcerated and

treated for their addiction (Brecher 1972). The first of these farms

was the U.S. Public Health Service Hospital in Lexington, KY, which

opened in 1935, with a second facility established in Fort Worth, TX

a few years later. The Lexington-Fort Worth approach was simple

and to the point. As Lexington’s director, Dr. Harris Isbell, once

commented:

Drug addicts were to be treated within the institution,

freed of their psychological dependence on drugs, their

basic immaturities and personality problems corrected by

vocational and psychiatric therapy, after which they would

126
be returned to their communities to resume their lives.

(Kramer 1971, p. 666)

Dr. lsbell went on to note that this original approach had a number

of basic flaws. lt lacked (1) mechanisms for holding voluntary

patients until they had achieved some benefit from hospital treatment;

and (2) some provision for intensive supervision and aftercare. Dr.

lsbell was reacting to the growing number of reports suggesting that

the Lexington and Fort Worth programs were almost total failures.

Followup studies had indicated, for example, that between 1935 and

1984 there were 87,000 admissions to the two centers, of which

63,600 were voluntary patients and 23,400 were Federal prisoners. Of

the voluntary cases, 70 percent had left against medical advice, and

of all the patients, 90 percent had relapsed into drug use within a

few years (U.S. Comptroller General 1971; Cole 1987).

The followup studies of the Lexington-Fort Worth experience received

considerable criticism (O’Donnell 1965). Nevertheless, the general

belief that the Federal model had been an almost total failure,

combined with rumors of success with a parole-based narcotic project

in New York, influenced legislators and clinicians of the 1960s

contemplating the civil commitment approach, to take several things

into account.

(1)

(2)

(3)

(4)

(5)

(6)

The 6- to 12-month period of treatment at Lexington had been

far too short.

A mandatory minimum length of stay would be necessary even

for voluntary cases.

Intensive inpatient vocational and counseling services were

highly desirable.

A period of community aftercare was necessary.

Close supervision in the community after release might improve

success rates.

For criminal and civil commitments alike, the threat of

reinstitutionalization might enhance aftercare response.

Guided by this philosophy, as well as by fears of growing drugrelated street crime and public demands for “getting addicts off the

street,” a series of new programs based on a rational authority design

127
were established during the 1960s. in 1961, California launched a

large-scale civil commitment program for narcotic addicts, which

included institutionalization for up to 7 years, without first being

convicted of a crime. At the Federal level, the Narcotic Addict

Rehabilitation Act of 1966 (NARA) provided for the compulsory

treatment of drug users charged with committing nonviolent Federal

crimes, treatment instead of sentencing for drug users convicted of

Federal crimes, and the voluntary commitment of drug users not

involved in criminal proceedings. Also in 1966, New York State

announced a civil commitment program of its own, to be operated by

the newly created Narcotic Addiction Control Commission (NACC).

Throughout the 1960s, much attention was focused on the New York

approaches to compulsory treatment. in addition to the NACC’s

statewide civil commitment program, there was also a New York Citybased parole project that received considerable recognition as an

apparent “breakthrough” in the treatment of addiction. Both

approaches represent rather unusual case studies in the history of

drug abuse treatment—the parole experiment for its alleged high

success rates and the civil commitment undertaking for its

overwhelming failure. Although each may have been unique in its

own way, much can be learned from the New York experience as it

relates to future considerations of compulsory-treatment programming.

THE NEW YORK PAROLE PROJECT

In 1956, the New York State Division of Parole announced its Special

Narcotics Project, a new approach for the community supervision of

parolees with histories of narcotics use. The plan called for “intensive supervision, using the casework approach in an authoritative

setting” (Diskind 1960, p. 57). The parole officers used in the

project were reported to have been “specially selected and trained.”

in addition, their caseloads were small, thus permitting closer and

more intensive supervision. An initial followup of the first cohort of

cases found that some 45 percent had abstained from drugs while

under supervision (Diskind and Kionsky 1964a). Subsequent studies

reported even more remarkable successes (Diskind and Kionsky 1964b;

Diskind et al. 1963), suggesting to observers of the rational authority

approach that compulsory treatment might indeed be the key for

curing heroin addiction.

But there was much that was misleading in the New York parole

findings.1First, most of the parole officers in the project were not

particularly well trained for the task. Some had been “specially

128
selected” on the basis of previous experience in caseloads that had

high numbers of heroin users, while other parole officers were

relatively new recruits, with no prior involvements with parolees,

heroin users, criminal justice, treatment, or casework. Moreover, the

training was minimal, generally limited to a few lectures on social

work approaches, one or two visits to local treatment programs, and

the reading of selected journal articles on drug abuse problems.

Second, not all drug cases, at least at the outset, were assigned to

the Special Narcotics Project. Case selection was rather

discriminating, generally limited to those parolees whose records

suggested at least some chance of success.

Third, one measure of failure was rearrest for a new crime, but, as

subsequent studies have so dramatically demonstrated, arrest is a

rather poor measure of the incidence and prevalence of criminal

activity (Inciardi and Chambers 1972; inciardi 1979; lnciardi 1988). A

second measure was drug use, and, in this respect, concerted efforts

were undertaken to make the project appear better than it actually

was. Parolees who were found to be using drugs were often not

declared delinquent, and their drug use never became a matter of

record. Similarly, a number of project subjects who failed to make

their office reports to parole officers-typically because of drug use—

were also never declared delinquent.

Fourth, parolees who had reverted to drug use generally knew how to

beat the system. “Arm checks,” the periodic examination of a

parolee’s arms for needle marks, was the typical mechanism for

determining reversion to drugs. Urine tests were never used, and it

did not take parolees long to figure all of this out. Subsequent to

the first followup study, it was learned that many parolees were

injecting heroin into their groins or were snorting heroin and/or

cocaine to avoid detection. One female parolee on the project had

actually admitted to her parole officer that she had been injecting

heroin into her vagina. Yet procedures for drug detection were

never changed, and many regular users of heroin and other drugs

were reported as successes in the followup studies.

Fifth, on numerous occasions, when project parolees were found to be

using heroin and/or in possession of drugs or stolen property, their

parole officers elected not to report the fact to supervisors, in the

hope of building a more effective therapeutic relationship with

clients.

129
in 1969, a parole prediction study focusing on cases in the Special

Narcotics Project targeted an additional problem (Inciardi 1971a).

Two cohorts of parolees were followed up. Adjustment was defined

as “unfavorable” if, within 1 year of release from prison, the parolee

had been returned to prison for violation of parole, had been arrested

for a new offense and not restored to parole supervision, had

absconded, had been declared criminally insane, or had died as the

result of the commission of a crime or from a drug overdose. Ail

other outcomes were defined as “favorable.” Although more than 50

percent of the parolees in each cohort were defined as having

successful parole adjustment, the study uncovered a factor that

further tainted the findings of the narcotics project studies. lt

appeared that, given the growing racial tension in New York City

during the 1960s, the predominantly white, middle-class parole staff

were making fewer supervision contacts in those minority

neighborhoods where rates of addiction and crime were high. In fact,

there were times when certain parts of New York City were

specifically designated “not to be visited.” Therefore, in many

instances, the parole officers were not particularly well informed as

to parolee behavior.

in contrast, there were two aspects of the Special Narcotics Project

that demonstrated significant clinical efficacy but were never

reported in the literature. in 1985, a special arrangement was made

between the Division of Parole and Daytop Village, a therapeutic

community located on New York City’s Staten Island. Although the

intake procedures at Daytop were rigorous and the waiting list for

admission was often lengthy, parolees would be given special

preference under four conditions. First, ail cases had to be assigned

to one parole officer, who would visit the facility three times a week

and participate in seminars and group encounters; second, that officer

had to move into Daytop for a 1-month period as a resident for the

sake of better understanding the therapeutic community process.2

Third, should a parolee admitted to Daytop split from the program

prior to the typical 18- to 26-month stay, such an action would

result in an automatic violation of parole and a return to prison.

Fourth, in the event that a parolee considered splitting from the

program, the assigned parole officer (or his backup) had to be on call

at all times. The intent was to do whatever was necessary—either

counseling or threats—to keep the parolee in treatment, even if it

meant arriving at Daytop with handcuffs and an arrest warrant and

taking the parolee into custody as he or she exited the facility.

130
The Division of Parole unofficially agreed to these requirements and,

from 1965 through 1967, a total of 43 parolees were accepted into

Daytop Village. By June 1968, 16 of the 43 parolees had remained

for the duration and graduated from Daytop. Although no formal

followup of these cases was ever undertaken, other studies have

demonstrated a strong relationship between length of stay and

treatment success (Chambers and lnciardi 1975; De Leon 1984).

A second positive feature of the parole project was a rudimentary

form of multimodality programming. One of the options available to

parole officers assigned to the Special Narcotics Project was referring

relapsed cases to local programs for treatment. Yet, during the

better part of the project’s first decade, few public treatment

services were available. As a result, referrals were generally based

on one or two personal contacts established by each officer; treatment was generally limited to a 21-day detoxification program, a 6-

month stay at a State hospital, or a train ticket to Lexington. By

the mid-1960s, however, treatment services had begun to expand in

New York City; therapeutic communities, outpatient detoxification,

group therapy, and methadone maintenance were added to the existing

inpatient detoxification programs. Furthermore, in 1966, 5 of the

project’s 22 parole officers volunteered for a 9-month (2 evenings per

week) training program sponsored by the New York City Addiction

Services Agency. The officers were schooled in peer-group and

reality therapy approaches as well as a number of diagnostic tools for

assessing which type of treatment might be most appropriate for any

given case. Although the clinical efficacy of this experience was

never empirically assessed, these parole officers did observe that

their parolee’s retention-in-treatment rates were better than those of

their lesser-trained colleagues.

THE NARCOTlC ADDICTION CONTROL COMMISSION

The Narcotics Control Act, passed by the New York State legislature

in 1966, served to establish the NACC—a drug treatment system that

proved to be both the largest and the most costly in history. A

focused analysis of the NACC experience seems warranted here, not

because of any clinical successes, but because it dramatically

illustrates what not to do when contemplating the structuring of civil

commitment for the treatment of drug dependence.3

Why the NACC was established in the first place is a perplexing

question. lt was a civil commitment program in which individuals

could be judicially certified to treatment for 3 to 5 years. Subjects

131
eligible (or at risk) for certification included those arrested for drugrelated crimes (drug law violations as well as offenses committed for

the sake of supporting a drug habit); volunteers; and others whose

friends, family members, or relatives petitioned the courts. The

treatment process included a period of institutional commitment

followed by community aftercare. The perplexing aspect was that

previous research had not convincingly demonstrated that incarceration alone, incarceration plus treatment, or incarceration plus

intensive aftercare supervision were effective approaches to the

rehabilitation of narcotic addicts. Thus, a planned expenditure of

$200 million during the first 3 years for the treatment of 4,500

addicts and alleged addicts, was based on a rather unsubstantial

foundation. This was the NACC’s first mistake.

The NACC’s second mistake was in its selection of institutional

facilities. Many of the “rehabilitation centers,” as they were called,

had been purchased from the New York State Department of

Corrections. They were actually medium and maximum security

institutions with high walls, barbed wire, observation towers, cell

blocks, bars, and all the other visible trappings of penitentiary life.

in addition, when the facilities were purchased, civil service

regulations required that their existing custodial staff be retained.

As a result, a characteristic feature of most of the NACC’s

rehabilitation centers was former prison guards patrolling halls and

cell blocks with riot clubs tucked in their belts—a situation hardly

conducive to creating a therapeutic atmosphere.

The NACC’s third mistake was in the selection of its treatment

facility directors. Rather than seeking out individuals with demonstrated clinical and administrative skills, the NACC filled the majority

of these positions with political or civil service appointments. The

result was a collection of parole officers with seniority and an ability

to pass civil service examinations, combined with local politicians,

community leaders, and members of the clergy. Few of these appointees had any experience rehabilitating addicts or running treatment

facilities.

The NACC’s fourth mistake was in the way it structured its aftercare

program. Although the NACC officials vigorously denied that the

supervision approach had been modeled after that of the parole

system, the NACC’s Associate Commissioner in charge of aftercare

had been the founder and the director of the parole Special Narcotics

Project. in addition, a significant number of the NACC’s aftercare

officers and supervisors had come to the new agency directly from

132
the Division of Parole. As a result, the aftercare supewision model

was a carbon copy of that found in parole—but with two significant

exceptions. First, caseload size in the NACC aftercare centers was

too large to permit close supewision. Second, unlike parole officers,

the NACC’s “aftercare officers” were not armed peace officers, with

the authority to arrest a client in the community for violation of his

or her aftercare conditions. Thus, abscondence rates were

exceedingly high.

The NACC’s fifth mistake was its loss of public support through a

number of lapses and omissions. For example, by early 1970, having

spent more than $345 million, it still had published no statistics from

which a success rate might be calculated. indeed, things were not

going well with the program and data were closely guarded. An

analysis by a member of the NACC research staff compared escapes

from NACC’s facilities with those of the State’s prison system, and

abscondance rates from the NACC aftercare with those of the parole

system. The data showed NACC abscondance rates to be 12 times

higher and NACC escape rates 80 times higher (Inciardi 1971b). The

NACC’s officials were, in this writer’s opinion, less than candid in

their public statements about the program’s results. Relatively little

in the way of research findings was released by the NACC staff, and

responses to inquiries about program success tended to be formal and

selective. In 1971, the NACC’s research director testified before a

Congressional committee that a relatively small number of people had

been processed through the entire civil commitment process, and that

of those “25 percent are currently abstinent, according to physical

followup” (Chambers 1971).

in spite of these guarded efforts, the NACC encountered a wave of

bad publicity. A report by the New York City District Attorney’s

office indicated that the NACC was playing a curious role in

contributing to the overcrowded conditions in the city jails (New

York Times, February 22, 1971). Arrested addicts, the report stated,

preferred a short prison sentence to a 3- or 5-year civil commitment.

Hence, prosecutors were able to convince arrestees to plead guilty

and go to jail; if not, they would be threatened with commitment to

a State treatment center. Also, there was the report of the New

York City Health Policy Advisory Center:

The program promises to return the addict to a useful life

“through extended periods of treatment in a controlled

133
environment followed by supervision in an after-care

program.” The emphasis is in “controlled.” The addict

receives about as much in rehabilitation as the criminal

prisoner with about as much result—the recidivist rate for

addicts is much higher than for criminals. Moreover, the

rehabilitation centers are run like prisons. There are

guards, most of whom receive training for prison work—

one guard for every two inmates, recalcitrant addicts are

beaten up and placed in isolation on reduced diets; inmates

are sexually abused; there is no separation of the young

from the old. The few rehabilitation programs that do

exist are staffed by instructors and therapists who have

received little or no training. For the 5,000 or so inmates

in the 14 separate institutions there are only 4

psychiatrists, 16 psychologists, and 78 teachers and

vocational instructors. The prison-like atmosphere has

caused a large percentage of the addicts to try to escape.

(New York City Health Policy Advisory Center 1970,

pp. 16-17)

The NACC officials repeatedly stated that the purposes and

approaches of New York’s civil commitment program were

“misunderstood” (Meiselas 1971; Meiseias and Briii 1974). On the

other hand, New York Governor Nelson A. Rockefeller, who had high

hopes for the NACC when he launched it in 1966, was more candid.

in 1970 he conceded failure, stating:

it is a god-damn serious situation. I cannot say we have

achieved success. We have not found answers that go to

the heart of the problem. (Moritz 1970)

By 1971, the NACC officially had been deemed a failure, and, in

subsequent months, its gradual dismantling began.

DISCUSSION

In retrospect, the New York parole experiment was little more than a

treatment initiative that had been poorly conceived, inappropriately

designed and studied, and considerably misrepresented. The political

environment within which the NACC had been created initially

resulted in a leadership that was ill-experienced and ill-equipped to

deal with the magnitude of its task, and, ultimately, in a bureaucracy

gone out of control, concerned more with its own survival than with

therapeutic efficacy. But, in light of subsequent developments and

134
recent research findings, the New York experience can now be viewed

as significantly more important than just a historical anecdote In the

annals of drug abuse treatment.

Conscious of the dubious outcome of civil commitments in New York,

but, nevertheless, convinced of the need for coercing heroin and

other drug abusers into treatment, President Richard M. Nixon’s

Special Action Office for Drug Abuse Prevention developed, in 1972, a

national compulsory treatment strategy of its own. Initially funded

by the Law Enforcement Assistance Administration, the idea was to

divert drug-addicted criminal offenders out of the court system and

into appropriate community-based treatment facilities. Known as

TASC (Treatment Alternatives to Street Crime), the approach sought

to establish a multifaceted intervention strategy featuring jail

screening, comprehensive medical and clinical diagnosis, referral to

suitable treatment facilities, monitoring of patient progress, and

custodial counseling. To eliminate many of the difficulties associated

with civil commitment, TASC was structured initially as a court

diversion program. Drug-using arrestees were diverted into the array

of existing, ongoing treatment facilities in the local community. The

offender’s original criminal charge was held in abeyance until

treatment was completed. Failure to remain in treatment could result

in the offender’s arrest, a visit to court, and prosecution on the

original charge. Later TASC activities were established in parole

settings, and subsequent studies of TASC clients, as well as

commitments to the California Civil Addict Program, began to

demonstrate that compulsory treatment did indeed have its successes

(De Leon 1994; De Leon and Rosenthal 1979; McGlothiin et al. 1977).

The recent indications of success with compulsory treatment, when

contrasted with the overwhelming failure of New York’s NACC,

provides an important lesson for the future direction of mandatory

treatment initiatives—that the implementation of any new approaches

should avoid, at all costs, the creation of new, large-scale treatment

bureaucracies. Part of the NACC’s problem was an all too hastily

structured treatment and control system as a response to the hysteria

surrounding the growing epidemics of heroin use and drug-related

street crime. It was likely for this reason that the NACC’s staffing

structure became so tainted by politics and inexperience. Moreover,

by creating new treatment facilities and a comprehensive aftercare

network, the NACC had committed itself to large capitalization costs.

Finally, it was the fact that the NACC was almost exclusively a

political entity, with its awesome expenditure of tax dollars, that

contributed decisively to its failure.

135
With the growing concern about AIDS and the position of the

intravenous drug user in the transmission of this disease in the

heterosexual community, it is not unlikely that many observers and

legislators might reconsider a NACC-like entity as a mechanism of

quarantining the addict for the purpose of AIDS control. But the

same mistake should not be made. The obvious alternative to the

NACC approach is the expansion of compulsory treatment in an

already existing infrastructure—such as TASC. Such an arrangement

delegates rehabilitation to established treatment structures and

management and control activities to the courts, parole, and

probation.

Should compulsory treatment expand in a TASC-like direction, then

the New York parole experiment offers some guidelines. The first is

the notion of some type of treatment contract. The apparent success

of parolees placed in Oaytop Village was, in part, the result of the

parole system’s agreement to Daytop’s requirements. In future

initiatives, perhaps there should be written contracts between client,

clinician, and criminal justice representative, which spell out each

participant’s expectations, requirements, and responsibilities.

The second issue relates to evaluation. There was much going on in

the New York Parole system that project researchers and evaluators

were either unaware of and/or chose to ignore. There were so many

uncontrolled-for variances in training, supervision approaches, parolee

behavior, parolee/parole officer interaction, case assignment, and

decisionmaking that whatever data were collected were far too

tainted to be of any value. Therefore, research endeavors to

evaluate program effectiveness must go beyond their traditional

concerns to focus also on the structure and policies of criminal

justice system components that manage clients receiving compulsory

treatment.

FOOTNOTES

1. The observations reported here are those of the author, who was

a parole officer in the Special Narcotics Project from 1962 to

1968.

2. The author of this essay was the officer assigned to Daytop

Village.

136
3. From June 1968 through October 1971, the author was Associate

Director of Research for the Narcotic Addiction Control

Commission, and a number of the observations recorded here are

unreported in the literature.

REFERENCES

Brecher, E.M. Licit and lllicit Drugs. Boston: Little, Brown, and

Co., 1972. 623 pp.

Brill, L, and Lieberman, L. Authority and Addiction. Boston:

Little, Brown, and Co., 1989. 318 pp.

Chambers, C.D. Statement in Narcotics Research, Rehabilitation, and

Treatment. Hearings before the Select Committee on Crime, House

of Representatives, 92nd Congress, 1st Session, April 26-28 and

June 2-4. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1971. p. 566.

Chambers, C.D., and Inciardi, J.A. Three years after the split: A

post-treatment evaluation of Phoenix House splitees. In: Senay,

E., and Alksne, H., eds. Developments in the Field of Drug Abuse.

Cambridge: Schenkman, 1975. pp. 124-131.

Cole, J. Report on the treatment of drug addiction. In: President’s

Commission in Law Enforcement and Administration of Justice.

Task Force Report: Narcotics and Drug Abuse. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1967. pp. 135, 140-141.

De Leon, G. The Therapeutic Community; Study of Effectiveness.

DHHS Pub. No. (ADM) 85-1286. Rockville, MD: National Institute

on Drug Abuse, 1984. 95 pp.

De Leon, G., and Rosenthal, MS. Therapeutic communities. In:

DuPont, L.; Goldstein, A.: and O’Donnell, J.A., eds. Handbook on

Drug Abuse. Rockville, MD: National Institute on Drug Abuse,

1984. pp. 3947.

Diskind, M.H. New horizons in the treatment of narcotic addiction.

Federal Probation 24:56-63, 1960.

Diskind, M.H.; Hallinan, R.F.; and Klonsky, G. Narcotic addiction and

post-parole adjustment. Unpublished master’s thesis, Fordham

University, 1963.

Diskind, M.H., and Klonsky, G. A second look at the New York State

parole experiment. Federal Probation 28:34-41, 1964a.

Diskind, M.H., and Klonsky, G. Recent Developments in the

Treatment of Paroled Offenders Addicted to Narcotic Drugs.

Albany, NY: New York State Division of Parole, 1964b.

Inciardi, J.A. The use of parole prediction with institutionalized

narcotic addicts. J Res Crime and Delinquency 8:65-73, 1971a.

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Inciardi, J.A. Escape and abscondence from NACC facilities.

Unpublished manuscript, Division of Research, New York State

Narcotic Addiction Control Commission, 1971b.

Inciardi, J.A. Heroin use and street crime. Crime and Delinquency

25:335-346, 1979.

Inciardi, J.A. The War on Drugs: Heroin, Cocaine, Crime, and Public

Policy. Palo Alto: Mayfield, 1986. 231 pp.

Inciardi, J.A., and Chambers, C.D. Unreported criminal involvement

of narcotic addicts. J Drug Issues 2:57-64, 1972.

Kramer, J. Statement in Narcotic Research, Rehabilitation, and

Treatment. Hearings before the Select Committee on Crime, House

of Representatives, 92nd Congress, 1st Session, April 26-28 and

June 2-4. Washington, DC: Supt. of Docs., U.S. Gov. Print. Off.,

1971. p. 668.

McGlothlin, W.H.; Anglin, M.D.; and Wilson, B.D. An Evaluation of

the California Civil Addict Program. DHEW Pub. No. (ADM) 78-

558. Rockville, MD: National Institute on Drug Abuse, 1977. 102

pp.

Meiselas, H. The New York State Narcotic Addiction Control

Commission: Its programs and activities. In: Straus, N., ed.

Addicts and Drug Abusers: Current Approaches to the Problem.

New York: Twayne Publishers, 1971. pp. 88-94.

Meiselas, H., and Brill, H. The role of civil commitment in

multimodality programming. In: Inciardi, J.A., and Chambers, C.D.,

eds. Drugs and the Criminal Justice System. Beverly Hills: Sage

Publications, 1974. pp. 171-182.

Moritz, O. Drug program at $250 million, deemed a failure. National

Observer, June 8, 1970.

New York City Health Policy Advisory Center. Health/PAC Bulletin

June:16-17, 1970.

O’Donnell, J.A. The relapse rate in narcotic addiction: A critique of

follow-up studies. In: Wilner, D.M., and Kassebaum, G.G., eds.

Narcotics. New York: McGraw-Hill, 1965. pp. 226-246.

U.S. Comptroller General. Limited Use of Federal Programs to

Commit Narcotics Addicts for Treatment and Rehabilitation.

September 20, 1971.

AUTHOR

James A. Inciardi, Ph. D.

Professor and Director

Division of Criminal Justice

University of Delaware

Newark, DE 19716

138
Identifying Drug-Abusing Criminals

Eric D. Wish

INTRODUCTlON

This chapter describes issues relevant to the identification of drug

abusers within the criminal justice system. In the first section, some

of the reasons why the identification of drug-abusing offenders may

be an important role for the criminal justice system are discussed.

This is followed by a review and comparison of available methods for

screening large numbers of offenders for recent drug use. The

chapter concludes with a discussion of the implications for establishing compulsory treatment programs within the criminal justice

system.

WHY IDENTlFY THE DRUG-ABUSING OFFENDER?

To Identify Active Criminals

During the past decade, substantial information collected from diverse

offender populations has converged to show that addicted offenders

are especially likely to commit both drug and nondrug crimes at high

rates (Wish and Johnson 1986). Heroin addicts in Baltimore reported

committing six times as many crimes during periods when they used

narcotics frequently as in periods of lesser use (Ball et al. 1981;

McGlothlin 1979). Violent predators, the most criminally active class

of incarcerated persons, were distinguishable by their histories of

juvenile drug abuse and adult high-cost heroin habits (Chaiken and

Chaiken 1982). Offenders’ drug abuse has been prominent in many of

the more useful criminologic scales designed to predict recidivism

(Blumstein et al. 1986). Recent studies of arrestees in Washington,

DC and New York City have found that persons who test positive by

urinalysis at arrest for one or more drugs (usually cocaine, heroin, or

139
PCP) had a greater number of rearrests than did arrestees with a

negative test result (Toborg et al. 1986; Wish et al. 1986a). Perhaps

most important, treatment-induced reductions in narcotics use have

been associated with concomitant reductions in individual crime rates

(McGlothlin et al. 1977). While early research focused primarily upon

the link between heroin use and crime, a number of recent studies

have documented the growing role of cocaine in street crime (Collins

et al. 1985; Hunt et al. 1984; Johnson et al. 1985).

There are a number of reasons why drug abuse and crime are

associated. In some instances, persons are so dependent upon a drug

that they are driven to commit income-generating crimes like theft,

robbery, drug selling, and prostitution. For other persons, drug abuse

appears to be merely one of the many deviant behaviors they engage

in; while for still others, crime may be the result of a violent,

bizarre reaction to a drug. In planning effective responses for each

person, it may be necessary to understand which of the above

motives apply.

Because drug-abusing offenders account for a disproportionate share

of all crime, a policy that focuses upon identifying drug-abusing

offenders and applying appropriate interventions has promise for

producing a substantial impact on community crime and the

overburdened criminal justice system. Certainly, one would prefer to

apply limited criminal justice resources to the most active offenders.

There is growing evidence that criminal justice referral of offenders

to drug abuse treatment programs, often accompanied by urine

monitoring, can result in persons remaining in treatment longer and

in a reduction in both drug use and crime (Anglin and McGlothlin

1984; Collins and Allison 1983; Stitzer and McCaul, in press). There

is also the possibility that one might reduce jail and prison

overcrowding by referring drug-abusing detainees to treatment and/or

urine monitoring programs. In addition, because younger offenders

are less likely to inject drugs and to use heroin, identification of the

youthful offender, who is abusing such drugs as marijuana, PCP, or

cocaine, has promise for enabling society to intervene and prevent

the progression to more extensive drug use (Dembo et al. 1987; Wish

et al. 1986a).

To Identify Persons in Need of Drug Abuse Treatment and Health

Care

Drug abusers, especially persons who inject drugs, are at high risk

for health problems (Goldstein and Hunt 1984). Intravenous drug

140
users are especially at high risk for contracting AIDS by sharing

dirty needles that contain blood from infected fellow addicts (Marmor

et al. 1984). Prostitutes are also likely to have serious drug abuse

and associated health problems. The probability of a urine positive

for drugs was higher for female arrestees in New York City than for

male arrestees (Wish et al. 1986a). More than 89 percent of the

prostitutes among the female arrestees studied in New York City in

1984 were positive for cocaine. These females frequently reported

instances of childhood sexual abuse and protracted histories of

emotional and health problems. Because prostitutes usually receive

fines or very short sentences (often as time served), they are usually

back on the streets of New York within hours of arrest, with no

effort made to identify and treat their drug abuse or health problems.

Given that more than one-half of the arrestees in Washington, DC

and in New York City have been found to test positive for one or

more drugs, it would seem that the criminal justice system offers an

unusual opportunity to society for identifying persons in need of

immediate health care.

To Monitor Community Drug Use Trends

As illicit drugs become available in a community, more deviant

persons can be expected to be among those who first use them. In

time, use spreads to the larger society. One might, therefore, predict

that changes in the level of illicit drug use in an offender population

would be a leading indicator of community drug use. A comparison

of urine test results for arrestees in Washington, DC with the

traditional indicator of community drug use showed this to be the

case (Wish 1982; Forst and Wish 1983). In Washington, DC, the rise

in heroin use between 1977 and 1980 showed up in the statistics from

the arrestee urine testing program 1 to 1.5 years before it appeared

in local statistics on overdose deaths, hospital emergency room

admissions, and drug abuse treatment program admissions. Results

from the arrestee urine testing program in Washington, DC and

research in New York (Wish 1986b) have also documented the rising

use of cocaine in these cities in the 1980s.

By operating a program of arrestee drug testing on a regular basis,

communities may derive a secondary bonus of being able to detect

drug epidemics earlier and being able to plan community responses.

The potential benefit of offenders’ urine testing for tracking drug

crime trends has prompted the National Institute of Justice to

establish a national Drug Use Forecasting (DUF) system based on

urine samples obtained periodically from arrestees in large cities

141
(Science 1968, Wish 1987). The impact of law enforcement and other

interventions designed to reduce drug use and production can also be

measured by an ongoing drug testing program. A study, conducted in

the 1970s establishing the feasibility of urine screening in jail

facilities serendipitously uncovered the availability of propoxyphene in

the community. These results alerted law enforcement agencies to

the problem, so that action to locate the suppliers could be taken

(National Institute on Drug Abuse 1979).

HOW CAN ONE IDENTIFY THE DRUG-ABUSING OFFENDER?

For a civil commitment program to operate within the criminal justice

system, there must be a feasible means available for screening large

numbers of persons for recent drug use. The methods utilized must

be low in cost, accurate, and capable of being implemented with

minimum disruption to the already overburdened criminal justice

systems in most large cities. Four methods are used: offenders’

self-reports, criminal justice records, urinalysis tests, and

radioimmunoassay of hair (RIAH). Blood tests are excluded from

consideration because of the general difficulty presented by drawing

blood from large numbers of detainees, as well as because of the fear

of AIDS transmission. Also excluded are breathalyzer tests, because

alcohol is a licit drug and is not in itself an indicator of high-rate

criminal activity (Wish et al. 1986b). Physical and behavioral signs of

drug use as well as intoxication are also excluded, primarily because

they are already widely employed to identify the sick drug-abusing

offender who is experiencing withdrawal symptoms or strong drug

reactions, but also because they are less useful for identifying other

users. Hair analysis is also discussed, even though it is in an

experimental stage and still very expensive, because it has some

interesting potential advantages over the other techniques. A more

detailed description of these techniques can be found in Wish (1986b).

Offenders’ Self-Reports

There is a long tradition in social science research of being able to

obtain valid self-reports about deviant behaviors, including illicit drug

use. Some of the best estimates of drug use have come from studies

involving personal interviews or self-administered questionnaires

(Robins 1974; Elliott and Huizinga 1984; O’Donnell et al. 1976;

McGlothlin et al. 1977; Johnston et al. 1977). Much of what is known

about the relationship of drug abuse to crime has also come from

studies that have relied upon offenders’ self-reports. The validity of

the information obtained in these studies has usually been tested and

142
confirmed by comparing the respondent’s self-reports with information

in official records or the results of a urine specimen obtained at the

conclusion of the interview (Wish and Johnson 1986; Harrell 1985).

Even when we have interviewed active criminals in our secure,

confidential research storefront in East Harlem, we have found

considerable agreement between self-reported drug use and the urine

tests (Wish et al., unpublished manuscript: Wish et al. 1983). Among

the most important reasons why the respondents in these studies

appear willing to disclose sensitive information about themselves are

that the data are collected voluntarily, for research purposes only, in

a safe environment, and that the anonymity and confidentiality of the

information is assured.

These are conditions that do not exist when attempting to identify

drug-using offenders detained in the threatening criminal justice

system. The evidence is convincing that detainees will severely under

report their recent drug use, even in a voluntary, confidential

research interview. Table 1 compares self-reported drug use,

obtained in a research interview, with urine analyses for an arrestee

population. The Enzyme Multiplied Immune Test (EMIT) was used to

analyze the urine samples. It is clear that twice as many arrestees

were found positive for any drug by urinalysis than admitted to

recent use in a confidential, voluntary research interview in

Manhattan Central Booking. Arrestees who refused to participate in

the confidential research interview had a high likelihood of rearrest,

similar to that found for arrestees who provided a urine sample that

was positive for multiple drugs. When the pretrial release interview

information was compared with their urinalysis test results, arrestees

in Washington, DC were also found to underreport their recent use of

drugs by about one-half (Toborg et al. 1986). Similar findings were

obtained from a recent study of probationers assigned to the

intensive supervision probation program in New York City (Wish et al.

1986c). In that study, only 24 percent of the probationers admitted

to recent drug use in a confidential research interview in the

probation department office, while 68 percent tested positive by

urinalysis (table 2). Moreover, probation officers, who indicated that

they relied the most on the probationer for information about his

current drug use, also underestimated by 23 percent the prevalence of

current drug use in their cases.

If valid self-reports of recent drug use cannot be obtained in a

voluntary, confidential research interview held within the criminal

justice system, it is obvious that they cannot be obtained when the

143
TABLE 1. A confidential research interview: Extent to which

arrestees underreport their recent use of drugs

(n=4,847 specimens from male arrestees in Manhattan

Central Booking in 1984)

Repotted Using Drug

24 to 48 Hours Positive by EMIT

Before Arrest at Arrest

(Percent) (Percent)

Cocaine 20 42

Opiates 14 21

Methadone 6 8

PCP 3 12

Any of the above: 28 56

2+ of the above: 11 23

TABLE 2. Estimates of recent drug use in probationers from selfreports, urine tests, and probation officer ratings

(n=66)

Drug

Probationer

Reported Use

in 24 to 48

Hours Before

Interview

(Percent)

Probationers Rated

by Probation Officer

as Using Drug

In Past Month

(Percent)

Urine Test

at Interview

(Percent)

Marijuana 24 21 42

Cocaine 3 9 52

Heroin 3 3 2

PCP 0 0 2

Methadone 2 3 0

Any of the Above 24 23 68

144
information is to be used to require a person to enter treatment or

a urine-monitoring program.

In spite of these limitations, there are important reasons for using

self-reports to identify drug abusers detained by the criminal justice

system. Although self-reports would detect only a small portion of

drug users, persons who do admit to drug use are a bona fide group

for further action. A study of juvenile detainees (Dembo et al. 1986)

found that youths who tested negative for marijuana but admitted to

recent marijuana use had detention records that were more similar to

persons who tested positive than to youths who were negative by test

and self-report. The authors conclude that it would be beneficial to

target for further assessment youths who were positive by urine test

or who reported recent drug use.

Furthermore, in our study of New York City arrestees, our research

found that self-reports of current drug dependence or of a need for

treatment were valuable in differentiating which of the persons who

tested positive were more seriously involved with drugs and crime.

Table 3 shows that, among all arrestees who tested positive, those

who admitted to drug or alcohol dependence at arrest or to a need

for treatment were much more likely to report recent drug use,

injection of cocaine, and prior treatment. The dependent persons

also had more extensive criminal records than did nondependent

persons.

Thus, while many drug abusers will conceal their drug problems, those

who do report serious drug problems while in the criminal justice

system may be a valid group for further assessment and diversion to

treatment. Jurisdictions wishing to implement some immediate, lowcost action to identify drug abusers could assign persons to interview

detainees and to refer them to treatment programs. Although many

drug abusers would go undetected, the number of persons identified

would probably be what most cities could handle, given the usually

overburdened and limited treatment resources.

In summary, self-report information can be very valuable for

obtaining indepth details about drug abuse, if the offender is willing

to disclose the information. It is a poor method to use as the

primary tool for screening detained drug users. The most promising

use of offender self-reports for the criminal justice setting is

probably to combine them with other evidence of drug use to

motivate the offender to discuss his behavior.

145
TABLE 3. Drug use and criminal history in male arrestees who tested

positive for drugs (New York City, 1983) by self-reported

dependence or need for treatment

Not Dependent

(n=1,651)

(Percent)

Dependent*

(n=926)

(Percent)

Drug Use (From Self-Reports)

Reported Using

24 to 48 Hours Prior to Arrest

Cocaine

Heroin

Marijuana

Downers

Illicit Methadone

PCP

Injects Cocaine

Ever received drug

treatment:

Criminal History (from records)

Ever Arrested Before

Two or More Prior

Misdemeanor Convictions

Two or More Prior

Felony Convictions

Had a Prior Arrest for

a Drug-Related Offense

15 61

6 53

34 36

2 12

1 8

3 6

9 61

11 60

76

32 60

10

33

91

14

59

*Male arrestees who tested positive for one or more drugs (opiates, cocaine, PCP. or

methadone) and who reported current dependence on drugs or alcohol or a need for

treatment.

146
Criminal Justice Records

The criminal justice system maintains extensive information files on

offenders. In view of the preceding discussion, and the fact that

much of the information in these records is obtained from the

offender, it is not surprising to find that information about the

offender’s involvement with drugs is often minimal and unreliable

(Goldstein 1986).

Even when an arrest report has a place to enter information about

the arrestee’s drug use, it typically is not completed. This is

probably because the police officer is often unaware of the arrestee’s

involvement with drugs and because information not of immediate

relevance to an officer tends not to be reliably entered into a data

system. Even in Washington, DC where the U.S. Attorney has

installed the prosecutor’s management information system (PROMIS)

to track case information, the arresting officers identified only 22

percent of those who were found positive for drugs at arrest by

urinalysis (Wish et al. 1981). Presentence investigation reports should

contain more information about the offender’s background. However,

in the absence of urine tests, the investigator must rely upon the

defendant’s admission of drug use or information from a family

member. In large cities, the time and resources available for

soliciting such information is limited.

If records do not contain detailed information about drug involvement, can a person’s arrest record of drug offense convictions serve

as an accurate indicator of drug use? The evidence indicates that

persons charged with the sale or possession of controlled substances

are most likely to be drug users (table 4).

Almost three-quarters of male arrestees in New York City (and of

arrestees in Washington, DC) charged with these offenses in 1984

tested positive for opiates, cocaine, methadone, or PCP. However,

more than half of the persons charged with robbery, burglary,

larceny, or murder were also positive for drugs (Wish et al. 1986a).

Fifty-six percent of these arrestees were positive for a drug, while

only 20 percent of the sample were charged with a drug offense.

Only 10 percent of the 17,000 male and female arrestees who were

drug positive by urinalysis in Washington, DC in 1973 and 1974 were

charged with a drug offense (Wish et al. 1981). Thus, while

offenders with a history of drug offenses are most likely to be using

drugs, it is clear that offenders charged with a variety of other

147
TABLE 4. Charges most associated with a positive urine test,

male arrestees in New York in 1984

Arrest Charge Number

Percent

Positive*

Possession of Drugs

Sale of Drugs

Possession of Stolen

Property

Forgery

Burglary

Murder/Manslaughter

Larceny

Robbery

Weapons

Stolen Credit Cards

Criminal Mischief

Gambling

Sexual Assault

Public Disorder

Assault

Fare Beating

Fraud

Other Offenses 269 45

Total 4,833 56

615 76

355 71

474 61

94 60

348 59

64 56

667 56

676 54

157 53

56 52

66 48

147 45

79 41

108 37

506 37

98 37

54 30

*Positive by EMIT for opiates, cocaine, PCP, or methadone.

offenses may be drug users. By relying solely upon a drug offense to

identify the drug user, the majority of users are missed.

Urinalysis Tests

In recent years, urinalysis tests have received considerable attention

as a source of information about an offender’s drug use (Wish 1982;

Forst and Wish 1983). It should be noted, however, that researchers

have used urinalysis for the past 15 years to validate information

obtained in interviews about recent drug use, and drug abuse

treatment programs have often monitored patients’ drug use by

148
urinalysis (McGlothlin et al. 1977). Urine tests were employed

successfully by the Department of Defense to screen army personnel

before they left Vietnam for the United States in the 1970s, and have

been used in recent years to combat a growing drug use problem.

Furthermore, in the initial years of the federally sponsored Treatment

Alternatives to Street Crimes (TASC) program, urinalysis was used to

identify drug-using offenders for diversion into treatment programs.

Urine tests have been used by the U.S. Department of Probation and

by local probation departments to screen suspected drug users. Mass

screening of offender populations for drugs has been used only in

Washington, DC, however, where all arrestees detained in the

Superior Court lockup prior to court appearance have been tested

since 1971.

There are a number of possible urinalysis techniques, and a common

error made by persons assessing the validity of drug testing is their

failure to consider the type of test used. Until recently, most urine

testing of offenders in the criminal justice system and in treatment

programs was conducted using a Thin Layer Chromatography (TLC)

general screen. This technique is especially economical because it

can screen for a variety of drugs, but it is an extremely subjective

process requiring experienced technicians to interpret the results.

Primarily because of their low cost, sensitivity, and ease of use, the

most commonly used urine test today is the EMIT. The EMIT

involves a chemical reaction of the specimen with an antibody

designed to react to a specific drug. The chemical reaction causes a

change in the specimen’s transmission of light. This change in

transmissibility is detected by a machine that provides a quantitative

reading that is compared with the reading from a standard solution

containing a known concentration of the drug. If the reading from

the specimen is higher than that of the standard, the specimen is

positive for that drug. Because the determination of a positive is

based on specific numbers, the level of subjectivity involved in the

EMIT is less than that for TLC. TLC appears to be more economical

because, for approximately $2, as many as 20 different types of drugs

can be tested. EMITS are specific to one drug and cost between $1

and $5 for each drug tested. (These are high volume, reduced rates

charged to researchers by the New York State Division of Substance

Abuse Testing Laboratory.)

Table 5 presents a comparison of the results from 4,647 specimens

obtained from arrestees in New York City and tested by TLC and the

EMIT technique by the New York State Testing Laboratory.

149
TABLE 5. Drugs detected in urine specimens from male arrestees by

type of test (n=4,847 specimens from arrestees in New

York City in 1984)

Drug Detected TLC (Percent) EMIT (Percent)

Cocaine 14 42

Opiates (Morphine) 9 21

PCP NA 12

Methadone 4 8

Table 5 makes clear that the TLC test underdetects the common

street drugs by almost two-thirds. Many laboratories have used a

two-test approach to identifying drugs. These labs first screen for

drugs using TLC and then confirm any positive result by an EMIT.

Such procedures would clearly result in many drug users escaping

detection. As a result of the above findings, EMITS are being

substituted for TLC tests across the country.

The growing popularity of the EMIT has brought several legal

challenges. The primary criticism is that the EMIT has too high a

rate of false positive errors. That is, the test falsely indicates the

presence of a drug. Much of the debate surrounds the possibility

that some common licit drugs can cross-react with the test’s reagents

to produce a positive result (Morgan 1984). The ingestion of poppy

seed bagels has produced a positive test result for opiates.

Furthermore, the EMIT for opiates will detect heroin (morphine) as

well as prescribed drugs such as codeine. Sloppy recording

procedures by laboratory staff and failure to maintain the chain-ofcustody for the specimen can also produce serious test errors.

There are other urinalysis techniques available for detecting drugs,

including radioimmunoassay and gas chromatography/mass spectrometry

(GC/MS) (Hawks and Chiang 1986). Some of these techniques have

not been used frequently in the criminal justice system, and sufficient

case law does not exist regarding whether the courts consider them

to be valid. GC/MS is too costly and time consuming to be used as

the initial test in large-scale screening programs, although it has

been required by some courts as a confirmation test.

A study by the Center for Disease Control (CDC) has been cited for

revealing substantial errors in the results from the 13 labs surveyed

150
(Hansen et al. 1985). In a blind experiment, CDC sent a group of

blank urine specimens as well as specimens containing known

quantities of drugs to the labs for analysis (the specific urinalysis

tests used by the labs were not specified). The study found that

while some labs failed to detect specific drugs contained in the

specimens, few instances occurred where a lab reported a drug in one

of the blank specimens. In fact, the average accuracy of the

analyses of the blank specimens was 99 percent; there were so few

false positive results that the analyses of this issue were limited.

There were too few false positive results to permit analysis of their

occurrence.

The experience of this writer in using urine tests in offender

populations also indicates that the problem of false negatives is much

larger than that of false positive errors. In contrast to controlled

laboratory experiments, tests for illicit drugs in offenders cannot

control for many of the factors that influence the drug concentration

in the urine. The quantity of the drug taken, its purity, and its time

since ingestion are unknown. It is, therefore, somewhat amazing

when a test does detect a drug. Studies by this writer show that

even when a person admits to taking a drug 1 or 2 days before the

test, it is found in only 70 to 80 percent of the cases. Many drug

users will, thus, escape detection by urinalysis.

It is probable that the future of urine testing in the criminal justice

system will depend on a satisfactory solution of the problem of false

positive errors. Preliminary NIDA guidelines for testing state that all

positive test results from immunoassay tests should be confirmed by

GC/MS. GC/MS is the most accurate technique currently available

for identifying drugs in the urine, but it costs about $70 to $100 per

specimen. It seems appropriate to require such a procedure when a

single test result may cause a person to lose their job or liberty.

However, when a test result is used solely to trigger further

investigation of whether a person is involved with drugs, it may be

that confirmation by other methods (urine monitoring or diagnostic

interview) would be equally acceptable. The courts have yet to

decide this issue.

Even though urine tests do contain some degree of error, the

evidence is strong that the tests have a high degree of validity. The

EMITS have been ruled valid by judges, although courts have differed

on the need for confirmation of positive results (Wish 1986).

Furthermore, the construct validity of urine tests, the evidence that

the relationships found with the tests are consistent with the current

151
knowledge about drug use, is impressive. Studies of arrestees and

probationers in New York City and Washington, DC have found

hypothesized relationships between detected drug use and age, prior

arrest history, type of arrest charge, and recidivism (Wish and

Johnson 1986; Wish et al. 1986a; Toborg et al. 1966). A positive test

for marijuana was related to greater lifetime use of marijuana and a

greater number of juvenile detentions in Tampa, FL (Dembo et al.

1986). In fact, this writer first discovered the lesser sensitivity of

the TLC test because the analyses of specimens from unapprehended

offenders interviewed in a research storefront in East Harlem did not

confirm the heavy drug use that these persons were reporting. Only

after the EMITS were used was the claimed drug use verified by the

urine tests (Wish et al. 1983). Perhaps of primary significance is

the finding from studies in Washington, DC and New York City that

not only the presence of a drug, but also the number of drugs

detected was related to criminal behavior. For all age groups,

arrestees positive for two or more drugs (usually cocaine and opiates)

had the greatest number of rearrests (figure 1). Furthermore, 60

percent of the rearrests for multiple drug users were for offenses

other than the sale or possession of drugs.

The proportion of offenders who are found positive and are seriously

involved with drugs is unknown. For this reason, a positive urine

test should be used with other information (self-reports, criminal

justice records, or repeated urine testings) to determine if the

offender chronically abuses drugs and is in need of treatment.

RIAH

RIAH is an experimental procedure with potential for drug detection.

As hair is formed in the scalp, the cells are nourished by the blood,

and drugs present in the blood are deposited in the cells at the root

level. One can extract the drugs from the hair for analysis by

radioimmunoassay. Researchers have found that the level of the druG

taken is correlated with the amount deposited in the hair cells.

Perhaps of most importance is that a historical record of a person’s

drug use level can be obtained. While hair at the scalp level

contains evidence of current use, hair further from the root contains

evidence of use months before the root was formed. Thus, by

analyzing sections of hair, especially in persons with long hair, a

trend in drug use over time can be obtained (Thanepohn 1986;

Witherspoon and Trapani 1983), and procedures are available for

detecting the most commonly abused drugs.

152
FIGURE 1. Mean number of rearrests by urine test and age,

Washington, DC and New York City, 1984 (n=4,847 male

arrestees in New York City in 1984)

NOTE: Rearrests are measured in an 11- to 17-month period after the index arrest.

These findings do not control for time-at-risk on the street. Differences

would be expected to be more extreme, however, because drug users were

somewhat more likely to be remanded after arraignment than were nonusers.

SOURCE: Wish et al. 1986a.

One possible advantage of RIAH is that the test cannot be easily

falsified. For example, an individual cannot suspend use before a

scheduled test to avoid detection. Once the drug is stored in the

hair, it remains there permanently. The technique of obtaining hair

is noninvasive and less objectionable to some persons than that of

obtaining urine. The analysis can provide evidence of the level and

trend of use over time. In addition, if the test is inconclusive or a

retest is required, a similar sample for analysis can be easily

obtained. The largest drawbacks to the test include the fact that it

requires radioactive materials and the types of precautions usually

needed in handling such substances, the cost (roughly $50 per drug

tested), the turnaround time of approximately 24 hours, and the

unavailability of standardized and accepted extraction techniques. In

addition, there is some possibility that hair content can be influenced

by environmental contaminants (Puschel et al. 1983).

153
Even if current research confirms the utility of RIAH, the long

turnaround time for the analysis and the cost may prohibit the

adoption of the method for large-scale screening of offenders. In

addition, it will take considerable time for the courts and the

scientific community to acknowledge the validity of the new

technique. If the technique is eventually accepted and the analysis

time remains long, it will most likely be less useful than other

techniques for testing pretrial arrestees, where the judge typically

requires the results quickly at the time of arraignment. Perhaps the

most valuable use for RIAH with offenders will be for the

confirmation of other test results and for the verification of changes

in the person’s use.

Summary

In a criminal justice setting, urine testing is the most feasible and

accurate method now available for screening large numbers of drugusing offenders. Self-report and record information can be

effectively used to verify and extend information about the

seriousness of use for those who test positive. The newer RIAH

methods offer promise for delineating patterns of drug use over time

if the method is valid, can be standardized, and gains acceptance

from the scientific and judicial communities.

CONCLUSIONS AND IMPLlCATlONS FOR COMPULSORY

TREATMENT

For the purpose of this chapter, compulsory treatment is defined as

the involuntary or voluntary ordering of persons from the criminal

justice system into some form of drug abuse treatment and/or urine

monitoring. The following conclusions may be drawn from the

research as presented here.

Fewer than one-half of the adults detained or supervised by the

criminal justice system will voluntarily admit to recent use of

illicit drugs.

Those persons who do report current drug abuse problems or

dependence tend to have serious problems and are a valid group

for treatment consideration.

Urinalysis can be an effective tool for screening large numbers of

offenders for recent drug use. However, the tests only indicate

probable use and must be followed by confirmation of the amount

154
of drug involvement. Confirmation can be achieved through

repeated testing over time, confrontation and interview with the

persons, and information obtained from records or reports from

persons who know the detainee.

This discussion has intentionally been limited to the methods available

for identifying drug abusers within the criminal justice system.

Other papers in this volume describe the efficacy of various types of

treatment for persons who have been referred from the criminal

justice system. lt is important to note, however, that, because little

systematic screening for drug abusers has occurred in the criminal

justice system, most research has examined treatment process and

outcome for the select group of offenders who were referred from

the courts. Little is known, outside of the research from the pretrial

testing program in Washington, DC (Carver 1986), about the level of

effectiveness of such interventions for a larger, more diverse group

of treatment referrals that would result from a wide-scale urine

screening program. Additional research on matching criminal justice

referral clients to appropriate, effective interventions will be

necessary in order to make compulsory treatment a viable option for

the criminal justice system.

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158
AUTHOR

Eric D. Wish, Ph.D.

Visiting Fellow

National Institute of Justice

U.S. Department of Justice

633 Indiana Avenue, NW

Washington, DC 20530

159
Legal Pressure in Therapeutic

Communities

George De Leon

INTRODUCTION

Compulsory treatment as a legal mechanism for changing the behaviors of antisocial substance abusers is not new to therapeutic communities (TCS). In the years 1965 through 1975, numbers of drug

abusers were court mandated to TCs as an alternative to Federal and

State treatment programs operated under civil commitment legislation.

After 1975, the civil commitment programs were largely replaced by

community-based treatment centers that have included TCs; accordingly, civil commitment procedures were replaced by the less uniform

set of activities termed “legal referral.” Thus, our understanding of

compulsory treatment in TCs is mainly drawn from research and clinical experience with legal referrals, rather than with civil commitment

per se.

The present chapter reviews what is known about compulsory treatment in drug-free TCs. The initial section summarizes research on

posttreatment outcomes and retention in treatment for legally referred clients. The concluding sections discuss policy issues and

implications for research. The treatment research literature surveyed

is not exhaustive. It is primarily restricted to program-based studies

in TCs of acceptable design, which include variables termed “legal referral,” "legal status,” “criminal justice referral,” and “nonvoluntary

referral.” These different labels constitute a problem in assessing

outcome research, since they describe a variety of activities and procedures that are not necessarily similar across the studies.

There are approximately 500 drug-free residential treatment settings

in the United States, of which less than one-third label themselves as

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traditional TCs. The latter have been characterized in other writings

(De Leon 1986a).

LEGAL REFERRAL TO THERAPEUTIC COMMUNITIES

TCs have always served clients referred from the criminal justice

system. Indeed, there are notable pioneering demonstration programs

in which TC models have been introduced directly into the correctional system (Tech 1980). Contemporary variations on the TC within

the correctional system are described in the literature (Wexler 1986).

What is known about compulsory treatment for TC clients has been

learned mainly from those residential treatment programs that are

community based and are outside the correctional system.

Legal referrals constitute less than one-third of all admissions to

drug-free residential modalities documented in the Client Oriented

Data Acquisition Process (CODAP) (National Institute on Drug Abuse

1980). Most of these programs, however, are not representative of

the traditional long-term TC. Among the latter, legal referrals

approximate 30 percent (De Leon 1960). Although there are wide

program differences, some TCs serve criminal justice clients almost

exclusively.

Legal referral rates to TCs have varied across the years. For

example, more than 40 percent of admissions to Phoenix House in

1970 were legally referred, compared to less than 20 percent in 1985.

Other TCs have informally reported a similar decreasing trend in

legal referral.

Although not fully understood, trends in legal referral to TCs generally relate to at least two broad issues. First, there has been a

significant change in drug use patterns. Admissions to TCs now include significantly fewer opiate users and increasing numbers of nonopiate abusers. This change in admissions to TCs may reflect an

actual decrease in the number of new heroin abusers, or it may indicate a shift to other treatment modalities. Generally, the pervasive

use of drugs at all levels of society has resulted in more users who

are minors or who have noncriminal backgrounds. As a result, there

has been less need for TC programs to recruit clients from the criminal justice system.

Second, policy issues may affect referral rates. For example, criminal

justice enforcement policy on drug-related crimes has varied over

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time. Implementation of street arrest and sentencing practices shifts

in relation to a variety of social, economic, and political forces.

A subtle policy issue concerns the relationship between the criminal

justice and drug treatment systems. The criminal justice system has

remained either uninformed or unpersuaded about the positive role of

rehabilitation for the drug-abusing criminal offender. This view may

have influenced referral rates to community-based treatment after the

phasing out of civil commitment programs. Nevertheless, current

social pressures, crowded courtrooms and jails, and the threat of

AIDS spreading through the intravenous-drug-using population have

rekindled interest in treatment as an alternative to incarceration for

drug abusers.

THERAPEUTIC COMMUNITY OUTCOMES

The literature on the effectiveness of TCs has been reviewed in other

writings (De Leon 1965; De Leon and Rosenthal 1979). Some outcome

studies have been executed by investigative teams engaged in largescale multimodality comparisons that include TCs, e.g., the Drug

Abuse Reporting Program (DARP) and the Treatment Outcome Prospective Study (TOPS). Others have been conducted on, and by, individual TCs. Although cited here when relevant, the findings for the

multimodality studies are reported elsewhere in this volume. This

section summarizes the main findings of program-based studies.

All studies reveal that immediate and long-term outcomes for clients

are significantly improved over their pretreatment status. Drug use

and criminality decline, while measures of prosocial behavior, e.g.,

employment and/or school involvement, increase (e.g., Barr and Antes

1981; Brook and Whitehead 1980; De Leon 1984; De Leon et al. 1972;

De Leon et al. 1979; Pompi et al., unpublished manuscript; Wilson and

Mandelbrote 1978).

A few studies have utilized a composite index of successful outcome

combining measures of criminal activity, drug use, and employment.

In these studies, maximally or moderately favorable outcomes occurred

for approximately half the clients (De Leon 1984).

Studies that examine differences between clients who complete treatment, i.e., graduates, and those who drop out indicate that graduates

are significantly better than dropouts on all measures of outcome.

Among dropouts, however, there is a positive relationship between

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outcome and length of stay in treatment (e.g., Barr and Antes 1981;

De Leon 1964; Holland 1983).

Research has yet to delineate a client profile that predicts successful

outcome. Several background correlates of positive outcomes on drug

use, criminality, or employment have been identified, e.g., lower

lifetime criminality, lower pretreatment baseline levels of drug use or

crime, and higher employment. Though significant, these associations

are small when compared with the effects of time in program.

Outcomes for Legal Referrals

Most TC followup studies report either small or no differences in

posttreatment improvement by legal referral, depending upon the

outcome measures employed (Barr and Antes 1981; Holland 1983;

Pompi et al., unpublished manuscript; De Leon 1984). For example,

followup status based upon agency records indicates that total arrest

rates are higher for legally referred clients, but the posttreatment

reduction in arrest rates for legally referred clients is equivalent to

that of voluntary clients (figure 1).

Using a composite measure of self-reported outcome status, the

Phoenix House studies reveal that “best success rates” (no crime and

no drug use) are somewhat higher for voluntary clients. Regression

analyses of the same data confirm that voluntary entry on admission

is a statistically significant correlate of posttreatment outcome

(De Leon 1964). The magnitude of the prediction is quite small;

controlling for criminal background eliminates the significance of the

legal referral variable.

The multimodality DARP and TOPS studies also find that legal

referral is not a statistically strong predictor of posttreatment

outcomes in TCs or other modalities (Hubbard et al., this volume;

Simpson and Friend, this volume). A similar relationship between

outcome and time in program for both voluntary and nonvoluntary

clients is also obtained from studies of European TCs (Wilson and

Mandelbrote 1976; Zimmer-Hoefler and Meyer-Fehr 1966).

Adolescent Legal Referrals

Among admissions to drug-free treatment, younger clients are more

likely to be legally referred than adults. For example, nearly half of

all male adolescent admissions to residential and outpatient programs

in the TOPS survey were legally referred (Hubbard et al. 1984). At

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FIGURE 1. Arrest fate for dropouts year by year, by legal status at

entry (age at entry 19 and older)

SOURCE: De Leon et al. 1979, Copyright 1979, Marcel Dekker, Inc.

Phoenix House, approximately 40 percent of the adolescent admissions

are legally referred, compared with less than 20 percent of adult clients. Indeed, there are TCs that serve legally referred adolescents

almost exclusively, e.g., Abraxas in Pennsylvania.

Findings are unclear for posttreatment outcomes of legally referred

adolescent substance abusers. For example, outcomes in DARP and

TOPS drug-free residential modalities do not differ by age; however,

analyses involving the interaction of age and legal referral are not

reported in those investigations. In Pennsylvania, a traditional TC

study of adolescents reported outcomes only for client status at

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discharge (Rush 1979). Results indicate that legal referral is not a

significant predictor of discharge outcomes in TCs or in outpatient

settings for adolescents.

Table 1 shows the main findings of a Phoenix House investigation of

age, legal status, and outcome assessed with a composite measure of

success (De Leon 1986b). Adolescent best success rates are similar to

those of adults, although more unfavorable outcomes were obtained

among clients under 19 years of age who had a legal status. Nevertheless, the evidence suggests that the TC exerts a considerable

effect on this more antisocial group of adolescents.

Retention and Legal Referral

Considerable research demonstrates a direct relationship between

retention and posttreatment outcome. For example, multivariate

studies identify time in treatment as the most consistent predictor of

positive outcome, even when the contribution of other client-related

variables is removed (Simpson and Sells 1982; De Leon 1984; Holland

1983; Barr and Antes 1981).

Because of its obvious importance, retention has increasingly been a

focus of investigation in TCs (De Leon 1985). A key conclusion from

this research is that client factors in general are not strong predictors of retention. However, legally referred admissions remain significantly longer in TCs than do voluntary admissions. Similar retention

findings are reported in other data systems involving TCs and other

treatment modalities (Condelli 1986; Sheffet et al. 1980; Simpson and

Friend, this volume; Hubbard et al., this volume: Anglin, this volume).

TC research indicates that the relationship between legal referral and

retention is complex. In particular, figure 2 shows that, among legal

referrals to a national consortium of TCs (Therapeutic Communities of

America (TCA)), Qmonth retention decreases with age compared with

voluntary admissions, for whom retention increases with age (De Leon

1980), suggesting an age/legal referral/retention interaction.

This finding is further supported in large-scale comparisons of retention in TCs (Pompi and Resnick 1987). Figure 3 presents curves for

10 TCs displaying the characteristic temporal pattern of retention

described in the literature (De Leon and Schwartz 1984). Dropout is

maximal in the first 30 days of treatment and declines steadily thereafter. Although the shapes of the curves are similar, the level

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TABLE 1. Success at 2 years’ followup: Age and legal status

(males)

KEY: Success 4=most favorable (no crime and no drug use): 3=favorable (drug use, but

no crime); 2-unfavorable (crime, but no drug use); and 1=least favorable (crime

and drug use).

NOTE: Percents may not add to 100.0 due to rounding. Positive change from pretreatment distribution of success index is statistically significant. The actual

proportion of Individuals who changed is more clarly shown when absolute

success status is ignored. Almost 84 percent of the sample had the lowest

success Index (1) for the year prior to treatment. Positive change over pretreatment levels occurred in almost 60 percent of the sample and was significant by age and legal status with the exception of the youngest legally

referred clients. They showed the smallest reduction in change for clients

with the lowest category.

of retention is markedly elevated, particularly in the first 30 days,

for one program, in which 90 percent of the admissions are adolescent legal referrals. In the other TC programs, legal referrals

constitute considerably smaller proportions of all admissions.

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FIGURE 2. Retention of court-referred adolescents

NOTE: Retention cures for Abraxas (1979 to 1983 admissions); Gateway Foundation

(February 1981 to June 1983 admissions); Phoenix House (January to April 1981

admissions); and seven members of a TCA consortium (February 1 to

August 15.1979, admissions).

SOURCE: Pompi and Resnick 1987, Copyright 1987, Marcel Dekker, Inc.

The effects of legal referral on short-term retention appear more

evident in younger clients. However, results from recent Phoenix

House analyses indicate that longer retentions (1 year or more) and

program completion rates (graduation) are significantly correlated

with clients more than 27 years of age, legally referred to treatment

(De Leon, in preparation). Thus, although legal referral is clearly

associated with increased retention, age-related factors still need

clarification.

SUMMARY OF MAIN FINDINGS

Outcomes

There is little evidence for differential outcomes between legally

referred and nonlegally referred clients. Significant posttreatment

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FIGURE 3. Legal status (CODAP definition), age, and 9-month

retention for all admissions (February to August 1979)

to a consortium of seven member programs of TCA

SOURCE: De Leon 1980.

improvements in criminality, drug use, and employment occur for both

groups and are directly related to time spent in treatment. Some

regression studies report that legal status is a significant but small

predictor of higher posttreatment criminality. However, this mainly

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reflects the importance of criminal background, which is correlated

both with legal referral and posttreatment criminality.

Retention

Time in program is the largest and most consistent predictor of

treatment outcomes; legal referral relates significantly to retention in

treatment. In general, clients referred by the criminal justice system

to TCs (as well as to other modalities) remain longer in treatment

than do voluntary clients. Relatively more adolescents are legally

referred to drug-free treatments, particularly to TCs. However, the

relationship between age, legal referral, and retention needs to be

clarified.

On the whole, the main findings suggest a complex relationship

between legal referral and treatment outcomes. Posttreatment status

does not relate directly to legal referral. Nonetheless, retention in

treatment is the best predictor of outcome, and legal referral is a

consistent predictor of retention. Thus, there is an indirect

relationship between legal referral and outcome that appears to be

mediated through retention in treatment. Research has shown that

the more criminally involved client has a less favorable posttreatment

outcome. The retention-enhancing effect of legal referral offsets the

higher probability of negative outcomes among a number of the

criminally involved clients, which may explain the similar outcomes

for voluntary and legally referred TC admissions.

Legal Pressure

Several interrelated issues from research and clinical experience in

TCs have confounded interpretation of the research findings on legal

referral and, broadly, the efficacy of compulsory treatment. There

are relevant distinctions among the terms “legal referral,” “legal

status,” and “legal pressure.” The failure to make these distinctions

has been an important source of variance in assessing treatment

effectiveness for the criminal justice client.

Legal referral is an explicit procedure. lt may be one of a variety of

criminal justice procedures, e.g., parole, probation, court diversion, or

sentencing stipulations, that essentially direct drug abusers to a

treatment alternative.

Legal status denotes any form of legal involvement, e.g., warrants

pending, case pending, arrested, in jail, awaiting trial or sentencing,

169
on bail, and may include the conditions of legal referral. Actually,

undetermined numbers of TC admissions are legally involved, i.e.,

enter treatment with a legal status, but are not legally referred.

Although the two terms are used interchangeably, they imply

different influences on treatment entry.

A further distinction concerns the term “legal pressure.” lt is

commonly assumed that legal referral, an action, is equivalent to legal

pressure, a presumed effect. However, legal referral procedures do

not assure the existence of the pressure, which is presumed to be the

effective element in a compulsory process. Perceived legal pressure,

or how individuals experience legal referral, is important. Those who

are legally referred may not experience any discomfort over the

consequences of noncompliance during treatment (leaving treatment,

the certainty of reincarceration, or even being in jail). Indeed, some

legally referred clients prefer jail to TC treatment.

The candidates most suitable for legal referral to drug treatment have

not yet been identified through research or clinical experience. In

part, this reflects the fact that the currently used dichotomy of

legally referred vs. nonlegally referred is too crude a classification to

capture the spectrum of addict differences, particularly with respect

to perceived legal pressure. Some voluntary clients may have histories of legal involvement and may experience legal pressure indirectly.

Conversely, as noted earlier, significant numbers of legally referred

drug abusers may not actually perceive or experience legal pressure

for compliance or change. Failure to distinguish among these subgroups of voluntary and nonvoluntary clients has introduced unmeasured error associated with the legal referral or legal status

variables commonly used in research.

lt is not within the purview of the present paper to detail a new

system for classifying legally referred or legally involved drug

abusers. Based upon the two factors of legal referral and perceived

pressure, at least four subgroups of clients could be specified: legal

referrals with and without actual perceived pressure; and legally

involved voluntary referrals with and without actual perceived pressure. lf a third factor, such as motivation (intrinsic pressure), is

introduced, the number of subgroups multiplies accordingly. Clarification of these subgroup differences is important in research on

compulsory treatment.

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Implementation Effects

The efficacy of legal referral procedures in yielding positive treatment outcomes is also related to the fidelity of their implementation.

Legally referred clients who do not perceive consistency or uniformity in the legal process may not feel pressed to comply with treatment demands.

Implementation failures can occur at any stage in the referral process. For example, the initial referral may contain ambiguities concerning the consequences or options for clients who either refuse

treatment or arbitrarily leave a particular treatment program. During

treatment, consistency should be maintained with respect to drug use

surveillance by urine testing (ii regularity and the actions taken) or

monitoring non-drug-use infractions (detection and consequences).

Generally, effective implementation requires a strong working relationship between the criminal justice and treatment systems. In particular, interaction and communication must be maintained between

the two systems to maximize the rehabilitative effects. For example,

legal officers must be familiar with the approach, have regular contact with clients, and routinely visit the treatment program. Programs should report regularly and promptly. Mutual agreements must

be developed on conditions for clients changing or dropping out of

treatment. An alliance must be forged in which a legal presence is

evident, and treatment is free to carry out its mandate.

Treatment Program Variance

An identified weakness in several of the civil commitment programs

initiated in the last 25 years has been the quality of treatment programs. For example, individual programs differ widely with respect

to philosophy, staff experience, program resources, and training.

Treatment technologies may not be explicitly described, or the relationship between the treatment model’s philosophy, or perspective,

and its practice is often abstract, distant, or weak. Moreover, even

well-designed protocols may not be faithfully executed. Thus,

program-related sources of variance have obscured the measurement

of treatment effectiveness for legally referred clients.

Recovery: The Role of Legal Pressure in Rehabilitation

Clinical experience and existing research underscore the multivariate

and interactional nature of behavioral change. Entire domains of

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variables, much less single measures, are inherently limited as

predictors of rehabilitation. lt is not surprising, then, that the

contribution to outcomes of one variable, such as legal referral, is

minimal, obscure, or ambiguous. This can be briefly illustrated in

terms of the recovery process in TCs.

The primary goal of rehabilitation is to facilitate the development of

a drug-free, prosocial lifestyle. This goal is achieved through a

social learning methodology that fosters maturation, skills training,

insight, and personal growth.

The process of change unfolds as a continuous interplay of client

factors, e.g., motivation, and treatment influences. Three stages of

the process can be characterized that reflect shifts in the factors

that influence treatment involvement and behavioral change:

(1) compliance—adherence to the rules and regulations of the TC to

avoid negative consequences such as disciplinary sanctions,

discharge, or reincarceration;

(2) conformity—adherence to the expectations and norms of the

group or community to avoid loss of approval or disaffiliation;

and

(3) commitment—adherence to a personal resolve to change one’s

lifestyle.

These stages are inclusive and interactive in that conformity requires

compliance, and commitment subsumes both conformity and compliance

toward achieving the personal goal of self-change. The appearance

of prosocial behavior in each stage does not necessarily imply its

causes or assure its stability. lf the commitment stage is not

attained, recovery is incomplete, and the potential is greater for

relapse to drug use or crime.

Thus, the recovery process itself may be the primary source of

variance affecting the measured efficacy of compulsory treatment.

Nevertheless, research and clinical experience in TCs do provide

hypotheses concerning the role of legal pressure in rehabilitation.

Some drug abusers require external pressure to seek, remain in, and

benefit from treatment. For these individuals, legal pressure is

viewed as having a limited but potent role in the recovery process.

Legal pressure can provide the initial force that sustains individuals

through the compliance stage of treatment, permitting the influences

172
of maturation, therapy, and retraining that occur in the later stages

of recovery.

Broadly, the above perspective on recovery can be applied to various

ways that perceived legal pressure could affect individual change,

both within and outside treatment settings.

Legal pressure can maintain abstinence and prosocial behavior during

the period of surveillance only (duration of probation, parole, courtmandated time). In this case of compliance only, behavioral change

is likely to be temporary and unstable after removal of the pressure.

Legal pressure in the form of surveillance can maintain compliance

until maturational factors assume a greater influence in the acquisition and maintenance of prosocial behavior. This undoubtedly has

been of major significance in some of the non-TC studies reporting

positive results of civil commitment (Angiin and McGlothlin 1994).

Finally, compliance can lead to rehabilitation when legal pressure

maintains compliance during the transition to the conformity and

commitment stages in the recovery process.

IMPLICATlONS FOR RESEARCH ON COMPULSORY TREATMENT

The efficacy of compulsory treatment is related to implementation,

client differences, and the multivariate complexity of the recovery

process itself. These issues can be better understood through

research in several ways.

Individual Differences

As yet, there is no typical profile of the client most suitable for a

compulsory treatment referral. However, important client factors can

be specified, particularly in terms of perceived legal pressure, motivation, readiness, and suitability for treatment. Research can develop

criteria for classifying client differences and provide comprehensible

tools for criminal justice personnel to use for identification, assessment, and referral.

Although new and appropriately designed studies are necessary to

demonstrate convincingly the contribution of compulsory treatment

approaches to outcomes, much information can be gleaned from further analyses of data already collected. In particular, the complex

173
relationships among legal referral, age, motivation, retention, and

outcome can be investigated to a certain extent in existing data sets.

Improved Implementation

Effective compulsory treatment requires an integrated involvement of

criminal justice systems and treatment systems. Models for developing links between the criminal justice and treatment systems must be

designed and tested. Such models should stress the following areas.

Education. The existing knowledge base with respect to treatment

effectveness must be disseminated to the Criminal Justice System,

which needs to be informed of the various treatment modalities, the

clients they serve, and their success and improvement rates.

Training. Treatment workers and criminal justice personnel, i.e.,

judges, correction officers, and district attorneys, must be trained to

work together in referral and rehabilitation. The focus should be on

mutual agreement of the goals of compulsory treatment for selected

clients, particularly in terms of the role of legal pressure in the

recovery process.

Uniform Procedures. Explicit and uniform procedures for referral and

surveillance must be established to maintain consistency in the legal

referral process.

Policy Considerations. Existing evidence suggests that treatment is

effective for some undetermined number of drug offenders who are

legally referred. Favorable outcomes for legal referrals appear in the

three major treatment modalities of methadone maintenance, drug-free

outpatient settings, and drug-free TCs. The latter modality, in particular, offers a unique alternative for criminal justice referrals.

Although posttreatment outcomes were stressed in the present review,

the impact of treatment is striking on all clients, voluntary and nonvoluntary, during their stay in the TC. Regardless of length of time

in program, there is virtually no crime or illicit drug use while clients are in residential treatment. Given their modest costs, the selfhelp traditional TCs offer an extremely favorable cost/benefit

alternative to incarceration.

Unlike other modalities, the TC provides long-term treatment in a 24-

hour environment that attempts to change lifestyles. Its emphasis

upon resocialization accords with the goals of the criminal justice

174
system and society in general for rehabilitating the drug-abusing

offender.

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AUTHOR

George De Leon, Ph.D.

Director, Research and Evaluation

Phoenix House Foundation

164 West 74th Street

New York, NY 10023

177
Basic Issues Pertaining to the

Effectiveness of Methadone

Maintenance Treatment

John C. Ball and Eric Corty

OPIATE ADDICTION IN THE UNITED STATES: A HISTORICAL

PERSPECTIVE

In an era of renewed public apprehension about the spread of drug

abuse in the United States, it is meaningful to review basic issues

pertaining to the effectiveness of treatment for intravenous drug

users for three reasons. First, heroin addiction-with some 500,000

active addicts—remains a persistent part of the drug abuse problem in

the United States (Kozel and Adams 1986). Second, the fact that

most heroin addicts are intravenous drug abusers, who constitute a

high-risk group in the AIDS epidemic, has aroused a new level of

scientific interest in this population (Drotman 1987). Thirdly, the

problem of heroin/opiate addiction has a long history in the United

States, so that treatment and policy issues can be placed within a

historical and scientific framework.

Before considering basic treatment issues pertaining to heroin

addiction, it seems worthwhile to comment upon the history of the

opiate addiction problem in the United States, define opiate addiction,

identify particular populations under study, and delineate what we

know about the treatment of heroin addiction to provide a framework

for further discussion.

The problem of opiate addiction has a long history in the United

States (Terry and Pellens 1928). In 1878, Marshall (1978) reported on

the characteristics of 1,313 opium and morphine eaters in Michigan.

By 1918, a special committee of the Treasury reported that there

were 237,655 addicts in the United States (Terry and Pellens 1928).

More recently, O’Donnell and Jones (1968) investigated the origin and

spread of intravenous opiate abuse and found that this route was

178
first utilized by U.S. addicts in the 1920s. This long history has also

produced a vast body of scientific and medical knowledge about the

life course of opiate addiction and its treatment (Bail and Chambers

1970; Lowinson and Ruiz 1981).

lt is important to note that demographic populations at high risk for

opiate addiction have differed by era and location within the United

States. Similarly, for those who do become addicts, age at onset of

daily opiate use and other characteristics of their addiction careers

also differ by period and place of residence. Furthermore, it is

significant that comparable or even greater variations in addiction

characteristics and consequences have been found in other nations

(Ball 1977; DuPont et al. 1979). Thus, the problem of opiate addiction

differs by nation and historical period, although most physiological

and pharmacological aspects of addiction, such as physical dependence, remain constant (Cooper et al. 1983; Kreek 1979).

Studies of drug addiction have usually focused on particular populations of abusers, classified specific drugs of abuse, and formulated

definite scientific questions to investigate. Thus, it is necessary to

indicate which population (adult males, metropolitan slum dwellers,

teenage females, college students, army personnel, factory workers,

prostitutes, criminals, doctors, pregnant housewives, etc.) and which

drugs of abuse (heroin, morphine, PCP, cocaine, marijuana, barbiturates, etc.) are to be studied. In addition, it is important to measure

frequency of use as well as to note route of administration (Ball and

Chambers 1970).

Studies of heroin addicts in the United States have found that most

compulsive users have both addiction and nonaddiction periods

following onset of daily use of opiates (Nurco et al. 1981). Each of

these addiction periods, or nonaddiction periods, commonly last a year

or longer. Nonaddiction periods are often periods of incarceration.

These consecutive periods of addiction, nonaddiction, or incarceration

provide a frame of reference for studying the life course of heroin

addiction. In this regard, the forces that cause the onset of

addiction are usually quite different from those that propel addicts to

continue daily abuse for many years. While the onset of heroin use

commonly occurs as a voluntary peer-group recreational endeavor

among inner-city youth, continuation of intravenous use leads to an

adult career in which the addict is enmeshed continually in a drug

abuse subculture.

179
Once opiate addiction has been established for a number of years, it

has proved to be exceedingly difficult to reverse this process and

effect a cure. Indeed, it has been stated that no treatment regimen

exists that will permanently cure most opiate addicts (Ball 1972).

Adults can be withdrawn from drugs in a controlled environment (i.e.,

hospital or prison), but most ex-addicts quickly relapse without

followup services. The life course of opiate addiction is so intractable to rehabilitation because this dependency is supported by a

complexity of physical, psychological, and social forces that reinforce

one another. Consequently, once intravenous heroin addiction is

established, the day-today pursuit of drugs becomes a way of Iife

that is not changed easily.

THE SOCIAL AND COMMUNITY CONTEXTOF HEROIN ADDICTlON

Drug addiction is learned repetitive behavior that is illegal and that

quickly becomes compulsive. Drug addiction is also social behavior

that commonly is learned from other abusers and is maintained by

means of their support. In this sense, drug addiction is socially

contagious. lt is not, however, an infectious disease like AIDS, and

it is not primarily a mental illness.

The 500,000 heroin addicts concentrated in metropolitan areas

constitute a major social problem for the nation, because of their

self-destructive lifestyle and antisocial behavior (Nurco et al. 1985).

in this regard, most addicts are involved continually in crime and

often find it difficult, or unrewarding, to pursue steady employment

(Ball et al. 1983).

Various public policies have been advocated to cope with the problem

of heroin addiction in the United States; many of these policies apply

to compulsive users of other illicit drugs, as well as heroin. lt seems

pertinent to comment upon current policies pertaining to drug abuse

because they often are advanced in conjunction with, or as substitutes for, treatment. A major public policy focuses on educating

youth about the dangers of drug abuse as a principal means of

controlling or eliminating the problem of drug abuse. This emphasis

upon didactic or moral teaching has had only limited effect in

changing adolescent peer-group behavior and is only one aspect of

prevention. However, it has been found that there are three discrete

domains that need to be reached in prevention: knowledge, attitudes,

and behavior (Grant 1986).

180
Countervailing institutional forces at work in society have limited the

impact of education. These forces include societal influences that

denigrate family life, religious values, and community responsibility,

while they extol drug abuse and other forms of deviant behavior.

The family also has a crucial role to play in the prevention of drug

abuse among children. However, many children do not have responsible parents and, consequently, they are deprived of suitable early

socialization. In this regard, there are not only orphans and

unwanted children, but parents who are themselves opiate addicts,

criminals, or prostitutes (Goldstein 1979).

A word about the inner cities is in order. These extensive, yet

forgotten, neighborhoods are a principal breeding ground of heroin

addiction. In a very real sense, addiction is a community problem,

rather than merely an individual problem (Chein et al. 1964). This is

because addiction is maintained and spread by drug-using cohorts

from generation to generation in metropolitan slum areas

(Mieczkowski 1986). Furthermore, the fact that minority group

members constitute a major portion of inner-city dwellers only

exacerbates the problem of awakening public interest and support. So

the scope and complexity of the slum problem remain intact, and the

poorer areas of our cities continue to be ignored.

The role of law enforcement is crucial to any policy for controlling

heroin addiction. As with crime, it is necessary to develop policies

for reducing the spread and continuation of the problem. In this

regard, it is important that law enforcement efforts and programs be

integrated with community needs and interests.

Treatment alone cannot be expected to contain the problem. Support

for treatment proclaims that a legitimate human need exists and this

need has public support (Jaffe 1979). It follows from what has been

stated that no one approach or single institution will be sufficient to

meet the heroin addiction problem in the United States. Rather, a

coordinated societal approach is necessary, in which increased

resources will be organized to meet prevention, education, and

treatment needs of communities, occupations, and other populations.

181
TREATMENT SERVICES PROVIDED TO METHADONE

MAINTENANCE PATIENTS IN NEW YORK, PHILDELPHIA, AND

BALTIMORE-RESEARCH FINDINGS

When consldering the role of treatment for opiate addiction in the

United States, it is pertinent to delineate the treatment services

commonly provided In methadone maintenance programs for various

types of addicts. Thus, the question of what types of patients profit

from methadone maintenance treatment can best be answered by

analysis of both patient characteristics and program characteristics.

Inasmuch as the analysis of treatment regimens and services delivered

has been largely Ignored, it seems appropriate to present research

findings pertaining to methadone maintenance treatment services.

Research pertaining to the scope, frequency, and variation in

treatment servicea provided to methadone maintenance patients was

obtained as part of a three-city National Institute on Drug Abuse

(NIDA) supported study of program effectiveness. Data collection

included confidential onsite interviews of each program’s staff,

indepth compilation of data from pharmacy and other clinic records,

and face-to-face patient interviews. Detailed program data were

collected at the clinics by four project staff members, which included

the authors, during a 2-year period (1985 to 1986).

The six methadone maintenance programs selected for study included

about 1,900 addict patients. The treatment services can conveniently

be classified under four headings: (1) attendance for oral methadone

medication; (2) urinalysis to detect illicit drug use; (3) counseling

services; and (4) medical services provided (table 1).

Attendance requirements at the six programs were quite strict.

Recent admissions and patients without take-home privileges were

required to attend the clinic every day—either 6 or 7 days per week,

depending upon whether or not the clinic was open on Sundays.

During this daily visit, patients were given an oral dose of methadone

by the dispensing nurse or pharmacist. At this time, patients were

also checked for obvious intoxication, provided an opportunity to

arrange for formal counseling services or medical services, and

monitored for treatment progress.

About 54 percent of the 1,898 patients earned take-home privileges;

that is, they were given one or more doses of liquid methadone in

bottles for consumption at home on days when they did not attend

the clinic. For those with take-home privileges, the mean number of

182
take-home medications was three. Most of these patients then

attended the clinic three or four times per week. The average daily

attendance rate at the six clinics was 94.2 percent. Only 5.8 percent

of the patients missed their scheduled daily attendance for medication.

TABLE 1. Fourteen treatment services provided to 1,898 outpatients

at 6 methadone maintenance clinics

Type of Treatment Frequency of Service

1. Attendance for Oral Methadone

Medication

Average daily attendance rate

at clinic

Mean days of scheduled attendance

per week

Mean methadone dosage

2. Urinalysis to Detect Illicit Drug Abuse

Mean number of urine specimens

“dropped” per month

3. Services Provided by 55 Counseling Staff

Patients with designated counselor

Mean number of counseling sessions

per month

Mean time of individual counseling

sessions

Patients also receiving group

counseling

Receiving vocational services,

in month

Receiving educational services,

in month

4. Treatment Provided by 44 Medical Staff

Patients receiving medical treatment,

past 90 days

Patients receiving physical exams,

past 30 days

Receiving other medication,

past 30 days

Receiving psychotherapy in

past 30 days

94.2 percent

5.4 days

45.6 mg.

4.9

99.6 percent

2.2

36.5 minutes

22.2 percent

2.5 percent

1.9 percent

41.8 percent

15.6 percent

4.9 percent

0.2 percent

183
A second major aspect of methadone maintenance treatment is

urinalysis. All patients were required to provide urine samples on a

regular basis. Commonly, this was done once a week on a random

basis, but in some programs it was done more often. On the whole,

4.9 urine specimens were obtained per patient per month. The

purpose of this urine screening was to monitor illicit drug abuse

(both opiates and nonopiates) and to check whether patients were

taking their take-home methadone.

Counselors represented the largest clinic staff group, and they

provided numerous treatment services to methadone patients. Each

patient was assigned a counselor at admission who had primary

responsibility for supervising the patient’s treatment progress.

Counselors provided regular individual sessions, with an average of

2.2 sessions per month, each lasting 37 minutes. In addition to these

individual sessions, 22 percent of the patients attended group

counseling sessions.

Although the counselor’s principal roles were individual face-to-face

conferences, daily monitoring with brief contacts, attendance checks,

and referrals, they also provided a variety of other services. For

example, 7 percent of the patients attended Narcotics Anonymous or

Alcoholics Anonymous meetings at the clinic on a monthly basis, 2

percent received family therapy, 2 percent attended educational

services, and 2 percent received vocational services.

When counseling was contrasted with educational and vocational

services, only 4 percent of the patients received either educational or

vocational services. Staff qualified to provide these services were

not available in most programs.

The 44-member medical staff at the 6 clinics included 11 physicians,

5 physicians’ assistants or nurse practitioners, 25 dispensing nurses,

and 3 pharmacists. Since many of these staff were part time, their

full-time equivalency (FTE) was about half that of the counselors—

29.2 FTE versus 53.0 FTE.

The treatment services provided by the medical staff consisted

primarily of dispensing methadone, conducting physical examinations,

and providing general medical care. Thus, most of the nurses’, as

well as most of the pharmacists’, workday was spent dispensing

methadone. In addition, 16 percent of the patients had had physical

exams in the past month, while 42 percent had received medical

treatment in the past 3 months. Only 0.2 percent of the patients had

184
received psychotherapy in the past 30 days, and only 5 percent were

on prescribed medication other than methadone.

A review of the total treatment services provided to patients at the

six programs supports the following conclusions. First, clinic

attendance and monitoring, which is focused upon regular scheduled

methadone dispensing, provides an ongoing network of contacts and

services that has a daily effect on patients.

Second, urinalysis fulfills an important function. lt provides an

objective test of compliance with treatment goals and serves as an

important measure of patients’ progress.

Third, the important role of counselors and nurses in the clinics must

be emphasized. These two groups provide the daily contact as well

as most of the individual care and rehabilitative services that patients

receive.

Fourth, marked variations were found among the six clinics in

medical staffing patterns and services provided (Ball et al. 1986).

Some programs had extensive medical coverage, while others had

almost none. The effect of these differential medical services upon

patients’ outcome remains to be investigated.

The Effect of Legal Pressure on Admissions to Methadone

Maintenance

A cohort of male patients representing 104 admissions to the 6

programs was examined. Of these admissions, 31 were under legal

pressure (probation or parole) and 73 were not. These patients were

interviewed at admission and then reinterviewed a year later.

With respect to background characteristics, the compulsory treatment

patients (those under legal pressure) were more likely to be separated

or divorced (48 percent versus 27 percent), had more criminal convictions (7.0 versus 3.6), had spent more time in prison (51 months

versus 18 months), and had more years of regular barbiturate abuse

(2.2 versus 0.6). However, the two groups did not differ significantly

with respect to age, race, employment history, age at onset of opiate

use, years of opiate use, or prior treatments for drug abuse.

The two groups of patients were quite similar at admission with

respect to their need for treatment, as measured by the Addiction

Severity Index (ASI). The only significant composite score

185
differences on the ASI scales (i.e., medical, employment, legal, familysocial problems, drug abuse, alcohol abuse, and psychiatric problems)

were drug abuse and crime. The compulsory treatment patients were

lower on the drug scale and higher on the legal problems scale.

The two groups appeared to differ with respect to treatment retention, although this difference was not statistically significant. Thus,

only 19 percent of the compulsory patients were in treatment a year

later, compared with 40 percent of the other patients. These results

indicate that the majority of criminal addicts who are under legal

coercion do not remain in methadone maintenance treatment for 12

months. When such rapid dropout occurs, it seems that it may be an

indication that the patient treatment match was inadequate or that

the treatment modality was inappropriate.

SEVEN BASIC: ISSUES PERTAINING TO THE TREATMENT OF

HEROIN ADDICTION IN THE UNITED STATES

A first issue pertains to the causes of heroin addiction in the United

States. Clearly, there are numerous causes and combinations of

causes. A considerable body of research has addressed this issue

(Nurw 1979), and it has been reported that numerous factors promote

heroin use (e.g., peer-group friends who are addicts, residence in

metropolitan slums, and prior delinquency), while others inhibit such

use (e.g., non-drug-using friends, stable family life in better neighborhoods, as well as the absence of delinquency). With no single

cause of heroin addiction, there is no simple or easy solution to this

social problem. As noted previously, epidemiological findings suggest

that populations at risk for opiate addiction change by historical

period, nation, and locale so that causal factors might also vary.

This is not to maintain, however, that significant causal factors

cannot be identified (e.g., drug-abusing peers and residence in a

metropolitan slum community).

A second issue pertains to whether or not education, religion, law

enforcement, or, indeed, any single institution can solve the problem.

The answer is no! None of these institutions has been able to stem

the tide of heroin addiction, much less eliminate the problem. As

stated, each of these institutions and others (mass media, sports, and

recreational enterprises) has a role to play. However, there is a lack

of consensus and coordination among these institutions.

A third issue pertains to the current role of treatment as a national

policy. It appears that there is an ambivalent attitude toward the

186
treatment of heroin addiction and, indeed, toward the treatment of

drug abusers in general. On the one hand, a belief in rehabilitation

and reform is proclaimed, and, therefore, some treatment is provided.

On the other hand, the problem of intravenous heroin addiction is

denied, so an intellectual dichotomy persists.

A fourth issue relates to the effectiveness of methadone maintenance.

lt has been noted that all of the major treatment modalities for

heroin addicts are successful for some patients. In this sense,

methadone maintenance, therapeutic communities, psychotherapy,

group counseling, and individual therapy are all effective. The

question now becomes one of ascertaining which treatment modalities

are appropriate for which types of patients in which types of

neighborhoods or communities (McLellan et al. 1982). But the issue

of what constitutes successful treatment for heroin addicts is not

simple and straightforward (Tims and Ludford 1984). Getting addicts

completely off opiates, or all illicit drugs, is only one criterion of

success. Their criminal behavior, psychiatric difficulties, or other

aspects of their lives cannot be ignored. As a consequence of

diverse lifestyles and attendant problems, it is necessary to measure

improvement in a number of respects. The most widely used measurement instrument for ascertaining addicts’ need for treatment and

progress in treatment, the ASI, uses seven specific areas of functioning: medical status, employment, alcohol abuse, drug abuse,

crime, family/social life, and psychiatric status. Within this context,

treatment effectiveness is based upon demonstrable improvement in

each of these areas. To the extent that a treatment modality

produces improvement, it is more or less effective. Consequently,

treatment effectiveness is not a matter of success or failure, but a

question of how much improvement, for how many patients, over how

much time.

The fact that many methadone maintenance patients stay in treatment

for extended periods of time (a sizable number continue for 3 or

more years) raises the issue of whether or not these programs seek

to cure addicts by making them completely abstinent. The rationale

for methadone maintenance treatment is founded upon three fundamental objectives: stabilization, improvement, and cure (Dole and

Nyswander 1965; Dole and Joseph 1978). Each of these objectives is

an acceptable outcome for some patients. Methadone maintenance

programs are able to effect significant improvement for most patients

who remain in treatment. Thus, stabilization of an improved way of

life generally occurs after 2 years of treatment.

187
A fifth issue, whether prolonged methadone maintenance treatment

tends to institutionalize patients and promote a welfarelike dependency, is crucial to public policy deliberations. Three observations

seem appropriate. First, the 500,000 addicts pose numerous problems

for their communities and sometimes seem to threaten the very fabric

of society through their self-destructive predatory acts and criminal

behavior. The addicts do exist, and therefore, long-term treatment

must be considered. Second, most addicts who enter methadone

maintenance programs improve (especially with regard to a reduction

in drug abuse and criminality) while they remain in treatment. In

this sense, methadone programs are effective and are a major benefit

to society. Third, the degree of institutional dependency involved in

outpatient methadone maintenance treatment is minimal; most patients

make two to five brief daily visits to the clinic per week, and the

number of visits is decreased after the first year or two.

The effectiveness of compulsory methadone maintenance treatment for

heroin addicts represents a sixth basic issue. The consideration of

what types of criminal addicts might be suitable for admission to

methadone maintenance treatment presents a dichotomy of goals. The

goal of containing the most dangerous or difficult criminals and

thereby removing a threat from society is one objective. Conversely,

the goal of effecting change and rehabilitation among criminal addicts

represents something quite different. On the basis of present

knowledge, a policy of compelling hardcore criminal addicts to attend

existing methadone maintenance programs seems ill advised, since the

chances of effecting positive change seem minimal, while the likelihood for program disruption seems high.

In addition, it would probably be necessary to establish separate

specialized clinics (or sections in clinics) to serve criminal justice

clients if they are mandated or court ordered to methadone maintenance treatment. This course of action would follow the growing

recognition that there is a need for specialized treatment services for

various addict or ex-addict populations (e.g., females, adolescents,

those at highest risk for AIDS, the aged, and stable working adults).

Establishing and maintaining viable links between treatment programs

and the criminal justice system will be extremely difficult to implement. Apart from inherent differences in philosophy, staff training,

objectives, and day-today operations, treatment programs do not

currently have staff and program resources to implement a meaningful

policy of coordination and mutual support.

188
A seventh possible issue is whether other modalities are more or less

effective than methadone maintenance in treating opiate addicts.

Perhaps a more appropriate question is how to determine the particular effectiveness of each treatment modality for specific types of

patients.

CONCLUSION

The problem of heroin addiction in the United States was discussed

from a historical and sociological perspective, with emphasis on

recent influences that have awakened concern about its scope and

consequences. The role of methadone maintenance treatment in

addressing the problem of heroin addiction in the United States was

considered. lt was concluded that methadone maintenance can be

effective, especially with respect to reducing illicit drug use and

crime. The question remains, however, as to which types of patients

can (and cannot) be treated successfully. In the present context, this

raises the issue of whether compulsory treatment will be effective for

persons involved in methadone maintenance treatment.

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McLellan, A.T.; Luborsky, L; O’Brien, C.P.; Woody, G.E.; and Druley,

K.A. Is treatment for substance abuse effective? JAMA

247(10):1423-1427, 1982.

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in Detroit. Criminology 25(4):645-666, 1986.

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Goldstein, A.: and O’Donnell, J., eds. Handbook on Drug Abuse.

Rockville, MD: National Institute on Drug Abuse, 1979. pp. 315-

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criminality of narcotic addicts. Nerv Ment Dis 173(2):94-102, 1985.

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technique among narcotic addicts. J Health Soc Behav 9:120-130,

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174 pp.

ACKNOWLEDGMENTS

Supported by the National Institute on Drug Abuse Grant number

51-RO1 DA03709-61.

AUTHORS

John C. Ball, Ph.D.

National Institute on Drug Abuse

Addiction Research Center

P.O. Box 5180

Baltimore, MD 21224

Eric Corty, Ph.D.

Bradley University

Department of Psychology

1501 West Bradley Avenue

Peoria, IL 61625

191
Civil Commitment—International

Issues

Barry S. Brown

INTRODUCTlON

The effort to apply cost-effectiveness analysis to civil commitment

procedures, as called for in this review, points to a central concern

that civil commitment has posed for many. In developing effectiveness studies of any type, it becomes necessary first to consider the

objectives of the interventions and then to construct outcome

measures appropriate to those objectives. In the case of civil

commitment procedures, the community institutes administrative or

judicial procedures, as permitted under civil law, to contain and

modify behaviors that the society finds inappropriate, typically

dangerously inappropriate. This suggests that a major, if not the

major, effectiveness measure for civil commitment procedures is the

reduction of disturbance in a community associated with the offending

behaviors. In that spirit, civil commitment procedures, as they relate

to drug abuse, have been more largely concerned with maintaining or

achieving a societal homeostasis than have other drug abuse treatment procedures. While most would agree that all drug abuse

treatment, and arguably all forms of public health care, have as an

objective the protection of society in addition to the permitting of

individual well-being and accomplishment, a weighting in the direction

of societal protection appears particularly significant in the case of

civil commitment practice. Costs then become proportional to the

community’s felt need for social control and the potential societal

gains seen with the achieving of that control.

Those costs may be dear if the societal gains are deemed sufficiently

great. Thus, Mussa Hatam, the Malaysian Deputy Prime Minister,

could explain that civil commitment and enforcement strategies had

become necessary in his country because the drive toward

192
modernization and accompanying economic prosperity was leading a

significant minority of youth to drug abuse or, and also highly

undesirable, toward an excess of religious zeal (Hatam 1985). Thus,

for Malaysia, some level of youthful deviance, in tandem with

stringent enforcement measures and a program of compulsory treatment were seen as tolerable costs in paying for the nation’s economic

well-being. More commonly, costs are measured in the toll potential

for civil liberties since civil commitment can permit detention for

inappropriate behaviors without providing legal counsel, judgment by

one’s peers, or witnesses for one’s defense (Porter et al. 1986a).

Little wonder that Bejerot (1983) and Webster (1986) argue that

democratic countries cannot move massively against drug abuse

without clear evidence of strong public support. Van Bilsen and van

Ernst (1986) argue that, from the standpoint of their clinic in the

Netherlands, the marshaling of support to achieve such an objective

is unnecessary. They argue that behavioral change is potential within

the interaction of therapist and client and that controlled use of

drugs—including heroin—need not threaten the larger society. van

de Wijngaart (1988) notes that addicts are themselves ambivalent

about the use of heroin as opposed to methadone maintenance, and

that the Dutch must remain open to different strategies for coping

with addiction.

Perhaps with those assessments in mind, Webster (1986) argues, with

somewhat Machiavellian intensity that:

For a major intervention program to be successful,

especially one which places heavy reliance upon the use of

compulsion . . . . First, the problem must be isolated and

perhaps enlarged: it may even have to be created in

certain instances (italics added). Public interest has to be

won and the imperative need for a solution must be

propagated. Second, a remedy must be offered and

projected through the media. It is worth noting that the

inherent logic of the plan may be a relatively unimportant

ingredient. . . it is helpful to be able to project the ideal

to the public that the plan is humane, or. . . that it is

decidedly in the public interest. . . . The point is that the

public must be induced to share the rationale which itself

must be simple and straightforward . . . . (Webster 1986

p. 134)

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In a real sense, Webster (1986) and Hatam (1985) argue that civil

commitment can be justified where the level of risk to the society at

large, as posed by a health-care issue, is of such magnitude as to

warrant a use of social control or quarantinelike strategies. For

Webster, that risk is posed to societal maintenance; for Hatam, that

risk is posed to societal progress.

In fact, the laws of a substantial proportion of countries provide for

civil commitment procedures. Of 43 countries surveyed by Porter et

al. (1986a), 27 provide for civil commitment under selected conditions.

In addition, 47 countries are parties to the 1971 Convention on

Psychotropic Substances, a treaty which holds, in part, that each

government may mandate treatment either as an alternative to

conviction or punishment or in addition to conviction or punishment

(Noll 1977).

GROUNDS FOR COMMITMENT

The rationales used to implement civil commitment procedures differ

markedly and are associated with their legislative bases—whether they

are included under mental health legislation or under legislation

specific to drug abuse. In general, civil commitment under mental

health legislation requires evidence of psychiatric impairment

involving (1) threat to others; and/or (2) threat to self; and/or

(3) inability to care for oneself. Countries with mental health civil

commitment legislation are likely to include provision for commitment

both for threats to others and to self. In this regard, German,

Japanese, and Somalian laws provide for civil commitment where the

drug-related disorder constitutes an imminent threat to public safety

or where the individual poses a danger to his/her own life and

health. Other countries operating under mental health legislation

specify only the existence of psychiatric disturbance without elaboration of threat (Bangladesh) or emphasize the individual’s inability to

provide for himself/herself and the need for supervision (Trinidad and

Tobago).

Where civil commitment is covered under legislation specific to drug

use, as is the case in 15 of the 43 countries surveyed by Porter

et al. (1986a), the rationale for civil commitment can be limited to

evidence of dependence or addiction (Mexico, Columbia, Peru,

Thailand, and Malaysia) or may include reference to the threat posed

to others and/or to the need for treatment (Argentina, Italy,

Australia, and Sweden).

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of the 15 countries with drug legislation, 11 also use mandatory

reporting of drugdependent persons (Porter et al. 1986b). In 10

countries, responsibility for reporting is vested in medical or law

enforcement personnel and, in one instance (Burma), the individual is

required to report himself/herself to the authorities.

Registration has several purposes. In Burma, a self-reported addict

can be remanded to the nearest medical treatment center. After

treatment, that person’s name may be removed from the central

registry. Registration in Hong Kong is used as an epidemiologic

device and as a means for evaluating the government’s treatment

programs. Thus, Hong Kong’s registry is used to monitor trends in

drug use and in the characteristics of the drug-using population, as

well as treatment reentry and the individual’s functioning at time of

government agency contact. Columbia’s national registry is used to

chart trends in illicit drug traffic throughout the country, while

Pakistan’s registry was actually used, in part, to provide opium to a

portion of the addict population. Specifically, opium addicts, 25 years

of age and older, could obtain opium ration cards from the Civil

Surgeon of Karachi, Pakistan, entitling them to purchase opium for

personal use from their locally authorized opium vendor.

WHO REQUESTS CML COMMITMENT FOR DRUG ABUSE?

Civil commitment applications may be made by the following 5 groups

in the 27 countries identified by Porter et al. (1986a) as providing

civil commitment:

(1) Family or community members, i.e., “significant others,” were

frequently cited. These individuals typically include spouse or

near relatives but may extend to a business partner (Australia),

to members of the worker’s collective (Hungary and the Russian

Soviet Federal Socialist Republic of the U.S.S.R.), or to any

person in the community when the individual creates a disturb

ance for his/her neighbors (Argentina).

(2) Private or public health-care providers may be required to

advise the government of known drug-dependent persons. In

Mexico, for example, the physician must report cases of drug

addiction to the Ministry of Health and Welfare within 8 days of

seeing the individual.

195
(3)

(4)

(5)

Social service agencies may also have responsibility for implementing civil commitment processes. In Malaysia, a social

welfare officer may apprehend an individual suspected of drug

dependence. However, they must then present that person to

the local magistrate within 24 hours.

The drug-addicted individual may also apply for civil

commitment.

Law enforcement agencies or governmental authorities are

frequently empowered to initiate civil commitment procedures.

In some instances, the police officer must be of comparatively

high rank to institute procedures (Australia and Malaysia): in

others, power is vested in the public prosecutor (Hungary) or a

comparable legal authority (Japan).

Frequently, of course, countries provide more than a single. method

for the initiation into civil commitment procedures.

REVIEW AUTHORITIES

There are three types of review authorities which decide if there are

sufficient grounds to justify civil commitment. Again, different

authorities frequently act in concert.

(1)

(2)

Courts are typically given the primary responsibility for

determining appropriateness of civil commitment procedures.

Argentina provides for defense counsel to make certain that no

other provision for care can appropriately be made for the

addict and, if commitment is ordered, to make certain that

commitment is not for any longer than “absolutely necessary.”

In Nova Scotia, a justice of the peace or police magistrate may

remand the addict to detention and treatment in any hospital,

jail, or place of detention in the Province.

An existing governmental agency or a specially created governmental agency may be assigned jurisdiction over civil commitment practices. In Burma, the Drug Addicts Registration and

Medical Treatment Supervision Board has been constituted to

oversee the compulsory treatment of addicted persons. In Japan,

the governor of the jurisdiction exercises that responsibility,

and in Singapore the Director of the Central Narcotics Bureau

acts in cases of civil commitment.

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(3) In some instances, the reviewing authority is a medical agency

acting alone. In Mexico, the Ministry of Health and Welfare

may require drug treatment; in Tunisia, authority is vested in

the Commission on Drug Dependence, a board of three physicians acting on behalf of that nation’s Secretary of State for

Public Health.

In 24 of the 27 countries with compulsory civil commitment, medical

examinations were required. In several instances, those examinations

need not, by law, include medical personnel but do need to involve an

appraisal of the individual’s condition. In some instances, second and

even third medical opinions are required (Australia and British

Columbia).

TREATMENT PROGRAMMING

Treatment methods or requirements may be stated in law and/or in

ministerial regulation and directives. As might be expected, the

specifics of treatment selection and administration are the responsibilities of local treatment agencies and authorities. Nonetheless, the

law may specify the existence of inpatient, residential, and outpatient

facilities (Australia); institutionalization (Hungary): or may specify

institutionalization only if outpatient treatment is unsuccessful (Italy

and Iraq).

In terms of treatment services, some legislation provides for a

comparatively wide range of treatment activities by naming the

services to be provided. For example, Thai law provides for education, training, aftercare, and social reintegration as part of the

rehabilitative process. German (Hamburg) law includes medical and

psychosocial counseling, aftercare, social welfare assistance, and

medical services. Finnish law provides for individual counseling,

family counseling, medical services, continuing surveillance, and an

elaborate program of aftercare. The aftercare program includes, in

part, contact with prosocial companions, developing prosocial leisure

pursuits, and providing housing and job assistance.

Most statutes are considerably less explicit in describing treatment

services. Some specify detoxification only (Tunisia and Singapore) or

detoxification and unspecified rehabilitative services (Peru). Others

vaguely refer to services in such terms as rehabilitation or medical

care (Indonesia and Burma), while still others stipulate the process

for individuals to get treatment. For example, Malaysian law

specifies that the magistrate may order the individual to a

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rehabilitation center for a period of 6 months or to community

supervision by a social welfare officer for 2 years. In some

instances, laws provide broad outlines for treatment services and

clarify responsibility for the provision of services, e.g., Mexican law

gives to the Ministry of Health and Welfare responsibility for the

development and promulgation of treatment standards, issuance and

dissemination of a directory of drug abuse treatment facilities, and

consultation regarding referral to treatment programs, etc.

In other instances, statutes specifying treatment reflect societal

concerns or values that go beyond the immediate issue of drug abuse.

Hungarian law stipulates that, during treatment, the institutionalized

person will forego rights and obligations associated with membership

in the workers cooperative. Additional language specifies that the

individual will be assigned appropriate work within the institution and

may be coerced to work but must be remunerated for that work.

Swedish law provides that care must be based on respect for the

individual’s self-determination and privacy and must, as far as

possible, be planned and conducted in partnership with the individual.

LENGTH OF STAY

Laws governing the length of time an individual can be held in

treatment vary dramatically. Several countries set maximum periods

for stay, frequently with provision for an additional period contingent

on behavior in treatment—but again with a specified time limit. At

one end of the continuum, Australia provides for 7 days, with the

medical officer capable of adding an additional 7 days. German

(Hamburg) law provides for a stay of up to 1 year. Finnish law

provides for a stay of up to 1 year, unless the individual has been in

treatment during the preceding 3 years, in which case he/she may be

detained for 2 years. Hungarian law provides a maximum of 2 years.

Russian law (Russian Soviet Federal Socialist Republic of U.S.S.R.)

provides for detention for up to 10 years, with the capacity to add

up to 1 additional year if it is determined that treatment has been

evaded. Swiss law provides for commitment of drug abusers for up to

3 years and for the alcoholic until such time as he/she is no longer a

threat to the community. Malaysian, Thai, and Singaporean laws,

often seen as comparatively restrictive, each provide for up to 6

months detention, with additional periods of 6 months each. In

Singapore, 6-month periods of detention may be added to reach a

combined maximum of 3 years. Of the 15 countries with civil

commitment legislation specific to drug abuse, 8 do not specify the

length of stay.

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REVIEW PROCESS

Periodic reviews of individuals’ functioning while committed may be

provided by specially constructed review bodies, or by existing (and

typically judicial) review bodies. In Japan, the Narcotic Addiction

Examination committee is empowered to recommend to the governor

of the jurisdiction shorter or increased hospital stay. In Singapore,

the Director of the Central Narcotics Bureau or the specially

appointed institutional treatment review committee may discharge or

transfer detainees. In Thailand, the Secretary General of the

Narcotics Control Board determines whether an additional period of

commitment beyond the initial 6 months is required. In the Soviet

Union, Germany, and the United States, courts are empowered to

conduct reviews.

Review Procedures may be automatic at certain time intervals (every

6 months in Bavaria and every 3 months in Italy) and/or they may be

instituted after submission of a request by the detainee, concerned

relatives (Norway and United States), or by the treatment program

director (British Columbia, Canada). Again, in most instances, there

is no provision for periodic review of the detainee. In 8 of the 15

countries with drug abuse civil commitment procedures, there is no

provision for periodic review, according to data from Porter et al.

(1986a).

Of the 32 governmental jurisdictions in 27 countries with provisions

for civil commitment under legislation governing mental health or

substance abuse issues, 9 make no provision for length of detention,

appeal, or review procedures.

DISCHARGE FROM COMMITMENT

Discharge is based on the period of commitment coming to an end or

on treatment conclusion. The latter instance may involve referral to

the courts or other government agencies or officials or may be taken

by the treatment provider independently. Thus, in Italy, the treatment center may advise the court that an individual no longer needs

treatment, and the individual is released. In Iraq, the psychiatrist in

charge of a case may discharge an individual at any suitable time. In

Norway and Australia, only the medical superintendent decides on the

individual’s release. In some instances, provision is made for

continued community supervision. In Malaysia, individuals are

supervised by the social welfare officer for 2 years. If the individual

fails to comply with all supervision requirements, he/she can be

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recalled to treatment. If the individual does not then return

voluntarily, he/she can be arrested and returned for a period up to 8

months. In Switzerland, supervision may extend for 2 years. In

Finland, individuals may be discharged prior to the 1-year period

provided in Finland’s civil commitment legislation; however, surveillance is also provided for 1 additional year or longer if deemed

appropriate. Moreover, if the individual under surveillance continues

to use illicit drugs, he/she Can then be returned to treatment for the

remainder of the year originally assigned.

Again, 5 of the 15 countries with civiI commitment legislation specific

to drug abuse are mute on the issue of discharge procedures. In

addition, the same 9 of 32 governmental jurisdictions make no

provision either for length of stay, appeal, review procedures, or

discharge procedures.

Porter et al. (1986a), reporting on behalf of the World Health

Organization (WHO), made the following recommendations to member

nations regarding civil commitment:

(1)

(2)

(3)

(4)

persons in need Of short-term emergency commitment for

incapacitation due to drug dependence should be immediately

released from detention on completion of treatment, i.e., of

detoxification;

“Compulsory civil commitment (for other than emergency Care) is

justified Only when an effective treatment programme, as well as

adequate and humane facilities, are available”;

“the period of confinement should be limited . . . and a person’s

involuntary status subject to periodic review”;

“the person concerned should be afforded certain substantive and

procedural rights during the commitment proceedings,” e.g.,

“timely judicial hearing . . . counsel . . . a standard of proof,”

etc.

Porter et al. (1986a) also recommended that the civil commitment

process and associated treatment programming be a subject for action

by the relevant WHO interministerial coordinating committee.

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EFFICACY OF CIVIL COMMITMENT PROCEDURES

One can argue that the widespread use of drug abuse civil commitment procedures represents an expression of considerable confidence

in treatment programming. By focusing our treatment expertise, a

significant impact can be made on a country’s drug abuse problem.

Admittedly, other explanations are possible. Civil commitment

procedures may also be a strategy for reducing pressure of the

judicial system and correctional facilities, while guaranteeing the

continuing surveillance of individuals who constitute some level of

threat to the community. Nevertheless, the emphasis on treatment

demands an effort to assess the efficacy of treatment services

provided under civil commitment. Unfortunately, such study, in terms

of the several countries providing for civil commitment, is almost

unknown; Most are content to maintain records of admissions,

dropouts, and periods of retention (Anti Dadah Task Force 1985;

Narcotics Control Board 1984). Others report data which are largely,

or solely, anecdotal in nature.

Babaian (1979) describes the virtual eradication of drug abuse in the

Soviet Union following the October Revolution. He reports that

cocaine and other drugs were widely used in major cities while opium

smoking was common in Central Asian regions of the U.S.S.R. under

czarist rule. He ascribes the disappearance of drug abuse largely to

the creation of new social conditions after the Revolution. In

addition, he believes that the imposition of severe penalties for

lawbreaking related to preparing, selling, or using narcotic drugs was

probably useful. When addicts are discovered in the Soviet Union,

they must be registered immediately and then are divided into those

who may be treated voluntarily and those who will need to be treated

against their will. The first stage of treatment is a period of at

least 60 days inhospital care followed by an extensive period of

outpatient care using a complex of “narcological” services. The

capacity to rehabilitate even unwilling addicts is viewed by Babaian

(1979) as essential to his country’s progress in this area.

In a similar fashion, Marek and Redo (1978) argue that compulsory

drug abuse treatment has given very positive results in Poland. They

cite a Polish-language study that suggests 3 months of treatment as

sufficient. In Poland, as in several countries, compulsory treatment

may also be provided in a correctional facility. The authors emphasize the use of a drug abuse program. They also place reliance on

treatment and rehabilitation rather than punishment. Although they

do not cite treatment effectiveness data, the authors present survey

201
and estimate data regarding drug abuse in Poland and cite Polish

language journals which report treatment effectiveness.

Reports of the efficacy of restrictive programming in containing drug

use routinely cite the actions taken by Japan and by the People’s

Republic of China. Bejerot (1983), McGlothlin (1980), Morimoto

(1957), and Nagahama (1968) all report on the national campaign

organized in Japan to contain that country’s postwar epidemic of

amphetamine abuse. lt was estimated that perhaps 2 million Japanese

were involved in amphetamine abuse, with about a quarter of those

using amphetamines intravenously. Harsh penalties were imposed: 3

to 6 months for possession of amphetamines, 1 to 3 years for drug

sales, and 5 years for illicitly producing amphetamines. After the

program was initiated, arrests for amphetamine offenses dropped from

56,000 to 271 in 4 years (1954 to 1958), and the epidemic was

effectively over. McGlothlin (1980) suggests that the Japanese

situation points out the success of a country’s restrictive policy in a

situation involving intensive public education, a homogenous population, and a culture with a tradition of regard for authority. Similarly, Bejerot (1983) points to broad political agreement on the

wisdom of the Japanese drug policy.

In China’s anti-opium campaign (Lowinger 1977), efforts were made to

link that campaign to other popular reforms, notably land reform and

the growing of much needed food crops. In addition, the opium

importer was characterized as an enemy of the people, i.e., of the

State. The importing of opium was described as an imperialist

approach to destroying the Chinese nation. Massive educational

programs were organized involving 1-hour-a-day discussions which

linked political and health topics and concluded that those topics

were of national consequence. Specifically, on June 3, 1951, AntiOpium Day was proclaimed in Canton, and over 10,000 persons

assembled in a mass meeting. In conjunction with the suppression of

opium growing, compulsory registration of opium addicts began, as did

the treatment of opium addicts in urban areas. In rural areas, the

treatment was reportedly self-imposed detoxification. Harsh penalties

were reserved for individuals identified as major dealers; much lighter

penalties were assessed for lower level members of opium manufacturing and distribution gangs.

The Chinese action is usually described as demonstrating the adoption

of a popular restrictive drug abuse program as part of a well orchestrated uprising against opium use, where that opium use was characterized as a pernicious problem serving foreign interests. In this

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assessment, the drug abuse policy was part of a larger political action

that demanded both individual and national commitment. As in Japan,

the goals were achieved in a remarkably short period of time, largely

between 1951 and 1953, and in a country with a 300-year history of

opium smoking and a population of 20 million opium smokers at the

campaign’s inception.

McGlothlin (1980) provides the most rigorous analysis of the impact

of a restrictive national policy directed against drug abuse.

McGlothlin also points to the characterization of threat posed by

drug abuse to the larger society—in this instance to the city-state of

Singapore. A heroin epidemic affecting that country’s youth was used

to marshal public support for Singapore’s antidrug program.

Singapore’s newly found prosperity was dependent on maintaining a

fully employed workforce. The heroin epidemic among young men

made drastic governmental action both acceptable and necessary. In

about a 3-year period (1974 to 1977), it was estimated that 3 percent

of Singapore’s young male population had become involved in smoking

heroin. Further, it was expected that those figures would continue

to grow rapidly. In 1977, the Singapore government established an

enforcement policy relying heavily on the commitment of opiate users

to the city-state’s newly created Drug Rehabilitation Centers.

The Singapore effort included an existing law that provided for a 6-

month commitment, without trial, for individuals with urines positive

for any illicit drugs. With the advent of a heroin-smoking epidemic,

the law was amended to permit the death penalty for major drug

traffickers, to create a registry of heroin users, and to open six

rehabilitation centers. Most important to the Singapore effort was

Operation Ferret, which was initiated in 1977. That effort involved

the arrest of large numbers of suspected heroin users. Urine

specimens were obtained, and arrestees who tested positive were

forcibly referred to rehabilitation centers.

McGlothlin (1980) reports that nearly 20,000 people were arrested and

directed to give urine specimens during the first 9 months of

Operation Ferret. He also indicates that 40 percent were found

positive for drugs, overwhelmingly heroin, and those found to be

positive were sent to rehabilitation centers for 6-month periods. The

goals for this dramatic action were to slow the spread of heroin

smoking through the youthful population and to modify the behavior

of persons already invested in heroin smoking.

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The treatment approach, as described by McGlothlin, consisted of cold

turkey withdrawal efforts to instill discipline in terms of work behavior, as well as an exercise and a personal care regimen: education

regarding the individual’s responsibilities to society and about the

evils of drug use; schooling and job training as warranted: and

religious and personal counseling. In addition, a 2-year period of

compulsory supervision after discharge from the rehabilitation center

was required. That supervision involved urine testing and visits to

home and work, as well as some limited counseling (up to 10 minutes

each visit).

McGlothlin concludes that using the adopted measures achieved the

objective of arresting the Singapore epidemic. The number of

commitments to rehabilitation centers dropped from 700 cases a

month in 1977 to under 200 a month in 1979, while new users were

being added to the registry at a much lower rate than had been the

case earlier. Relapse, l-year posttreatment, as measured by returns

to treatment and/or convictions, was found to be 37 percent.

McGlothlin reasons that the success of the Singapore program was

due to three factors. First, the program could be sold to the public,

and was in fact heavily marketed, as an effort to protect and

guarantee the country’s economic prosperity. The heroin epidemic

among youth threatened to remove from the workforce the very

persons on whom Singapore’s continued prosperity depended. Second,

Singapore’s size made police activity and surveillance both feasible

and effective. As a city-state, there was permitted a greater

cooperation of enforcement agencies than might be possible in a

larger geographic area. Finally, the government in power had more

than 15 years of popular administration by the time a drug crisis was

recognized and, in McGlothin’s words, had established “one of the

most closely regulated societies in South East Asia” (McGlothlin 1980

p. 12).

While McGlothlin takes care to relate the utility of civil commitment

measures to the political climate and geography of the area affected,

one may take some issue with the degree of success reportedly

achieved in Singapore, at least insofar as that success is interpreted

from the decrease in cases referred to treatment. The diminution in

cases referred to rehabilitation centers, even assuming the same

aggressive zeal attached to Operation Ferret 2 years after its

initiation, must be understood in terms of the high level of success

likely with a new operation involving, in significant part, a

“creaming” of naive addicts. Certainly, any new operation of this

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type can be presumed to enjoy a greater degree of success in its

beginning stages than it will even a short time later. Thus, it is

impossible to know to what extent the reduced rate of treatment

referral reflects reduced use of heroin, as opposed to an increased

capacity to use heroin covertly. Similarly, a relapse rate of 37

percent, while again suggesting success of the commitment/surveillance program, must be interpreted with some caution, since the only

outcome data available to McGlothlin were returns to treatment or

convictions. While the close supervision of rehabilitation center

releasees argues for the accuracy of those figures, McGlothlin himself

raises the specter of a switching to other drugs not tested (as of

1979) in supervisees’ urine specimens. One can again posit that

heroin users also became more expert at hiding their drug use from

the authorities.

Nonetheless, while arguing about the degree of success, it seems clear

that civil commitment and related enforcement practices in Singapore

achieved the desired goal of containing the heroin crisis. That is,

the procedures achieved the societal objective of permitting

Singapore’s continued economic growth and prosperity. Again, civil

commitment was justified as necessary to the well-functioning of the

society. A health issue could be seen as carrying a threat sufficient

to demand social-control behaviors.

THE SPECIAL CASE OF AIDS

In that context, it is interesting to consider Connell’s address to the

Annual Meeting of the Society for the Study of Addiction, in London,

in November 1985 (Connell 1986). Connell notes the opportunities

available to manage and treat addiction problems in the United

Kingdom, but raises, as a potential and dramatic threat to British

efforts, the likely emergence of AIDS in the United Kingdom.

Connell himself makes no mention of civil commitment or of any

policy initiative in relation to AIDS. It is, for Connell, simply an

issue about which his colleagues should be aware. Nonetheless, we

can raise the question as to whether AIDS has the potential to

encourage civil commitment practices directed toward intravenous

drug users in at least some parts of the world. Given that AIDS is a

lethal disease spread, in significant part, through the sharing of

needles by intravenous drug users, there would certainly appear to be

potential for marshaling public support in response to a clear and

dramatic health risk. Moreover, it can be argued that the risk of

AIDS will not stay long and, indeed, is not staying exclusively in

traditionally pariah populations, e.g., gays and drug users. Again, at

205
least in the United States, AIDS has edged its way into the heterosexual population, and, to the extent it has, the origins of the

disease have been largely traceable to the sexual activity of addicts.

Similarly, the intravenous drug user has been viewed as largely

responsible for cases of pediatric AIDS. There are, of course, many

constraints on national policy and behavior in relationship to any

threat, including that posed by AIDS. Certainly one such constraint

is that the health risk is not viewed as of sufficient moment to

society or, if one will, to the heterosexual society, to warrant socialcontrol measures. lf that threat increases, given the availability of

commitment procedures specific to a population many feel they

already have reason to disparage, civil commitment may become a

policy for serious consideration.

CONDITIONS NECESSARY TO IMPLEMENT CIVIL COMMITMENT

In summary, the conditions that follow have been described as

necessary to implement civil commitment procedures.

First, and perhaps foremost, there needs to be the appearance of

major risk to the larger society by virtue of a subgroup’s inappropriate behavior.

There needs to be the capacity to marshal significant public

support for (or, at worst, neutralize public opposition to)

containing those behaviors.

There must be a capacity and/or a technology to identify and to

isolate the subgroup with the offending behaviors.

The offending subgroup must be without sufficient political support

or capability to mount a competing political pressure on its own

behalf.

Mechanisms must be available to process, detain, and confine

individuals whose behaviors can be seen to be inappropriate and

threatening.

Finally, there should be a belief in the community’s ability to

develop initiatives that will humanely change individuals’ behavior

for their own and for society’s well-being.

206
REFERENCES

Anti Dadah Task Force. Malaysia Country Report. Thirty-first

session of the United Nations Commission on Narcotic Drugs.

Vienna, Austria: Government of Malaysia, February 1985. 29 pp.

Babaian, E.A. Control of narcotic substances and prevention of

addiction in the U.S.S.R. Bull Narc: 31:13-22, 1979.

Bejerot, N. Prevention and control of drug abuse epidemics.

Presented at the annual drug conference of the National Parents

Resources Institute for Drug Education (PRIDE), Atlanta, GA, 1963.

11 pp.

Connell, P.H. ‘I need heroin.’ Thirty years experience of drug

dependence and of the medical challenges at local, national,

international and political levels. What next? Br J Addict 881:461-

472, 1986.

Hatam, Mussa. Presentation to the U.S. State Department. Kuala

Lumpur, Malaysia, April 1985.

Lowinger, P. The solution to narcotic addiction in the People’s

Republic of China. Am J Drug Alcohol Abuse 4:165-178, 1977.

Marek, A., and Redo, S. Drug abuse in Poland. Bull Narc 30:43-53,

1978.

McGlothlin, W.H. The Singapore heroin control programme. Bull

Narc 22:1-14, 1980.

Morimoto, K. The problem of abuse of amphetamines in Japan. Bull

Narc 9:8-12, 1957.

Nagahama, M. A review of drug abuse and countermeasures In Japan

since World War II. Bull Narc 20:19-24, 1968.

Narcotics Control Board. Treatment and Rehabilitation of Drug

Dependents in Thailand. Bangkok, Thailand: Government of

Thailand, 1964. 33 pp.

Nell, A. Drug abuse and penal provisions of the international drug

control treaties. Bull Narc 29:41-57, 1977.

Porter, L.; Arif, A.E.; and Curran, W.J. The Law and the Treatment

of Drug end Alcohol Dependent Persons—A Comparative Study of

Existing Legislation. Geneva, Switzerland: World Health

Organization, 1986a. 216 pp.

Porter, L; Curran, W.J.; and Arif, A. Comparative review of

reporting and registration legislation for treatment of drug and

alcohol dependent persons. Int J Law Psychiatry 8:217-227, 1986b.

Van Bilsen, H.P.J.G., and van Ernst, A.J. Heroin addiction and

motivational milieu therapy. Int J Addict 21:707-713, 1986.

van de Wijngarrt, G.F. Heroin addiction in the Netherlands. Am J

Drug Alcohol Abuse 14:125-136, 1988.

207
Webster, C.D. Compulsory treatment of narcotic addiction. lnt J

Law Psychiatry 8:133-159.1986.

AUTHOR

Barry S. Brown, Ph.D.

Chief, Treatment and Early

Intervention Research Branch

Addiction Research Center

Box 5180

Baltimore, MD 21224

208
The Costs of Crime and the Benefits

of Drug Abuse Treatment: A CostBenefit Analysis Using TOPS Data

Henrick J. Harwood, Robert L. Hubbard,

James J. Collins, and J. Valley Rachal

INTRODUCTION

The toll of drug abuse on society is high, both in social and

economic terms. Despite increases in Federal and State budgets, the

public resources for addressing the problems of drug abuse are still

limited. To reduce the high cost of drug abuse, available resources

must be allocated for cost-effective public efforts. Allocation of

resources requires careful consideration of the probable costs and

benefits of alternative public efforts to address the problems. One of

the principal efforts to reduce the social cost of drug abuse, particularly the costs attributed to crime, is drug abuse treatment. This

paper uses data from the Treatment Outcome Prospective Study

(TOPS) to assess the benefits of crime reduction attributable to drug

abuse treatment (Hubbard et al. 1984b).

ECONOMIC lMPACT OF DRUG ABUSE

Until recently, the major perceived economic cost of drug abuse was

the criminal activity ostensibly motivated by the high cost of

addiction to heroin and other expensive drugs. The extensive and

still growing literature on the drug/crime link (Gandossy et al. 1980;

Ball et al. 1980; Chaiken and Chaiken 1982; Collins et al. 1985;

Gropper 1984; Johnston et al. 1985) has spawned a literature on the

economic costs to society of drug-related crime (Harwood et al. 1984;

Cruze et al. 1981; Rufener et al. 1977; Goldman 1978; Lemkau et al.

1974; Arthur D. Little Company 1974).

The most recent economic-cost study (Harwood et al. 1984) found

that Crime-related costs of $18.343 billion were a major part of the

estimated $47 billion total cost to society of drug abuse (table 1).

209
Most of the crime-related costs ($10.2 billion) were attributable to

the loss of criminals’ potential legitimate productive activity and to

the cost of incarceration. Federal drug traffic control efforts totaled

$537 million, and other criminal justice system (CJS) expenditures

were $4.5 billion. Victim losses from property damage, lost productivity, and homicide were $1.8 billion, and private protection services

were $1.3 billion.

TABLE 1. Economic costs of drug abuse—1980

Costs of Drug Abuse Value

(dollars in millions)

Crime-Related Costs

Federal Drug Interdiction $537

Other Drug-Trafficking CJS 2,178

Other Drug-Related Crime CJS 2,276

Private Protection Services 1,297

Private Legal Services 48

Property Damage 111

Victim (Lost Productivity) 919

Homicide (Lost Productivity) 786

Incarceration of Criminals 1,466

Crime Career 8.725

Subtotal 18,343

Other Costs

Drug Abuse Treatment 1,200

Other Health Support Services 243

Drug Overdose Deaths 1,194

Reduced Workforce Productivity 25,716

Lost Employment 238

Subtotal 28,591

Total 46,936

SOURCE: Harwood et al. 1984.

210
Most of the non-crime-related costs were from reduced productivity

in the workforce ($25.7 billion). Other large costs were $1.2 billion

for drug abuse treatment and $243 million for other health

expenditures including education, prevention, and research.

PERSPECTlVES ON SOCIAL COST

The methodology used to estimate the social cost requires the use of

an accepted economic framework. Alternative perspectives on the

role of other factors (expenditures on illegal drugs, the value of

stolen property, and nonpecuniary effects of crime) need to be

carefully considered.

Expenditures on illegal drugs and the value of property stolen by

drug abusers are not included in the $47 billion calculation. Estimates of the retail value of illegal drugs consumed in 1979 range

from $21 billion to $65 billion (U.S. Department of the Treasury,

Internal Revenue Service 1983). The 1980 National Victimization

Survey (U.S. Department of Justice, Bureau of Justice Statistics 1984)

estimated that $7.3 billion was stolen from all individuals in 1980.

The study by Harwood et al. (1984) estimated that $1.5 billion of the

$7.3 billion could be attributed to thefts by drug addicts. These

values are excluded from the total crime cost estimate to avoid

double counting.

The issue of double counting drug expenditures and the income used

to purchase the drugs must be handled carefully. These two components are opposite perspectives on the same transaction, and the two

values are equal. Therefore, they should not be added together. Each

of the drug abuse cost studies cited above avoided the double

counting problem by using only the income side of the drug market

ledger in making total cost estimates. However, the problem of

double counting also arises when calculating the value of stolen

property. When property is stolen, it is, in effect, involuntarily

transferred from a law-abiding citizen to a criminal. While there is a

loss to the victim, the criminal gains. Therefore, there is no net loss

to society. Both the value of stolen property and how much is lost

in legitimate productivity can also be estimated. These two components, however, are not necessarily equal in value and should not be

added together.

It is also widely recognized that crime exacts a greater toll from

society than is typically measured in monetary terms. The lives of

victims, their families, friends, and neighbors are all disrupted by

211
fear, shock, pain, and suffering. Articles stolen may have value to

the victims far beyond the “market price” of a replacement or the

value of the stolen Rem on the street. Although quite real, these

dimensions of crime are excluded from consideration in this study (as

they are in virtually all studies on the economics of crime) because

dollar amounts for their values cannot be estimated.

OBJECTIVES OF THE CURRENT STUDY

The major objective of this study is to estimate the economic

benefits of drug abuse treatment in reducing criminal activity of drug

abusers during and after treatment. The study also examines whether

clients referred to treatment from the CJS demonstrate reduced crime

costs during the year following treatment discharge.

This chapter describes the methodology used to calculate the costs

and benefits in the established cost-of-illness economic framework.

Next, these methodologies are used to calculate costs in the periods

before, during, and after treatment for clients participating in TOPS.

Specifically, the costs of drug abuse treatment are compared with the

savings of lower crime rates. The primary comparison is between the

average cost of providing a day of treatment and the reduction in

crime-related costs during the year following discharge from treatment. In addition to these basic descriptive tabulations comparing

criminal activity costs before, during, and after treatment, the

posttreatment economic benefits have been estimated using multivariate regression analysis.

METHODOLOGY

The following sections describe: (1) the data base used to calculate

the crime-related costs and benefits; (2) the methodologies used for

the calculations; and (3) the potential effects of the quality of the

self-report data.

Data Base

TOPS is a longitudinal survey with data on over 11,000 drug abusers

admitted to 41 different treatment programs in 10 different cities

across the nation. TOPS has been described in detail in Hubbard et

al. (1984b). The programs included the major treatment modalities

(outpatient methadone, residential, and outpatient drug free).

Information from clients and program records was obtained to

indicate whether a client was referred to treatment from the criminal

212
justice system. Records were also checked to determine how long

clients stayed in treatment.

All participating clients were interviewed at admission to treatment

and during the period of time they received treatment services from

the participating TOPS program. Samples of clients were selected for

followup interviews at 3 months, 12 months, or 24 months following

discharge from treatment. Another sample was reinterviewed 3 to 5

years following admission to treatment. Most of the analyses

reported here are based on the 12-month followup sample of clients,

although some analysis has been done on the 24-month and 3- to 5-

year samples.

The TOPS data base is used for this analysis because it includes

detailed information about clients’ criminal activity and involvement

with the CJS. Self-reports were obtained of aggravated assault,

robbery, burglary, theft, auto theft, forgery/embezzlement, fencing,

gambling, pimping/prostitution, and drug sales or manufacturing. The

data covered the 12 months preceding the admission, each 3-month

period during treatment, and the specified periods after treatment

termination. The respondents were asked whether they were involved

in the illegal activity in each time period and, if so, how many times

they did the act. Other important information from the interview

was the number of arrests (by type of offense) and days spent in jail

or prison in each period.

In addition, respondents were asked about their income from “illegal

or possibly illegal sources, such as hustling or dealing,” and the

amount received. Other questions concerned income from a legitimate

job or business, various public assistance programs, family or friends,

and expenditures on illicit drugs.

Calculations for Components of Social cost of Drug-Related Crime

This study used the cost framework and methodology developed by

Harwood et al. (1984). In that methodology, the cost components are

the tangible consequences of drug abuse that can be assigned dollar

values. Values were estimated for three explicit kinds of drugrelated crime costs: victim costs, CJS costs, and crime career/

productivity costs.

Victim Costs: the value of medical services, property destruction,

and lost work and household productivity.

213
CJS Costs: the cost of police protection services, prosecution,

adjudication, public defense, and corrections services.

Crime Career/Productivity Losses: the value of legitimate

productivity lost because individuals pursued income through

predatory or consensual crime.

Each of these types of crime-related impacts or costs involves a loss

of resources to the detriment of society’s economic well-being.

Victim costs from crime include the expense of medical treatment,

the value of personal property damaged or destroyed in the crime,

victim loss of productivity at work or in the home because of injury

or simple inconvenience, and the value of the stolen property.

Crime career/productivity costs include the loss of legitimate

productivity when criminals never enter the economy or when they

leave it for illegal pursuits such as burglary, theft, drug trafficking,

prostitution, or gambling. Such costs also include incarceration costs

for drug-related crimes and the loss of opportunity to participate in

the legitimate economy.

This study has calculated the value of these costs for the year before

admission, the period in treatment, and the appropriate followup year

for each drug abuser admitted to treatment. These values were

estimated by assignlng average values (costs) to each criminal act the

client reported in the interview. Estimates of victim costs per crime

(by type of crime) are baaed on the 1979 National Victimization

Survey (U.S. Department of Justice, Bureau of Justice Statistics 1983).

These average values for medical costs, property damage, loss of

productive time, and value of property stolen are in table 2.

CJS costs per crime were calculated for police services, adjudication,

and incarceration. Police costs per act were based on an average

police cost per arrest in 1979 and adjusted by the probability that a

type of crime will result in an arrest. In 1979, total police expenditures In the United States were $17 billion (U.S. Department of

Justice, Bureau of Justice Statistics 1981). This value, divided by the

10 million arrests in 1979 (U.S. Department of Justice, Federal Bureau

of investigation 1981), indicates average police expenditures of $1,700

per arrest.

Although only a fraction of offenses result in arrests, police incur

costs for every offense they are required to investigate. Therefore,

the police investigation costs are averaged across the number of

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TABLE 2. Costs to victims per offense

Type of Offense Type of Cost

(dollars per victimization)

Property Property

Employment Stolen

Aggravated Assault $210 $80 $150 $0

Robbery 50 20 220 300

Burglary 0 30 140 690

Theft 0 10 110 130

Auto Theft 0 100 160 2,670

SOURCE: U.S. Department of Justice, Bureau of Justice Statistics 1984.

offenses per arrests. For example, the Uniform Crime Reports (UCR)

reported 500,000 arrests for aggravated assault in 1979, while there

were an estimated 4 million assaults according to the National Crime

Survey. Therefore, eight assaults occurred for every arrest for

assault; average police investigation costs were $212 per aggravated

assault (or $1,700 per arrest divided by eight offenses). The results

of these calculations for each offense type are presented in table 3.

Crime career/productivity costs are estimated for each drug abuser by

calculating the difference between the person’s actual self-reported

legitimate earnings and an expected or national average for persons

of the same age and sex estimated by the Bureau of Labor Statistics.

Virtually all drug abusers in this sample had actual earnings below

average, both before and after treatment. The proportional deficit in

expected productivity was also applied to expected fringe benefits and

household productivity.

All values in the following analysis are adjusted for inflation to 1979

dollars, the year of the first TOPS admission cohort.

215
TABLE 3. Police investigation costs

Offense Value

(dollars per

self-reported crime)

Aggravated Assault $290

Robbery 240

Burglary 140

Theft 80

Auto Theft 320

Forgery 110

Fencing 60

Gambling 0.10

Prostitution 0.20

Drug Trafficking 0.20

SOURCE: U.S. Department of Justice, Bureau of Justice Statistics 1984.

Methods of Summarizing Costs

The benefits of treatment can be weighed against the sums of various

cost components rather than a single cost component. Two summary

measures are described below.

(1) Costs to Society: the value of net losses of goods and services

to all of society, including victim losses, CJS costs, and crime

career/productivity losses.

(2) Costs to Law-Abiding Citizens: the sum of victim losses plus

CJS costs, plus the value of theft.

The cost to society includes costs to victims, CJS costs, and crime

career/productivity costs. The value of stolen property is not

included in the cost to society because the loss by law-abiding

citizens is offset by the gain to law-breaking individuals.

The cost to law-abiding citizens includes victim losses, the value of

property stolen, and CJS costs. Crime career/productivity costs are

excluded from this measure because foregone legitimate earnings are

not a loss to law-abiding citizens, but rather a loss to law-breaking

216
citizens and their families. While the concept of the cost to lawabiding citizens has appeal, a more complex calculation could include

factors such as income subsidies received by drug abusers or their

families, taxes, fines, or restitution paid by drug abusers. Because of

the complexity of attributing these costs to criminal activity, these

values have been excluded from this analysis.

Quality of TOPS Self-Reports of Illegal Activity

The quality of the data on criminal activity needs to be carefully

considered in the following analyses. Some clients appeared to

exaggerate their level of criminal activity. Others refused to respond

to the questions. lt was found that a small number of respondents

claimed to have committed 500 or more predatory offenses in a year.

Criminal activity counts of this magnitude were judged to be unrealistically high, although most of the individuals did appear to be

heavily involved in crime. Accordingly, annual activity values for

predatory crimes that were greater than 365 were reduced to 365

(one act per day).

The rate of missing data for the pretreatment illegal activity questions was three to four times as high as the rate on the posttreatment questions. One hundred and eighty-four of the 2,420 clients in

the l-year followup sample refused to answer the entire section on

criminal acts for the pretreatment period, compared to only 67 for

the posttreatment period. Nonresponse to selected items of the

criminal activity section was much higher, although the 3 to 1 ratio

of pretreatment to posttreatment nonresponse was maintained (table

4). Item nonresponse averaged 15 percent for the pretreatment

period (ranging from 10 to 20 percent), and about 4.5 percent for the

posttreatment period (ranging from 3 to 6 percent).

Several alternative approaches to handling nonresponse were

considered. One was to simply exclude any case with missing data.

This approach was rejected because too many cases would have been

lost. Several different procedures for estimating the level of criminal

activity of clients with missing data were also considered. The

results of these imputations are presented in table 5. The low

imputation for a criminal activity item assumes that nonrespondents

were as active on average as those with a valid response (either zero

or greater than zero). The high imputation assumes that nonrespondents were as active as respondents who admitted to any offenses on

that item. The middle imputation is an average of the low and high

imputations. Work by Chaiken and Chaiken (1982) suggests that

217
TABLE 4. Criminal activity in the year before and after treatment

(2,420 clients)

Before Treatment After Treatment

Total Total

Offense Refusals Admissions Acts Refusals Admissions Acts

Assault 283 216 678 78 168 659

Robbery 310 178 2,124 83 120 740

Burglary 320 296 3,096 88 227 3,554

Theft 387 486 13,544 111 325 9,302

Auto Theft 300 98 505 79 91 1,165

Forgery 315 230 3,977 93 136 2,902

Fencing 346 302 8,098 98 218 5,880

Gambling 377 255 23,244 119 215 14,116

Prostitution 329 159 16,935 100 123 15,776

Drugs 537 547 84,315 146 406 54,715

All Items 184 NA NA 67 NA NA

Any of Above NA 1,161 156,576 NA 917 108,809

TABLE 5. Effect of alternative nonresponse imputations for

self-reported criminal activity on selected estimates in

the year after treatment (2,420 clients)

Number of

lllegal Acts

Pre Post

Victim Investigation Value of

Costs Costs Theft

(acts and dollars per person per year)

Pre Post Pre Post Pre Post

Level of Imputation

None 65 45 $1,321 $1,045 $1.382 $1,109 $2,431 $2,890

Low 80 47 1,546 1,089 1,618 1,155 2.819 3,002

Mid 114 55 2,061 1,200 2,229 1,289 3,995 3,333

High 145 67 2,723 1,540 3,034 1,700 5,640 4,832

nonrespondents to criminal activity questions are more likely to have

committed those acts and at a higher rate than those who admit

218
criminal activity. The nonresponse problem suggests that pretreatment costs are likely to be greater underestimates than the posttreatment costs and that costs calculated with crime counts will be

underestimates.

The approach for handling nonresponse, adopted for all calculations in

this report, is to set any missing criminal activity value equal to zero.

This yields conservative estimates of the amount and concomitant

costs of criminal activity committed by our sample. The magnitude of

the nonresponse suggests that values calculated with these data will

underestimate costs, and that pretreatment values are likely to be

greater underestimates than the posttreatment values.

RESULTS AND DlSCUSSlON

Virtually all economic measures show that crime is lower after treatment than before. However, the magnitude of the reduction differs

considerably, depending on the economic measure. Although

the overall effects of drug abuse treatment are important from a

programmatic and public policy perspective, the cost benefits of each

modality and CJS involvement need to be compared.

The definitions of each cost component used in the analysis are

shown in table 6.

Overall Economic Impacts

The initial analyses presented below describe the cost benefits for

clients entering outpatient methadone, residential, and outpatient

drug-free programs. In the year before treatment admission, crimerelated economic costs to society were an average of $15,262 per

client and fell to $14,089 in the year after treatment discharge (table

7). This is a reduction of economic impact of only $1 ,173 per client,

or about 8 percent. Costs to law-abiding citizens fell from $9,190

per client to $7,379 (about 20 percent).

According to self-reported criminal activity, costs to crime victims

fell by about 30 percent (from $1,802 to $1,236), and costs to the CJS

fell by about 24 percent (from $3,926 to $3,049). Partially offsetting

these reductions was a decrease in productivity from $9,534 to $9,804

(about 3 percent). The productivity loss, or crime career costs,

increased slightly even though legal earnings increased from $3,437 to

$3,858. The apparent contradiction arises because drug abusers’

219
earnings did not increase as rapidly as would be expected for nonabusers of the same age. Drug abusers report little improvement in

legal earnings—indicating continued low employment levels.

The 20 percent reduction in costs to law-abiding citizens is composed

of the reductions in costs to victims and the CJS and in the value of

theft from $3,462 to $3,094.

TABLE 6. Definition of terms

Cost Components

Drug Expenditures: the self-reported net amount spent on the

purchase of drugs for one’s own consumption.

Victim Costs: the value of medical services, property destruction,

and lost work and household productivity.

CJS Costs: the cost of police protection services, prosecution,

adjudication, public defense, and corrections services.

Value of Theft: the estimated value of property or money stolen by

the drug abuser.

Illegal Income: the self-reported net dollar amount realized by

criminally active individuals from predatory or consensual crime.

Legal Earnings: the amount earned in legitimate employment.

Crime Career/Productivity Losses: the value of legitimate productivity lost because individuals pursue income through predatory or

consensual crime.

Summary Estimates

Costs to Law-Abiding Citizens: the sum of victim losses plus CJS

costs, plus the value of theft.

Costs to Society: the value of net losses of goods and services to all

of society, including victim losses, CJS costs, and crime

career/productivity losses.

220
The reduction in self-reported illegal income of drug abusers from

$6,937 per year to $2,546 per year is in strong contrast to the

modest improvements estimated above. Furthermore, it was found

that before admission drug abusers spent $6,854 per year (about $19

per day) on drugs (table 7) and in the year after treatment $2,687 (or

about $8 per day). The close correspondence between drug expenditures and illegal income cannot be ignored. They were virtually

TABLE 7. Economic impacts of drug abusers 1 year before treatment

and 1 year after discharge (2,420 clients)

Before After

Treatment Treatment

(dollars (dollars

per person) per person)

Cost Components

Drug Expenditures

Victim

CJS

Value of Theft

Illegal Income

Legal Earnings

Crime Career/Productivity

Losses

Summary Estimates

Costs to Law-Abiding Citizens 9,190 7,379

Costs to Society 15,262 14,089

$6,854 $2,687

1,802 1,236

3,926 3,049

3,462 3,094

6,937 2,546

3,437 3,858

9.534 9,804

identical in each period and declined by similar values and proportions. Similar high correlations between drug use and criminal

activity were also reported by Ball et al. (1980), Collins et al. (1985),

and Johnson et al. (1985).

The inconsistency of our findings on self-reported counts of criminal

acts and on self-reported dollar values needs to be examined. The

values based on criminal act counts reflect only modest reductions in

221
costs between pretreatment and posttreatment, while the self-reported

dollar values indicate major reductions. We considered three reasons

for the apparent inconsistency. First, pretreatment costs may have

been underestimated because of the high nonresponse rate in the

pretreatment period. Second, the illegal income estimate includes

“receipts” from all kinds of illegal activity, not simply predatory

crime. Drug abusers may have reduced involvement in consensual

crime proportionately more than in predatory crime. Finally, drug

abusers may have engaged in less lucrative crimes during the followup

period by stealing smaller amounts or making smaller drug deals in an

attempt to reduce their risk of arrest and incarceration. Resolution

of these issues would require more detailed data in both treatment

outcome studies and ethnographic observations.

Effects of CJS Involvement

Clients referred to drug abuse treatment by the CJS (CJS referrals)

are different than other criminally active but self-referred clients.

One major difference is that the CJS refers clients primarily to

residential and outpatient drug-free treatment. The results of this

section are based solely on clients entering TOPS residential and

outpatient drug-free treatment. The CJS referrals generally cost

society and law-abiding citizens more than the self-referrals in both

the pre- and posttreatment periods. This was largely because CJS

referrals admitted significantly more crimes (and the corresponding

victim, CJS, and theft costs) than the self-referrals.

Clients treated in residential facilities had appreciable reductions in

crime-related economic costs from the year before admission to the

year after discharge. This is true both for individuals referred from

the CJS and for self-referrals. The CJS referrals imposed costs on

law-abiding citizens of $17,392 per year in the 12 months before

admission to the TOPS treatment episode and $10,963 in the year

after discharge, a 35 percent reduction (table 8). In contrast, the

self-referrals had pretreatment costs of $11,123, which fell to $4,641

after discharge, a 60 percent reduction. Although the CJS referrals

reduced their costs by about as much as the self-referrals, the

proportional decrease was smaller due to their greater costs before

intake. The same pattern holds true for changes in costs to society.

In contrast to residential treatment, outpatient drug-free treatment

seems to have relatively small cost-reduction benefits. The CJS

referrals had costs to law-abiding citizens of $4,595 before treatment

and $4,108 after treatment, a reduction of about 11 percent (table 9).

222
The costs for self-referrals actually rose from $4,227 per year before

treatment to $5,343 after treatment. The reductions in costs to

society for both CJS referrals and self-referrals were modest (4

percent and 10 percent, respectively).

The types of individuals entering residential treatment are quite

different from those entering outpatient drug-free treatment. The

residential clients have much higher criminal costs both before and

after treatment than the outpatient drug-free clients. Although the

costs for residential clients improved substantially between the preand posttreatment years, in the year after treatment the residential

TABLE 8. Average economic impacts of drug abusers in the year

before treatment end the year after discharge from

residential treatment by source of referral (2,420

clients)

CJS Criminally Active

Referrals Self-Referred

(dollars per person) (dollars per person)

Before After Before After

Treatment Treatment Treatment Treatment

Cost Components

Drug Expenditures $5,398 $2,666 $7,965 $2,852

Victim 1,2 3,045 1,795 2,968 928

CJS1,2 7,137 4,778 3,550 2,093

Theft17,210 4,392 4,605 1,620

Illegal Income 6,799 3,747 9,932 2,444

Legal Earnings 2,601 2,940 3,056 3,054

Crime Career210,239 10,758 9,852 10,672

Summary Estimates

Costs to Law Abiders 17,392 10,983 11,123 4,841

Costs to Society 20,421 17,329 16,370 13,693

1

The sum of these items equals the costs to law abiders.

2

The sum of these items equals the costs to society.

223
CJS referrals still had significantly higher costs to law-abiding

citizens than the outpatient drug-free CJS referrals had. Selfreferrals in residential treatment had somewhat lower posttreatment

costs than outpatient drug-free self-referrals.

TABLE 9. Average economic impacts of drug abusers in the year

before treatment and the year after discharge from

outpatient drug-free treatment by source of referral

(2,420 clients)

CJS Criminally Active

Referrals Self-Referred

[dollars per person) (dollars per person)

Before After Before After

Treatment Treatment Treatment Treatment

Cost Components

Drug Expenditures

Victim1,2

$1,911 $1,592

647 608

CJS1,2 2,621 2,239

Theft11,327 1,261

Illegal Income 2,743 2,140

Legal Earnings 4,543 5,311

Crime Career27,484 7,467

Summary Estimates

Costs to Law Abiders 4,595 4,108 4,227 5,343

Costs to Society 10,752 10,314 8,693 7,764

$3,853 $2,429

1,266 1,006

1,498 1,551

1,463 2,786

3,411 1,406

3,849 5,223

5,929 5,227

1

The sum of these items equals the costs to law abiders.

2

The sum of these items equals the costs to society.

Cost-Benefit Ratios of Treatment

Residential treatment is more expensive than outpatient drug-free

treatment and yields greater reductions in costs from the pre- to

posttreatment periods. According to special tabulations from the 1979

National Drug and Alcohol Treatment Utilization Survey (NDATUS),

224
residential treatment costs three times as much as outpatient drugfree treatment: $18.50 per day compared to $6.00 per day. In TOPS,

the average residential treatment stay was 159 days, for a total

episode cost of $2941.50. The average outpatient drug-free episode

was 101 days, for an average cost of $606 per episode.

The average residential treatment episode cost $3,000 and yielded a

reduction of $6,000 in the costs to law-abiding citizens for both CJS

and self-referrals. Outpatient drug-free treatment cost $600 and

yielded a $500 reduction for CJS referrals and a $900 increase for

self-referrals. Residential treatment produced benefits to society of

about $3,000 per client for both CJS and self-referrals with treatment

costs of about $3,000. Outpatient drug-free treatment produced

benefits of $450 for CJS referrals and $900 for self-referrals with

treatment costs of $600.

The ratio of benefits, i.e., reduction in costs, to the expense of

providing the treatment is strong for residential treatment. The ratio

is somewhat weaker (even unfavorable for self-referrals, using the

costs to law-abiding citizens measure) for outpatient drug-free

treatment. Note, however, that residential clients are significantly

more criminally active on average than outpatient drug-free clients.

It is not reasonable to judge the relative efficacy of the two treatment modalities without a much more thorough and sophisticated

analysis. At this time, it may be sufficient to state that there are

notable economic benefits from drug abuse treatment and that these

benefits generally compare favorably with the cost of treatment in

the respective modalities. A positive cost-benefit ratio was obtained

in residential treatment and a breakeven was obtained for outpatient

drug-free treatment by the first year after treatment.

Modeling the Posttreatment Economic Benefits

Regression analyses were used to examine the correlates of crime

costs for outpatient methadone, residential, and outpatient drug-free

modalities for the 12 months after treatment. These analyses were

also used to estimate posttreatment benefits. In addition to

estimating the economic benefits from increased length of stay, the

models also examined the effects of previous treatment episodes,

pretreatment involvement in crime, and CJS involvement at entry into

treatment. In addition, sociodemographic (sex, age, race, and

education) and pretreatment drug use variables were included in the

models.

225
Notable findings from these regression analyses were as follows.

Previous treatment involvement was not significantly associated

with crime costs to society in the year after residential or

outpatient drug-free treatment. More previous treatment before

outpatient drug-free treatment was associated with &favorable

crime costs to law-abiding citizens, i.e., higher costs in the year

after treatment.

High pretreatment crime costs were associated with less favorable

(higher) crime costs to law-abiding citizens per day of treatment

in the year after outpatient methadone treatment.

CJS-involved residential clients had less favorable (higher)

posttreatment crime costs than residential clients not legally

referred or involved. Crime cost benefits were substantial for

legally referred or involved clients, but such clients had to stay in

treatment longer than clients not legally involved to accumulate

the same crime cost savings.

The most consistent correlate of favorable crime cost outcomes

was time spent in treatment; longer stays are associated with

lower posttreatment crime costs.

The above results are not definitive comparisons of the effectiveness

for the three treatment modalities because separate models were

estimated for each modality. The findings of this research need to

be replicated elsewhere before these recommendations can be made

with confidence.

However, the same variables were included in each model, and the

following suggestions are based on the results.

The referral of those with extensive previous treatment experience

to outpatient drug-free treatment should be carefully assessed.

The referral of clients heavily involved in criminal activity to

outpatient methadone treatment should be carefully evaluated.

Because length of time in treatment is associated with favorable

outcomes, clients should be encouraged to continue in treatment

for additional months, not weeks.

226
SUMMARY OF ECONOMIC RETURNS IN THREE TREATMENT

MODALITIES

There are positive economic returns to society from drug abuse

treatment. Similar conclusions are reached using two measures of

these benefits: costs to society (table 10) and costs to law-abiding

citizens (table 11). Benefits are estimated for the time clients are in

drug treatment and for the 12-month period following their discharge from the TOPS episode.

TABLE 10. Summary of costs and benefits of drug abuse

treatment: benefits in reduced costs to

society

Treatment Modality

(costs and benefits in dollars)

Outpatient Outpatient

Residential Methadone Drug Free

Estimated Costs and Benefits for Each Day of Treatment

Average Cost of Treatment

per Day $18.50 $6.00 $6.00

Average Benefit per Day

While in Treatment 15.77 5.54 7.63

Average Benefit per Day

Year After Treatment 21.40 (9.95)* 18.06

Estimated Costs and Benefits for a Treatment Episode of Average

Duration

Average Length of Stay (Days) 159 267 101

Total Cost of Treatment $2,942 $1,602 $606

Total Benefits in Treatment 2,507 1,479 771

Total Benefits After

Treatment 3,403 (2,657)* 1,824

227
TABLE 10. (Continued)

Treatment Modality

(costs and benefits in dollars)

Outpatient Outpatient

Residential Methadone Drug Free

Total Benefits in Treatment

and Year After Treatment 5,926 1,479 2,595

Ratio of Benefits to

costs 2.01 0.92 4.28

*Not statistically significant and, therefore, not included In benefits.

Intreatment benefits are estimated as the difference between an

individual’s costs during treatment and those costs before or after

treatment, as hypothesized costs (to society and law-abiding citizens)

during treatment were notably lower than either before or after

treatment. Posttreatment benefits are estimated from a multivariate

regression analysis estimating the returns from increased length of

stay. In general, the returns to increased length of stay in treatment are positive and significant both statistically and clinically. For

a complete discussion of these analyses see Harwood et al. (1987).

Residential

Residential treatment appears to have the greatest economic return of

the three modalities examined in this study. Using the reduction in

cost to law-abiding citizens, the return of an additional day’s

treatment is estimated at $37.62, somewhat higher than the return to

society of $21.40 per day. Clients admitted to residential treatment

imposed costs on law-abiding citizens of $43.17 per day before

treatment. This was only $0.65 per day while in treatment. Alternatively, the cost to society was $53.18 per day before treatment and

$33.13 during treatment. By either measure, the economic benefit of

the intreatment period was substantial, at $42.52 per day or $20.05

per day, depending on the measure chosen to estimate benefits. A

more conservative way of estimating treatment benefits is to compare

the intreatment value with costs per day following treatment. This

228
TABLE 11. Summary of costs and benefits of drug abuse treatment:

benefits in reduced costs to law-abiding citizens

Treatment Modality

(costs and benefits in dollars)

Outpatient Outpatient

Residential Methadone Drug Free

Estimated Costs and Benefits for Each Day of Treatment

Average Cost of Treatment

per Day $18.50 $6.00 $6.00

Average Benefit per Day

While in Treatment 33.44 13.30 7.65

Average Benefit per Day

Year After Treatment 37.62 10.96 (16.40)*

Estimated Costs and Benefits for a Treatment Episode of Average

Duration

Average Length of Stay (Days) 159 267 101

Total Cost of Treatment $2,942 $1,602 $606

Total Benefits in Treatment 5,317 3,551 773

Total Benefits After Treatment 5,982 2,926 (1,656)*

Total Benefits in Treatment

and Year After Treatment 11,299 6,477 773

Ratio of Benefits to Costs 3.84 4.04 1.28

*Not statistically significant and, therefore, not included in benefits.

conservative approach would indicate benefits of $24.36 per day for

law-abiding citizens or $11.38 per day for all of society.

229
A middle estimate of intreatment benefits, using all intreatment

analyses, is derived by averaging the high estimate and the conservative estimate. The middle estimates of intreatment benefits are

$15.77 in savings to society and $33.44 in savings to law-abiding

citizens.

After summing benefits from the intreatment and 12-month posttreatment periods, the return was $71.06 per day in residential treatment,

using the costs to law-abiding citizens, or $37.17 per day, using the

costs to society. The price paid to achieve these returns was about

$18.50 per day of treatment in publicly funded residential treatment

facilities in 1979 to 1981 (Allison et al. 1985).

The costs and benefits from a treatment episode in a residential

facility are readily summarized (tables 10 and 11). A stay of 159

days (the average for this sample) would incur treatment costs of

$2,942. Savings in costs to society would be $2,507 during treatment,

and another $3,403 in the year following treatment discharge. Total

benefits to society would be $5,926, for a ratio of benefits to costs

of 2.01. Savings in costs to law-abiding citizens would be $5,317

during treatment and another $5,982 in the year following discharge.

Total benefits would be $11,299, or 3.64 times the cost of the

treatment episode.

Outpatient Methadone

The economic returns to outpatient methadone treatment are also

positive, although more modest than to residential treatment. The

average reduction in cost to law-abiding citizens was $24.26 per day

of treatment ($10.96 per day during the followup year, plus $13.30 per

day while being treated). The return to society was $7.29 per day

while in treatment, but there were no statistically significant benefits

to society in the followup year.

The cost of methadone treatment is estimated to be $6 per client

day, based on data the TOPS programs provided NDATUS (Allison et

al. 1985). These values indicate that society virtually saves its total

costs for methadone treatment on the day that it is delivered, and

that longer lasting effects are an economic bonus. There were

statistically significant benefits to law-abiding citizens in the

followup year, although benefits were negligible or even negative for

treatment of the most criminally active clients.

230
The average episode of outpatient methadone treatment for this

sample lasted 267 days. Benefits to society for this episode were

almost equal to the cost of treatment ($1,479 and $1,602 respectively), and benefits to law-abiding citizens were four times as great

as treatment costs ($6,477 and $1,602, respectively). The ratio of

benefits to the cost of treatment was 0.92 for the costs-to-society

measure and 4.04 for the costs-to-law-abiding-citizens measure.

Outpatient Drug Free

The costs of outpatient drug-free treatment (about $6 per client day)

compare very favorably with the benefits estimated in this study.

Benefits to law-abiding citizens were $7.65 per day of treatment (all

from intreatment benefits); posttreatment benefits were sizeable,

although not statistically significant. Benefits to society were even

larger, at $25.69 per day of treatment ($7.63 per day while in

treatment and $18.06 per day during the followup year).

An average treatment episode for outpatient drug-free services was

101 days for this sample. The cost of treatment for an average stay

was about $606, while the benefits were $2,595 and $773 in costs to

society and law-abiding citizens, respectively. The ratios of economic

benefits to the cost of treatment are 4.28 for costs to society and

1.28 for costs to law-abiding citizens.

CONCLUSION

There are three critical questions that these estimates of benefits

raise. The first concerns the expected duration of the treatment

effect, the second concerns the relative efficacy of the three

treatment modalities, and the third concerns the economic value of

simply enrolling in treatment regardless of length of treatment.

The benefits totaled at this point include only the intreatment period

and the first year after treatment discharge. While no multivariate

estimates have been made, there is reason to believe that treatment

effects may last more than 1 year. Some clients are completely

rehabilitated through drug treatment, leaving their drug habits and

criminal careers behind. Even if it is contended that drug abusers

eventually “mature out” of their lifestyle without treatment, the

treatment effects estimated in this study indicate that clients who

stay in treatment for longer periods are more likely to mature out

than those with only short treatment episodes. Consequently, the

231
intreatment and 1-year followup values estimated in this study are

only a partial accounting of benefits.

While this study has estimated economic returns for three different

drug abuse treatment modalities, the issue of the relative efficacy for

these modalities to treat specific individuals has not been addressed.

In other words, issues of “treatment matching” or self-selectivity bias

are not included here. Although greater returns are estimated from

residential treatment than from methadone or outpatient drug-free

treatment in this quasi-experimental study design, there has been no

random assignment of clients to modalities or to length of stay. lt is

not possible to conclude that methadone and outpatient drug-free

clients assigned to residential programs would get the same benefits

as those observed for residential clients in this study.

Finally, these multivariate estimates of benefits do not indicate the

value to society of drug abusers voluntarily deciding to find help for

their addiction problem and to seek treatment. There may be crimereduction benefits to society from this voluntary decision to change

the “addict lifestyle,” regardless of how long drug abusers stay in

treatment. However, the TOPS database can only indirectly address

this issue, because no untreated drug abusers are included in the

TOPS database. One comparison group may be those who enrolled in

treatment and then left very quickly.

Despite the limitations cited above, it appears that there are real

returns to society and law-abiding citizens from greater length of

stay for CJS referrals. The benefits occur even though CJS referrals

are more criminally active than self-referrals in the followup year.

Unfortunately, there is no comparison group of drug abusers sent to

prison or put on probation without referral to drug treatment.

The findings from this study indicate that there are significant

economic benefits associated with drug abuse treatment. Generally,

these benefits seem to be at least as great as the expense of each

modality. There also appear to be greater crime-reduction benefits

accruing to treatment in residential facilities than in methadone or

outpatient drug-free programs. Longer term outcomes must be

assessed to determine the duration of these different benefits.

232
REFERENCES

Allison, M.; Hubbard, R.L; and Rachal, J.V. Treatment Process in

Methadone, Residential, and Outpatient Drug-Free Programs.

National Institute on Drug Abuse Treatment Research Monograph

Series. DHHS Pub. No. (ADM) 85-1388. Rockville, MD: the

Institute, 1985. 89 pp.

Arthur D. Little Company. Social Cost of Drug Abuse. Report for

the Special Action Office for Drug Abuse Prevention of the

Executive Office of the President. Cambridge, MA: Arthur D.

Little Company, 1974. 55 pp.

Ball, J.C.; Rosen, L; Flueck, J.A.; and Nurco, D.N. The criminality

of heroin addicts when addicted and when off opiates. In:

Inciardi, J.A., ed. Crime/Drug Nexus. Beverly Hills, CA: Sage,

1980. pp. 39-65.

Chaiken, J., and Chaiken, M. Varieties of Criminal Behavior. Santa

Monica, CA: Rand, 1982. 321 pp.

Collins, J.J.; Hubbard, R.L; and Rachel, J.V. Expensive drug use and

illegal income: A test of explanatory hypotheses. Criminology: An

Interdisciplinary Journal 23(4):743-764.

Cruze, A.M.; Harwood, H.J.; Kristiansen, P.L; Collins, J.J.; and Jones,

D.C. Economic Costs of Alcohol and Drug Abuse and Mental

Illness-1977. Research Triangle Park, NC: Research Triangle

Institute, 1981. 302 pp.

Gandossy, R.P.; Williams, J.R.; Cohen, J.; and Harwood, H.J. Drugs

end Crime. A Survey and Analysis of the Literature. Washington,

DC: U.S. Department of Justice, National Institute of Justice, 1980.

173 pp.

Goldman, F. The SociaI Costs of Drug Abuse. Draft. New York:

Columbia University, 1978. 105 pp.

Gropper, B.A. Probing the links between drugs and crime. NIJ

Reports/SNI 188:4-8, 1984.

Harwood, H.J.; Collins, J.J.; Hubbard, R.L; Marsden, M.E.; and Rachal,

J.V. The Costs of Crime and Benefits of Drug Abuse Treatment.

(RTl/3413/00-01FR.) Research Triangle Park, NC: Research

Triangle Institute, 1987. 48 pp.

Hat-wood, H.J.; Napolitano, D.M.; Kristiansen, P.L; and Collins, J.J.

Economic Costs to Society of Alcohol and Drug Abuse and Mental

Illness: 1980. (RTl/2734/00-01FR.) Research Triangle Park, NC:

Research Triangle Institute, 1984. 234 pp.

Hubbard, R.L.; Marsden, M.E.; and Allison, M. Reliability and Validity

of TOPS Data. (RTl/1901/01-15S.) Research Triangle Park, NC:

Research Triangle Institute, 1984a. 50 pp.

233
Hubbard, R.L; Rachal, J.V.; Craddock, S.G.; and Cavanaugh, E.R.

Treatment Outcome Prospective Study (TOPS): Client

characteristics and behaviors before, during, and after treatment.

In: Tims, F.M., and Ludford, J.P., eds. Drug Abuse Treatment

Evaluation: Strategies, Progress, and Prospects. National lnstitute

on Drug Abuse Research Monograph 51. DHHS Publication No.

(ADM) 84-1329. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1984b. pp. 42-68.

Johnson, B.; Goldstein, P.; Preble, E.; Schmeidler, J.; Lipton, D.;

Spunt, B.; and Miller, A. Taking Care of Business: The Economics

of Crime by Heroin Abusers. Lexington, MA: Lexington Books,

1965. 275 pp.

Lemkau, P.; Amsel, Z.; Sanders, B.; Amsel, J.; and Seif, T. Social and

Economic Costs of Drug Abuse. Baltimore, MD: Johns Hopkins

University, 1974. 85 pp.

Rufener, B.L; Rachal, J.V.; and Cruze, A.M. Management Effectiveness Measures for NIDA Drug Abuse Treatment Programs, Vol. II:

Costs to Society of Drug Abuse. Research Triangle Park, NC:

Research Triangle Institute, 1977. 84 pp.

U.S. Department of Justice, Bureau of Justice Statistics. Justice

Expenditures and Employment in the U.S., 1979. Washington, DC:

the Bureau, 1983a. 265 pp.

U.S. Department of Justice, Bureau of Justice Statistics. Sourcebook

of Criminal Justice Statistics. Washington, DC: the Bureau, 1983b.

693 pp.

U.S. Department of Justice, Bureau of Justice Statistics. The

Economic Cost of Crime to Victims. Washington, DC: the Bureau,

1984. 8 pp.

U.S. Department of Justice, Federal Bureau of Investigation. Crime in

the United States, 1980: Uniform Crime Reports. Washington, DC:

the Bureau, 1981. 308 pp.

U.S. Department of the Treasury, Internal Revenue Service. Income

Tax Compliance Research. Washington, DC: the Service, 1983.

173 pp.

AUTHORS

Henrick J. Harwood, B.A.

Robert L. Hubbard, Ph.D

James J. Collins, Ph.D

J. Valley Rachal, M.S.

234
Research Triangle Institute

Box 12194

Research Triangle Park, NC 27709

235
Compulsory Treatment: A Review

of Findings

Carl G. Leukefeld and Frank M. Tims

INTRODUCTlON

The current drug abuse treatment system has its roots in a number of

initiatives closely related to the criminal justice system (Maddux 1967;

Maddux 1978). Specialized treatment (Rasor 1978) for addicts in the

United States began with two Public Health Service hospitals which

opened at Lexington, KY, in 1935 and at Fort Worth, TX, in 1938.

These hospitals treated incarcerated Federal prisoners but voluntary

patients were also accepted. However, most voluntary patients did

not remain for the entire treatment program. In fact, treatment

before passage of Public Law 89-793, 1966, the Narcotic Addict

Rehabilitation Act (NARA), did not provide for community aftercare,

and followup studies reported an extremely high relapse rate (Vaillant

1966). Vaillant (1966) also concluded that the most significant

variable in determining abstinence in the confirmed user was the

availability of compulsory parole supervision.

Using State civil commitment programs (e.g., compulsory courtordered treatment as an alternative to incarceration) from California

and New York as models, and the logic from available followup

studies (Maddux, this volume), NARA was enacted at the Federal level

in 1966. This legislation established a close linkage between the

health-care system and the criminal justice system and provided civil

commitment to keep addicts in treatment beyond withdrawal. NARA

also included community-based followup care after detoxification,

initially provided at the Lexington and Fort Worth hospitals, Later,

NARA inpatient treatment facilities were established in several major

cities. NARA also set the stage for community treatment of narcotic

addicts and, subsequently, drug abusers by providing initial funding

and developing a group of treatment experts in drug abuse.

236
A second major effort in the drug abuse criminal justice area was the

Treatment Alternatives to Street Crime (TASC), which was established

in 1972 by the Special Action Office for Drug Abuse Prevention

(SAODAP) and was modeled, in part, on the court referral program

developed in Washington, DC. TASC is essentially a diversion

program for drug abusers. The program identifies clients, refers them

to treatment, and monitors their adjustment. It serves as an

“outreach” or “case-finding” function for treatment agencies

(Cook et al., this volume).

With the above brief history, the purpose of this volume is to review

existing research related to civil commitment and mandatory treatment that might be applied to reduce the spread of the AIDS virus.

With that purpose, a specific consensus statement was developed by

the participant authors and is included here as written by those who

attended the meeting. The consensus suggests that, based on the

research that indicates that treatment is effective in reducing

intravenous drug abuse and that the length of time in treatment is

positively related to treatment success, the criminal justice system is

important for identification and retention of drug abusers in treatment.

OVERVIEW OF THE FINDINGS

Using data from a 1974 to 1976 evaluation of the California Civil

Addict Program, the efficacy of mandatory treatment and civil

commitment was presented by Anglin (this volume). This evaluation

of nearly 1,000 addicts who came into the California Civil Addict

Program examined the joint effect of civil commitment and methadone

maintenance. That cohort was reinterviewed 25 years after admission

to the Civil Addict Program.

Using a time series approach, with the dependent variable the percent

of time spent using narcotics daily, data from 8 years prior to

admission (including an “out of control” period of usually 2 years

before admission to treatment) and 11 to 13 years following admission

showed significant changes. These changes show that civil commitment has the effect of suppressing daily drug use and criminal

involvement. Other outcome variables showed similar but moderate

effects corresponding to decreasing drug use and criminal involvement. However, the more prosocial the behavioral outcome, the less

dramatic the effect. For example, while significant effects on

employment were seen, they were not as dramatic as reductions in

antisocial behavior. While most of the changes reported were

237
moderate, Anglin maintains that a “long tail” of parole should be used

to monitor addicts against relapse to addiction. According to this

data, supervision without drug testing produced nearly the same

results as no supervision, while outpatient supervision and supervision

with testing showed major reductions in narcotics use. Therefore,

supervised aftercare with objective monitoring is the most important

component of civil commitment.

When Anglin examines the cohort in another way, civil commitment

reduced daily drug use for three groups—active drug users (showing

considerable addiction in the year prior to the interview), inactive

drug users (showing minimal addiction in the year prior to the

interview), and addicts on methadone maintenance at interview. From

these results, it can be concluded that civil commitment is an

effective approach for several behavioral types of addicts. However,

of the three programs reviewed (the California Civil Addict Program,

the New York State Civil Commitment Program, and NARA), only the

California program proved to be effective in modifying behaviors. It

was suggested that the New York State and NARA programs may not

have been as effective because they were administered through

agencies other than the criminal justice system.

Reviewing followup studies from the Lexington and Fort Worth Public

Health Service Hospitals, Maddux suggests that treatment with legal

coercion, when combined with compulsory community followup,

produced better outcomes but not vastly different from outcomes for

voluntary patients. Drawing on his experience at the Public Health

Service hospitals, Maddux also suggests that most opioid users enter

treatment with some type of coercion. NARA provided for supervised

aftercare following hospitalization at the Lexington and Fort Worth

Hospitals. That experience suggests that civil commitment will hold

about one-third of narcotic addicts in treatment. It appears that this

high attrition may have been related to the intensive psychosocial

approach. In addition, disruptive and noncompliant patients were

found not suitable for treatment and were quickly released. Further,

limited long-term followup research exists that examines coercion and

long-term abstinence. Therefore, civil commitment is useful for

bringing narcotic addicts into treatment, but it is not treatment and

cannot take the place of treatment.

TREATMENT OUTCOME STUDIES

The Treatment Outcome Prospective Study (TOPS) included 12,000

clients in 10 cities; 5 cities also had TASC programs. lt must be

238
noted that in a 3-year study, from 1979 to 1981, only 17 clients were

referred to methadone maintenance programs by the criminal justice

system. Those clients who were more likely to be referred to treatment by the criminal justice system included: males, younger clients

(21 to 25 years old), and those with no prior treatment. While some

of the TOPS data were not consistent with the California Civil

Addict data, the general conclusions are the same. Although there

are cautions, the bottom line from TOPS is that criminal justice

referral was effective for many addicts at an early stage in their

careers.

In outpatient methadone treatment, less than 3 percent of the TOPS

clients (by self-description) were criminal justice system referrals,

which contrasts with over 30 percent of the residential and outpatient drug-free clients. Among those clients who self-reported

legal status, about 20 percent had some form of involvement with the

criminal justice system, although they did not indicate treatment

referral by that system. These data are very different from the

southern California data which Anglin presented. Further, in some

jurisdictions the criminal justice system will not refer clients to

methadone maintenance programs because such treatment is viewed

only as a continuation of drug use.

TOPS data indicate that young users, ages 21 to 25, were nearly

twice as likely to be referred by the criminal justice system than by

any other source of referral. Or to put it another way, an active

heroin user in treatment is half as likely to have been referred by

the criminal justice system. The trend shows a preference for

individuals with less severe drug problems to be referred to outpatient drug-free treatment.

TOPS data confirm previous studies that found that criminal justice

system-referred clients often stayed in treatment longer, implying

stronger motivation. For example, regression coefficients indicate a

non-TASC/criminal justice system client would stay in treatment

approximately 28 days longer than a client with no criminal justice

involvement. Further, a TASC client would remain in treatment

nearly twice as long. However, this difference between TASC and

criminal justice referrals did not hold for residential treatment

clients. Another finding was a lower level of service for criminal

justice system referrals in outpatient programs. Looking at an array

of six different types of services, clients with no legal involvement

tended to receive more services in outpatient drug-free treatment.

Again, this differential did not appear in residential treatment. A

239
possible explanation noted was that clients with no legal involvement

tended to have more psychological problems and aggression than

criminal justice system-referred clients and, therefore, may be in

more need of comprehensive treatment services.

Using a sample of 405 male addicts from the Drug Abuse Reporting

Program (DARP), Simpson examines the influence of pretreatment

legal status for addicts in their 12-year treatment followup study.

Legal status was defined as probation, parole, or awaiting trial. The

405 subjects were divided, 204 with legal status and 201 with no legal

status. For this study, legal status was compared to reasons for

leaving treatment and to behavioral performance after leaving

treatment. With few exceptions, there were no significant relationships between legal status and these selected variables. More

specifically, and for each treatment modality (including methadone

maintenance, therapeutic community (TC), outpatient drug free, and

detoxification), the length of time in treatment, reasons for discharge, and posttreatment outcomes were similar for addicts with

legal status and for those with no legal status. However, it should

be noted that over 80 percent of the addicts involved in this analysis

had one or more prior arrests, and over half had spent time in jail

or in prison.

These findings for DARP suggest that legal status at treatment entry

is not related to treatment success. Nevertheless, there is evidence

from DARP and other treatment evaluation studies that treatment is

effective in improving behavioral outcomes. Longitudinal analysis of

opioid use patterns over time (Simpson and Marsh 1986) reveal that

25 percent of their sample never returned to daily opiate use during

the 12-year followup. In addition, and by year 12, 63 percent of that

total sample had not used opiates daily for at least 3 years.

Likewise, data from this 12-year followup indicates that, while they

were in a treatment program, 50 percent of the sample stopped using

opiates. Further, addicts who entered treatment were more often

influenced by legal pressures and family concerns. Finally, further

examination of the pre-DARP legal status variable reveals that addicts

who were admitted to DARP with legal involvement were more likely

to report in year 12 that probation, parole, and legal problems had

previously been important incentives for entering treatment.

EFFICACY STUDIES

After describing the TASC Program, Cook et al. depicts TASC as a

bridge between the criminal justice system and drug abuse treatment

240
programs. In other words, TASC identifies, assesses, refers, and

monitors appropriate drug- and/or alcohol-dependent, nonviolent

offenders. Thus, treatment serves as an alternate or supplement to

the criminal justice system. Although there is a lack of comprehensive data, several evaluations of TASC (Collins and Allison 1963;

Lazar 1976) found that the TASC linkage provided an alternative to

incarceration that is less costly, and TASC clients remained in

treatment longer. Currently, more than 100 sites in 16 States have

TASC programs. Perhaps, most important to the success of TASC is

the case-management aspect which “tracks” drug abusers through

their drug careers.

Joseph draws upon his experiences and research to present a historical review of selected New York City programs which were developed

to combat opiate addiction. After defining probation (community

supervision in lieu of incarceration) as well as parole (community

supervision after incarceration), he presents research findings from an

evaluation study of five probation clinics operated by the New York

Office of Probation during the early 1970s. Four of these clinics

operated directly within probation offices. Although 53 percent of

the 1,000 persons treated from 1970 to 1973 were unemployed, only

10.4 percent of the first 900 admissions were rearrested.

Results from a study of the New York City Addiction Services

Agency’s Diversion Program revealed a 50 percent retention rate for

those patients admitted to methadone maintenance treatment for 12

months in 1973 and also a 60 percent retention in methadone

maintenance treatment during 1974. These findings also hold for both

TCs and ambulatory drug-free programs. After presenting additional

data, Joseph concludes by urging that methadone maintenance

treatment can have a number of cost-effective benefits when the New

York experience and data are examined.

lnciardi suggests “what not to do” in the area of civil commitment by

using his personal experiences in New York with the Narcotics

Addiction Control Commission (NACC). Data from a 1956 New York

study show that, while under supervision by specially trained parole

officers, 45 percent of the parolees refrained from drug use (Diskind

and Kronsky 1964). A later study reported 66 percent of the parolees

had avoided drug use (Diskind 1967). lnciardi suggests that this data

may be misleading, since not all cases were randomly assigned to

parole supervision. Instead, selective case assignment was used for

those most likely to succeed. Measures of failure were rearrest

and/or return to drug use. However, either drug use frequently went

241
unreported by parole officers, or parolees learned ways to beat drug

detection. Finally, due to racial tension in New York during the

1960s many middle-class, white parole officers were out of touch with

the areas where the rates of crime and addiction were the highest—

the minority neighborhoods.

However, two aspects of the project demonstrated considerable

clinical efficacy. First, a special arrangement was made between the

parole project and Daytop Village, and from 1965 to 1967 a total of

43 parolees were accepted into Daytop Village for treatment.

Although no followup data are available, 16 of the 43 parolees had

graduated from Daytop Village by June 1966. The second aspect of

the project was a rudimentary approach to multimodality programming. One option of the parole officer was to refer relapsed cases

to available, although limited, local programs for treatment.

The New York State Narcotics Control Act of 1966 established the

NACC. The resulting civil commitment program, which can probably

be described as the largest and most costly in history, allowed

addicts to be committed to treatment for 3 to 5 years. Eligibles

included those arrested for drug-related crimes, those whose family

members petitioned the courts, and volunteers. The treatment

process included a period of incarceration followed by community

aftercare.

New York purchased facilities from the State Department of Corrections; such facilities provided an environment not conducive to

therapeutic treatment. lnciardi concludes by suggesting that if the

New York civil commitment experience is used, policymakers should

have learned that implementation is important, monitoring must be

carefully carried out, and compulsory treatment should utilize existing

treatment programs rather than creating a whole new separate

system.

Since drug abusers who are using drugs heavily report six times more

criminal activity, Wish reports that reducing drug abuse also reduces

crime. Therefore, a critical issue is identifying drug-abusing

offenders and deciding what to do with those identified. Drug

testing for all offenders is important to identify drug users. In

addition, testing offenders can help predict community drug-use

trends. Wish describes four techniques for identifying drug-using

offenders: offender self-report, criminal justice records, urine

testing, and radioimmunoassay of hair.

242
Results from a 1984 study in Manhattan of 6,406 male arrestees who

were being held in central booking awaiting arraignment reveal that

95 percent agreed to participate in the confidential research interview

and 84 percent provided a voluntary urine specimen for analysis. The

most common drug found was cocaine, followed by opiates (21 percent), PCP (12 percent), and methadone (6 percent). Overall, 56

percent were positive for one or more of these drugs and 23 percent

were positive for two or more drugs. The self-reported estimates of

drug use in the last 24 to 46 hours were about half of what was

detected by the urine tests. Female offenders were more likely to

test positive for drug use and more likely to self-report serious drug

abuse than males. Of the women who were charged with prostitution,

75 percent tested positive for one or more drugs, with intravenous

cocaine use in this group at approximately 45 percent. After arrest

most prostitutes are on the streets again within several hours.

Referral rates to TCs from the criminal justice system have steadily

declined from 50 percent in the mid-1960s to 16 percent in 1985,

which indicates that these linkages have been weakened. Using 1974

self-report data, in which success was defined by absence of drug use

and arrest as well as having a job or going to school, De Leon

reports a success rate of 38 percent. Data from 1971 and 1974

cohorts show that successful outcomes increase with length of time in

treatment. Likewise, data from 1970 and 1971 indicate that the

length of time in treatment reduces arrest rates for dropouts,

although outcomes are slightly better for volunteers than for legal

referrals. In addition, as time in treatment increases, the proportion

of legal referrals increases. Most TC dropouts occur within the first

120 days, with a peak during the first 15 days.

Recovery from drug abuse is an interactional phenomenon involving

the interplay of client factors with nontreatment factors, such as

social climate, as well as treatment itself. Interaction of these

domains needs to be considered in order to understand recovery.

Client factors include two critical areas—external pressure and

internal pressure. Legal referrals belong in the external pressure

category. A stable recovery cannot be maintained by external (legal)

pressure only; motivation and commitment must come from internal

pressure. The role of external pressure from this point of view is to

influence a person to enter treatment.

Subgroups, including legally referred, legally involved, volunteers with

past legal involvement, and volunteers with no legal involvement,

should be the focus of future research. lt is one thing to

243
operationally deliver pressure as an action—an individual enters

treatment. lt is another thing to perceive the pressure in the sense

that it is dangerous not to go to treatment and it is dangerous to

leave treatment, which may be one of the biggest sources of variance. In addition, legally referred clients may actually be pushed

into treatment, but their perception of legal consequences accounts

for dropouts among the legally referred clients. These sources of

variance need to be better understood to examine civil commitment.

Ball presents information on an ongoing 3-year study of methadone

maintenance and drug-free outpatient treatment programs in New

York, Philadelphia, and Baltimore. This study examines client characteristics related to treatment success and failure, characteristics of

the seven different programs, and the types of services received by

clients. Both client outcome and patient services are examined.

Clearly, not all methadone programs are the same.

Ball also notes that methadone maintenance is an ambivalent treatment modality, since most programs do not even have names. There

is still a lot of controversy about methadone maintenance. Many

program staff do not tell their friends that they are working in a

methadone program. Because methadone maintenance programs typically consist of three-fourths male clients and one-fourth female

clients, the study focuses on males only. The mean number of incarceration years was 4. Roughly 95 percent of clients in the study had

prior drug abuse treatment, and three-fourths of those clients had

prior methadone maintenance treatment. Since arrests are a poor

indicator of actual criminal involvement, “crime days” was used to

define the number of days per week on which a client was involved

in criminal activity. Specifically, crime days per week during the last

addiction period before treatment were approximately 80 percent, or 6

days per week of criminal involvement, indicating a high-crime

population. Results show that, after 1 year in methadone maintenance treatment, 77 percent of clients did not use heroin. By

comparison, cocaine use shows a major reduction, but some amount of

use persists even after 5 years in treatment. Marijuana use also

continues, and alcohol use to the point of intoxication remains

nearly consistent.

COSTS AND POTENTIAL BENEFITS

Brown examines the costs and benefits of civil commitment from an

international perspective but cautions that no hard data exist in this

area. The objective of civil commitment is twofold: containment of

244
objectionable persons, and changing those persons’ objectionable

behavior. These international differences are largely a matter of

degree; different countries have very different ways of implementing

civil commitment. There may or may not be an adjudication process.

Effectiveness is measured by the reduction of community disruption,

and costs can be measured as the toll on civil liberties. In democratic countries, a massive campaign against drug abuse requires clear

evidence of public support. For a major intervention program to be

successful, especially with reliance on compulsory treatment, the

problem must be isolated and enlarged—or, in certain circumstances,

even created.

Of the 43 countries studied by Porter et al. (1986), 27 had civil

commitment practices. Implementation of civil commitment procedures

differs markedly according to whether it comes under mental health

legislation or under separate legislation specific to drug abuse. lf

covered under legislation specific to drug abuse, the rationale for

civil commitment may be limited to evidence of dependence/addiction

and the need for treatment. Three different types of review authorities can determine whether commitment is appropriate: (1) the court

system; (2) existing or specially created government agencies; or (3) a

medical agency.

Reporting for the World Health Organization, Porter et al. (1986)

made the following recommendations regarding civil commitment: (1)

persons who need a short-term emergency commitment for incapacitation due to drug dependence should be immediately released from

detention on completion of treatment, that is, completion of detoxification; (2) compulsory civil commitment for other than emergency

care is justified only when an effective treatment program as well as

adequate and humane facilities are available; (3) the period of

confinement should be limited and a person’s involuntary status

subject to periodic review; and (4) the person concerned should be

afforded substantive and procedural rights during the commitment

proceedings. Brown concludes by raising the question of whether

AIDS has the potential to muster popular support for civil commitment of drug addicts in the United States. He cites constraints on

national policy in a democracy and notes that the health risk is not

now viewed as a sufficient threat to the heterosexual population.

Harwood identifies resource availability as the major constraint on

public efforts, with the present spotlight on both costs and benefits.

Before presenting specific study results, Harwood states that his

study’s objective was to estimate the economic benefits of drug abuse

245
treatment in reducing intreatment and posttreatment criminal activity

of drug abusers, as well as examining reduced-crime costs 1 year

after treatment. A 1984 economic-cost study by Harwood estimated

the cost of drug abuse at $47 billion in 1980, with crime-related costs

representing about $18.3 billion.

Using sample data from TOPS at 12 months, as well as 24 and

48 months, the major conclusion reached was that virtually all

economic measures show that crime is lower after treatment than

before treatment. Clearly, this finding varies by the measurement

used. In addition, when TOPS criminal justice referrals are compared

to self-referrals receiving treatment, a significant reduction of

primary drug use is seen among criminal justice system referrals in

residential treatment. However, alcohol remains a problem for all

groups studied, with drinking reported to be heavier or at the same

level as before treatment. This finding corresponds with other

studies showing positive cost-benefit effects of treatment, especially

residential treatment, which has a high cost-benefit ratio.

CONSENSUS STATEMENT REGARDING COMPULSORY

TREATMENT

With the above research findings as background, the following

consensus recommendations related to compulsory treatment for drug

abuse were developed. Except as noted below, there was little

controversy concerning these statements. The consensus statements

developed by the meeting participants are:

lt is recommended that the term “compulsory treatment” be used

rather than “civil commitment” to capture a wider range of

possible interventions, since civil commitment is only one type of

compulsory treatment. Further, it is essential that candidates for

compulsory treatment receive appropriate legal protections.

While there was considerable discussion, it was tentatively agreed

that the type of persons targeted for compulsory treatment should

be chronic drug abusers and, more specifically, the drug-abusing

offender who would benefit most from treatment. Since it will

not be possible to treat everyone who is identified or tests

positive for drugs, it will be necessary to examine drug abuse

careers and, initially, choose those intravenous drug abusers who

pose the greatest threat to themselves and the community.

246
Treatment has proven effective in reducing drug abuse and, most

specifically, in reducing intravenous drug abuse. Nonetheless, drug

dependence is chronic, and repeated interventions will probably be

needed for most clients.

Research has shown that the length of time in treatment is

related to treatment success and that long-term client aftercare

and monitoring is an essential part of treatment. In addition,

research has indicated that compulsory treatment in the form of

civil commitment increases treatment retention for intravenous

drug abusers.

Urine testing is an important tool for identifying and monitoring

drug use for both the criminal justice system and treatment

programs.

The efficacy of methadone treatment needs to be more clearly

presented to personnel in the criminal justice system, since there

seems to be a bias against methadone as a treatment approach.

The TC has a unique role for clients receiving long-term mandatory treatment and should remain an attractive treatment alternative for the judicial system.

Discussion of compulsory treatment must include the impact of

such a policy on the Nation’s treatment network. Treatment slots

must be readily available, and the treatment offered should include

the range of existing treatment modalities—methadone treatment,

TC, and drug-free outpatient treatments. Compulsory treatment

should not displace the treatment capacity available for other

clients.

The criminal justice system is important for client identification

and retention. A strong link needs to be developed at all levels

between treatment programs and the criminal justice system. The

interface involves education, development of common goals, and

inclusion of criminal justice as treatment items in data systems.

Compulsory treatment cannot be considered a panacea for dealing

with the AIDS problem among intravenous drug abusers. Consideration also must be given to other alternatives for curbing the

spread of AIDS infection. However, if one of the goals of a

compulsory treatment program is to reduce the spread of AIDS

infection, there needs to be a greater focus on prostitution. This

247
recommendation is based upon research that shows that a high

proportion of those arrested for prostitution are intravenous drug

abusers.

ADVANTAGES AND DISADVANTAGES

The following advantages of compulsory treatment and, more specifically, civil commitment emerged. lt is summarized as an approach

that:

helps get drug abusers into treatment;

appears to keep drug abusers in treatment longer if managed by

the treatment system;

makes treatment available before a crime has been committed;

is separate from postoffense criminal justice system processing;

provides clear due-process procedures: and

has clear treatment goals to contain the addict rather than only

providing punishment.

On the other side of the coin, several disadvantages of compulsory

treatment/civil commitment were evident. It can be summarized as

an approach that:

incorporates delays in processing;

would overwhelm treatment facilities unless more funding, facilities, and staff are available;

many addicts may be unwilling to use or found to be unsuitable

for;

at first Mush appears too costly, however, this is tempered when

compared to court and incarceration costs; and

is too cumbersome administratively.

248
RECOMMENDATIONS FOR FUTURE RESEARCH

The panel also recommended that research should be encouraged to

develop and extend knowledge related to compulsory treatment in the

following areas:

Treatment outcome studies should assess the impact of treatment

interventions on criminal activity and should also collect baseline

criminal data.

Treatment outcome studies should incorporate standardized

protocols to allow for clear understanding for replication.

Replication studies should be initiated to reexamine the efficacy of

intensive supervision and urine surveillance in reducing drug use

for probationers and parolees.

Diagnostic criteria should be further refined to identify clients

who could benefit from compulsory treatment and to match clients

to specific treatment approaches.

Linkage models to strengthen the relationship between the criminal

justice system and the treatment system should be further

examined.

Descriptive study, including criteria and use of State civil

commitment laws for drug abusers, should be undertaken.

Cost-benefit studies should be updated and should include criminal

justice variables.

Epidemiological studies that focus on drug abuse should incorporate criminal justice data.

Secondary data analysis of existing data sets should focus on

criminal justice questions.

Finally, it should be emphasized that compulsory treatment might be

only one of the many approaches to reducing the spread of AIDS

among intravenous drug users and the general population, and that

approaches like TASC may be useful in directing intravenous drug

users to treatment.

249
REFERENCES

Collins, J.J., and Allison, M. Legal coercion and retention in drug

abuse treatment. Hosp Community Psychiatry 34(12):1145-1149,

1983.

Diskind, M. The Role of the Parole Oficer in the Use of

Authoritative Casework Approach, Rehabilitating the Narcotic

Addict. Vocational Rehabilitation Administration. Washington, DC:

Supt. of Doc., U.S. Govt. Print. Off., 1967. pp. 285-292.

Diskind, M., and Kronsky, G. New Approaches in the Treatment of

Paroled Offenders Addicted to Narcotic Drugs. Albany, NY: State

Division of Parole, 1964. pp. 11-68.

Lazar Institute. Phase I Report, Treatment Alternatives to Street

Crime (TASC) National Evaluation Program Technical Report.

(NCJTF 34057.) Washington, DC: Law Enforcement Assistance

Administration, 1976.

Maddux, J.F. Treatment of Narcotic Addiction: Issues and Problems,

Rehabilitating the Narcotic Addict. Vocational Rehabilitation

Administration. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1967. pp. 11-21.

Maddux, J.F. History of the hospital treatment programs, 1935-74.

In: Martin, W.R., and Isbell, H., eds. Drug Addiction and the U.S.

Public Health Service. National Institute on Drug Abuse. DHHS

Pub. No. (ADM) 77-434. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1978. pp. 217-250.

Porter, L.; Arif, A.; and Curran, W.J. The Law and the Treatment of

Drug and Alcohol Dependent Persons—A Comparative Study of

Existing Legislation. Geneva, Switzerland: World Health

Organization, 1986. pp. 216.

Rasor, R. Reflections on the narcotic farms. In: Martin, W.R., and

Isbell, H., eds. Drug Addiction and the U.S. Public Health Service.

National Institute on Drug Abuse. DHHS Pub. No. (ADM) 77-434.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1978.

pp. 251-259.

Simpson, D.D., and Marsh, K.L. Relapse and Recovery in Drug Abuse.

National Institute on Drug Abuse Research Monograph 72. DHHS

Pub. No. (ADM) 86-1473. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1986. pp. 86-103.

Vaillant, G.A. A twelve-year follow-up of New York narcotic addicts,

Ill. Some social and psychiatric characteristics. Arch Gen

Psychiatry 15(6):599-609, 1966.

250
AUTHORS

Carl G. Leukefeld, D.S.W.

Frank M. Tims, Ph.D.

National lnstltute on Drug Abuse

National Institutes of Health

Parklawn Building, Room 10-A-38

5600 Fishers Lane

Rockville, MD 20857

251
monograph series

While limited supplies last, single copies of the monographs may be

obtained free of charge from the National Clearinghouse for Alcohol

and Drug Information (NCADI). Please contact NCADI also for information about availability of coming issues and other publications of

the National Institute on Drug Abuse relevant to drug abuse research.

Additional copies may be purchased from the U.S. Government Printing Office (GPO) and/or the National Technical Information Service

(NTIS) as indicated. NTIS prices are for paper copy. Microfiche

copies, at $6.50, are also available from NTIS. Prices from either

source are subject to change.

Addresses are:

NCADI

National Clearinghouse for Alcohol and Drug Information

P.O. Box 2845

Rockville, MD 20852

GPO

Superintendent of Documents

U.S. Government Printing Office

Washington, DC 20402

NTIS

National Technical Information

Service

U.S. Department of Commerce

Springfield, VA 22161

For information on availability of NIDA Research Monographs 1-24

(1975-1979) and others not listed, write to NIDA Office for Research

Communications, Room 10A-54, 5600 Fishers Lane, Rockville,

MD 20857.

252
25 BEHAVIORAL ANALYSIS AND TREATMENT OF SUBSTANCE

ABUSE. Norman A. Krasnegor, Ph.D., ed.

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30 THEORIES ON DRUG ABUSE: SELECTED CONTEMPORARY

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40 ADOLESCENT MARIJUANA ABUSERS AND THEIR FAMILIES.

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71 OPIATE RECEPTOR SUBTYPES AND BRAIN FUNCTION. Roger M.

Brown, Ph.D.; Doris H. Clouet, Ph.D.; and David P. Friedman, Ph.D.,

eds.

GPO Stock #017-024-01303-0 $6

256
72 RELAPSE AND RECOVERY IN DRUG ABUSE. Frank M. Tims,

Ph.D., and Carl G. Leukefeld, D.S.W., eds.

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73 URINE TESTING FOR DRUGS OF ABUSE. Richard L. Hawks,

Ph.D., and C. Nora Chiang, Ph.D., eds.

GPO Stock #017-024-01313-7 $3.75

74 NEUROBIOLOGY OF BEHAVIORAL CONTROL IN DRUG ABUSE.

Stephen I. Szara, M.D., D.Sc., ed.

GPO Stock #017-024-01314-5 $3.75

75 PROGRESS IN OPIOID RESEARCH. PROCEEDINGS OF THE 1986

INTERNATIONAL NARCOTICS RESEARCH CONFERENCE. John W.

Holaday, Ph.D.; Ping-Yee Law, Ph.D.; and Albert Herr, M.D., eds.

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76 PROBLEMS OF DRUG DEPENDENCE, 1986. PROCEEDINGS OF

THE 48TH ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON

PROBLEMS OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

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78 THE ROLE OF NEUROPLASTlClTY IN THE RESPONSE TO DRUGS.

David P. Friedman, Ph.D., and Doris H. Clouet, Ph.D., eds.

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79 STRUCTURE-ACTIVITY RELATIONSHIPS OF THE CANNABINOIDS.

Rao S. Rapaka, Ph.D., and Alexandros Makriyannis, Ph.D., eds.

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IN PRESS

77 ADOLESCENT DRUG ABUSE: ANALYSES OF TREATMENT

RESEARCH. Elizabeth R. Rahdert, Ph.D., and John Grabowski, Ph.D.,

eds.

80 NEEDLE-SHARING AMONG INTRAVENOUS DRUG ABUSERS:

NATIONAL AND INTERNATIONAL PERSPECTIVES. Robert J. Battjes,

D.S.W., and Roy W. Pickens, Ph.D., eds.

81 PROBLEMS OF DRUG DEPENDENCE, 1987. PROCEEDINGS OF

THE 49TH ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON

PROBLEMS OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

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82 OPIOIDS IN THE HIPPOCAMPUS. Jacqueline F. McGinty, Ph.D.,

and David P. Friedman, Ph.D., eds.

83 HEALTH HAZARDS OF NITRITE INHALANTS. Harry W. Haverkos,

M.D., and John A. Dougherty, Ph.D., eds.

84 LEARNING FACTORS IN SUBSTANCE ABUSE. Barbara A. Ray,

Ph.D., ed.

85 EPIDEMIOLOGY OF INHALANT ABUSE: AN UPDATE. Raquel A.

Crider, Ph.D., and Beatrice A. Rouse, Ph.D., eds.

258

U.S. GOVERNMENT PRINTING OFFICE: 1994 300-973/00008
National Institute on Drug Abuse

NIH Publication No. 94-3713

Formerly DHHS Publication No. (ADM) 88-1578

Printed 1988

Reprinted 1994