National Institutes of Health

U.S. Department of Health

and Human Services

Principles of Drug Abuse 

Treatment for Criminal 

Justice Populations | A Research-Based Guide

National Institute on Drug Abuse
3
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1. Drug addiction is a brain disease that affects 

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

and physiological characteristics that contribute to continued use of 

drugs despite the harmful consequences. Scientists have also found 

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

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

has stopped using drugs. This transformation may help explain why 

addicted persons are at a high risk of relapse to drug abuse even 

after long periods of abstinence and why they persist in seeking drugs 

despite the consequences.

2. Recovery from drug addiction requires 

effective treatment, followed by management of the 

problem over time. Drug addiction is a serious problem that 

can be treated and managed throughout its course. Effective drug 

abuse treatment engages participants in a therapeutic process, retains 

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

learn to maintain abstinence. Multiple episodes of treatment may be 

required. Outcomes for drug abusing offenders in the community can 

be improved by monitoring drug use and by encouraging continued 

participation in treatment.

3. Treatment must last long enough to produce 

stable behavioral changes. In treatment, the drug abuser 

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

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

severe drug problems and co-occurring disorders typically need longer 

treatment (e.g., a minimum of 3 months) and more comprehensive 

services. Early in treatment, the drug abuser begins a therapeutic 

PRINCIPLES OF 

DRUG ABUSE 

TREATMENT FOR 

CRIMINAL JUSTICE 

POPULATIONS
2

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

problems related to drug abuse and learns how to manage them as 

well.

4. Assessment is the first step in treatment.

A history of drug or alcohol use may suggest the need to conduct a 

comprehensive assessment to determine the nature and extent of 

an individual’s drug problems, establish whether problems exist in 

other areas that may affect recovery, and enable the formulation of 

an appropriate treatment plan. Personality disorders and other mental 

health problems are prevalent in offender populations; therefore, 

comprehensive assessments should include mental health evaluations 

with treatment planning for these problems.

5. Tailoring services to fit the needs of the 

individual is an important part of effective drug 

abuse treatment for criminal justice populations.

Individuals differ in terms of age, gender, ethnicity and culture, 

problem severity, recovery stage, and level of supervision needed. 

Individuals also respond differently to different treatment approaches 

and treatment providers. In general, drug treatment should address 

issues of motivation, problemsolving, and skill-building for resisting 

drug use and criminal behavior. Lessons aimed at supplanting 

drug use and criminal activities with constructive activities and 

at understanding the consequences of one’s behavior are also 

important to include. Tailored treatment interventions can facilitate 

the development of healthy interpersonal relationships and improve 

the participant’s ability to interact with family, peers, and others in 

the community.

6. Drug use during treatment should be carefully 

monitored. Individuals trying to recover from drug addiction may 

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

are varied; common ones include mental stress and associations with 

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

can progress to serious drug abuse, but detected use can present 

PRINCIPLES
3

opportunities for therapeutic intervention. Monitoring drug use through 

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

justice supervision, provides a basis for assessing and providing 

feedback on the participant’s treatment progress. It also provides 

opportunities to intervene to change unconstructive behavior—

determining rewards and sanctions to facilitate change, 

and modifying treatment plans according to progress.

7. Treatment should target factors that are 

associated with criminal behavior. “Criminal thinking” is 

a combination of attitudes and beliefs that support a criminal lifestyle 

and criminal behavior, such as feeling entitled to have things one’s 

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

accept responsibility for one’s actions, and consistently failing to 

anticipate or appreciate the consequences of one’s behavior. This 

pattern of thinking often contributes to drug use and criminal behavior. 

Treatment that provides specific cognitive skills training to help 

individuals recognize errors in judgment that lead to drug abuse and 

criminal behavior may improve outcomes.

8. Criminal justice supervision should incorporate 

treatment planning for drug abusing offenders, and 

treatment providers should be aware of correctional 

supervision requirements. The coordination of drug abuse 

treatment with correctional planning can encourage participation in 

drug abuse treatment and can help treatment providers incorporate 

correctional requirements as treatment goals. Treatment providers 

should collaborate with criminal justice staff to evaluate each 

individual’s treatment plan and ensure that it meets correctional 

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

which may include housing and child care; medical, psychiatric, and 

social support services; and vocational and employment assistance. 

For offenders with drug abuse problems, planning should incorporate 

the transition to community-based treatment and links to appropriate 

post-release services to improve the success of drug treatment 

and re-entry. Abstinence requirements may necessitate a rapid 

clinical response, such as more counseling, targeted intervention, 
4

or increased medication, to prevent relapse. Ongoing coordination 

between treatment providers and courts or parole and probation 

officers is important in addressing the complex needs of these 

re-entering individuals.

9. Continuity of care is essential for drug abusers 

re-entering the community. Offenders who complete prisonbased treatment and continue with treatment in the community have 

the best outcomes. Continuing drug abuse treatment helps the 

recently released offender deal with problems that become relevant 

after release, such as learning to handle situations that could lead 

to relapse, learning how to live drug-free in the community, and 

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

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

drug use and criminal behavior post-incarceration. Continuing drug 

treatment in the community is essential to sustaining these gains.

10. A balance of rewards and sanctions 

encourages pro-social behavior and treatment 

participation. When providing correctional supervision of 

individuals participating in drug abuse treatment, it is important 

to reinforce positive behavior. Nonmonetary “social reinforcers,” 

such as recognition for progress or sincere effort, can be effective, 

as can graduated sanctions that are consistent, predictable, and 

clear responses to noncompliant behavior. Generally, less punitive 

responses are used for early and less serious noncompliance, 

with increasingly severe sanctions issuing from continued problem 

behavior. Rewards and sanctions are most likely to have the desired 

effect when they are perceived as fair and when they swiftly follow the 

targeted behavior.

11. Offenders with co-occurring drug abuse and 

mental health problems often require an integrated 

treatment approach. High rates of mental health problems are 

found both in offender populations and in those with substance abuse 

problems. Drug abuse treatment can sometimes address depression, 

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

PRINCIPLES
5

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

disrupt drug treatment. The presence of co-occurring disorders may 

require an integrated approach that combines drug abuse treatment 

with psychiatric treatment, including the use of medication. Individuals 

with either a substance abuse or mental health problem should be 

assessed for the presence of the other.

12. Medications are an important part of 

treatment for many drug abusing offenders. 

Medicines such as methadone, buprenorphine, and extended-release 

naltrexone have been shown to reduce heroin use and should be 

made available to individuals who could benefit from them. Effective 

use of medications can also be instrumental in enabling people 

with co-occurring mental health problems to function successfully 

in society. Behavioral strategies can increase adherence to 

medication regimens.

13. Treatment planning for drug abusing 

offenders who are living in or re-entering the 

community should include strategies to prevent 

and treat serious, chronic medical conditions, such 

as HIV/AIDS, hepatitis B and C, and tuberculosis. 

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

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

offenders under community supervision than in the general population. 

Infectious diseases affect not just the offender, but also the criminal 

justice system and the wider community. Consistent with Federal 

and State laws, drug-involved offenders should be offered testing for 

infectious diseases and receive counseling on their health status and 

on ways to modify risk behaviors. Probation and parole officers who 

monitor offenders with serious medical conditions should link them 

with appropriate health care services, encourage compliance with 

medical treatment, and re-establish their eligibility for public health 

services (e.g., Medicaid, county health departments) before release 

from prison or jail.
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CONTENTS

PRINCIPLES OF DRUG ABUSE TREATMENT

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

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

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

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

FREQUENTLY ASKED QUESTIONS (FAQS).. 15

1. Why do people involved in the criminal

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

2. Why should drug abuse treatment

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

3. How effective is drug abuse treatment

for criminal justice-involved individuals? ....................................17

4. Are all drug abusers in the criminal justice

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

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

6. Are relapse risk factors different in

offender populations? How should drug

abuse treatment deal with these risk factors? ...........................19

7. What treatment and other health services

should be provided to drug abusers involved

with the criminal justice system? ................................................20
7

8. How long should drug abuse treatment last for

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

9. How can rewards and sanctions be used effectively

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

10. What is the role of medications in

treating substance abusing offenders?......................................23

11. How can the criminal justice and drug abuse

treatment systems reduce the spread of HIV/AIDS,

hepatitis, and other infectious diseases among

drug abusing offenders?.............................................................25

12. What works for offenders with co-occurring

substance abuse and mental disorders?...................................26

13. Is providing drug abuse treatment to

offenders worth the financial investment?..................................26

14. What are the unique treatment needs of

women in the criminal justice system?.......................................28

15. What are the unique treatment needs of

juveniles in the criminal justice system? ....................................29

RESOURCES.................................................... 32

REFERENCES.................................................. 34
8
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From the time it was established 

in 1974, the National Institute 

on Drug Abuse (NIDA) has 

supported research on drug 

abuse treatment for people 

involved with the criminal justice 

system.

Findings show unequivocally that providing comprehensive drug 

abuse treatment to criminal offenders works, reducing both drug 

abuse and criminal recidivism. The substantial prison population in 

the United States is attributable in large part to drug-related offenses 

and is accompanied by high rates of recidivism. As such, 

it is a matter of public health and safety to make drug abuse 

treatment a key component of the criminal justice system. Indeed, 

addressing the treatment needs of substance abusing offenders 

is critical to reducing overall crime and other drug-related societal 

burdens, such as lost job productivity and family disintegration.

Scientific research shows that drug abuse treatment can work 

even when an individual enters it under legal mandate. However, 

only a small percentage of those who need treatment actually 

receive it, and often the treatment provided is inadequate. To be 

effective, treatment must begin in prison and be sustained after 

PREFACE
10

release through participation in community treatment programs. By 

engaging in a continuing therapeutic process, individuals can learn 

how to avoid relapse and withdraw from a life of crime.

As reflected in our collaborative Criminal Justice–Drug Abuse 

Treatment Studies (CJ–DATS) Initiative, NIDA is committed to 

working across organizational boundaries to improve substance 

abuse treatment services. Multiple studies from different scientific 

disciplines have helped us understand the basic neurobiology of 

addiction, along with what constitutes effective treatment. Now 

we are at the point where the implementation of evidence-based 

treatment principles is called for within the criminal justice system to 

improve public health and public safety by reducing both drug use 

and crime.

This booklet—a complement to NIDA’s Principles of Drug Addiction 

Treatment: A Research-Based Guide—is intended to describe the 

treatment principles and research findings that have particular 

relevance to the criminal justice community and to treatment 

professionals working with drug abusing offenders. It is divided into 

three main sections: (1) research findings on addicted offenders 

distilled into 13 essential principles (see pages 1–5), (2) a series of 

frequently asked questions (FAQs) about drug abuse treatment for 

those involved with the criminal justice system, and (3) a resource 

section that provides Web sites for additional information. This 

booklet and other resources on drug abuse and the criminal justice 

system are available on NIDA’s Web site at http://www.drugabuse.

gov/drugpages/cj.html. 

With the release of this landmark publication’s revised edition, we 

are optimistic that correctional agencies have begun to understand 

how drug treatment programs are helping achieve public health and 

safety goals for the Nation.

Nora D. Volkow, M.D.

Director

National Institute on Drug Abuse

PREFACE
11

ACKNOWLEDGMENTS

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

Redonna K. Chandler, Ph.D., and the Office of Science Policy and 

Communications, National Institute on Drug Abuse.

This publication is in the public domain and may be used or 

reproduced in its entirety without permission from NIDA or the authors. 

Citation of the source is appreciated.

The U.S. Government does not endorse or favor any specific 

commercial product or company. Trade, proprietary, or company 

names appearing in this publication are used only because they are 

considered essential in the context of the studies described here.
12

The connection between 

drug abuse and crime is well 

known.

Drug abuse is implicated in at least three types of drugrelated offenses: (1) offenses defined by drug possession or 

sales, (2) offenses directly related to drug abuse (e.g., stealing 

to get money for drugs), and (3) offenses related to a lifestyle 

that predisposes the drug abuser to engage in illegal activity, for 

example, through association with other offenders or with illicit 

markets. Individuals who use illicit drugs are more likely to commit 

crimes, and it is common for many offenses, including violent crimes, 

to be committed by individuals who had used drugs or alcohol prior 

to committing the crime, or who were using at the time of the offense.

According to 2012 statistics from the Department of Justice’s 

(DOJ’s) Bureau of Justice Statistics (BJS), the total correctional 

population is 6,937,600, with 4,794,000 individuals on probation or 

under parole supervision, and drug law violations accounting for the 

most common type of criminal offense (Glaze and Herberman 2013). 

In a survey of State and Federal prisoners, BJS estimated that about 

half of the prisoners met Diagnostic and Statistical Manual for Mental 

Disorders (DSM) criteria for drug abuse or dependence, and yet 

fewer than 20 percent who needed treatment received it (Chandler 

et al. 2009; Mumola and Karberg 2006). Of those surveyed, 14.8 

percent of State and 17.4 percent of Federal prisoners reported 

having received drug treatment since admission (Mumola and 

Karberg 2006). 

INTRODUCTION
13

Juvenile justice systems also report high levels of drug abuse. 

In 2008, approximately 10 percent of the estimated 2.1 million 

juvenile arrests were for drug abuse or underage drinking violations 

(Puzzanchera 2009). As many as two-thirds of detained juveniles 

may have a substance use disorder (SUD); female juveniles who 

enter the system generally have higher SUD rates than males 

(McClelland et al. 2004a). 

Although the past several decades 

have witnessed an increased interest 

in providing substance abuse 

treatment services for criminal 

justice offenders, only a small 

percentage of offenders has access 

to adequate services, especially in jails 

and community correctional facilities 

(Taxman et al. 2007; Sabol et al. 2010). Not 

only is there a gap in the availability of these services for offenders, 

but often there are few choices in the types of services provided. 

Treatment that is of insufficient quality and intensity or that is not 

well suited to the needs of offenders may not yield meaningful 

reductions in drug use and recidivism. Untreated substance abusing 

offenders are more likely than treated offenders to relapse to drug 

abuse and return to criminal behavior. This can lead to re-arrest 

and re-incarceration, jeopardizing public health and public safety 

and taxing criminal justice system resources. Treatment is the most 

effective course for interrupting the drug abuse/criminal justice cycle 

for offenders with drug abuse problems.

Drug abuse treatment can be incorporated into criminal justice 

settings in a variety of ways. Examples include treatment in prison 

followed by community-based treatment after release; drug courts 

that blend judicial monitoring and sanctions with treatment by 

imposing treatment as a condition of probation; and treatment under 

parole or probation supervision. Drug abuse treatment can benefit 

from the cross-agency coordination and collaboration of criminal 

justice professionals, substance abuse treatment providers, and 

other social service agencies. By working together, the criminal 

justice and treatment systems can optimize resources to benefit the 

health, safety, and well-being of the individuals and communities 

they serve.

Treatment offers 

the best alternative 

for interrupting the 

drug abuse/criminal 

justice cycle.
14
15

1. Why do people involved in the criminal 

justice system continue abusing drugs?

The answer to this perplexing question spans basic neurobiological, 

psychological, social, and environmental factors. The repeated use of 

addictive drugs eventually changes how the brain functions. Resulting 

brain changes, which accompany the transition from voluntary to 

compulsive drug use, affect the brain’s natural inhibition and reward 

centers, causing the 

addicted person to 

use drugs in spite of 

the adverse health, 

social, and legal 

consequences (Baler 

and Volkow 2006; 

Volkow et al. 2010; 

and Chandler et 

al. 2009). Craving 

for drugs may be 

triggered by contact 

with the people, 

places, and things 

associated with prior 

drug use, as well as 

by stress. Forced 

abstinence (when it occurs) is not treatment, and it does not cure 

addiction. Abstinent individuals must still learn how to avoid relapse, 

including those who may have been abstinent for a long period of time 

while incarcerated.

FREQUENTLY ASKED 

QUESTIONS (FAQS)

Normal

Addictive drugs cause

long-lasting changes in the brain

Cocaine Abuser

(100 days of 

abstinence)

PET scans showing glucose metabolism in healthy 

(normal) and cocaine-addicted brains. Even after 100 

days of abstinence, glucose metabolism has not returned 

to normal levels.

Source: Volkow et al., 1992, 1993.

Cocaine Abuser

(10 days of 

abstinence) 
16

Potential risk factors for released offenders include pressures 

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

lifestyle. Tensions of daily life—violent associates, few opportunities 

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

to comply with correctional supervision conditions—can also create 

stressful situations that can precipitate a relapse to drug use.

Research on how the brain is affected by drug abuse promises 

to teach us much more about the mechanics of drug-induced brain 

changes and their relationship to addiction. Research also reveals 

that with effective drug abuse treatment, individuals can overcome 

persistent drug effects and lead healthy, productive lives.

2. Why should drug abuse treatment 

be provided to offenders?

The case for treating drug abusing offenders is compelling. Drug 

abuse treatment improves outcomes for drug abusing offenders and 

has beneficial effects for public health and safety. Effective treatment 

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

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

improve prospects for employment. In addition, it can save lives: A 

retrospective study of more than 30,000 Washington State inmates 

found that during the first 2 weeks after release, the risk of death 

among former inmates was more than 12 times that among other 

residents, with drug overdose being the leading cause (Binswanger et 

al. 2007).

Outcomes for substance abusing individuals can be improved when 

criminal justice personnel work in tandem with treatment providers 

on drug abuse treatment needs and supervision requirements. 

Treatment needs that can be assessed after arrest include substance 

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

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

prosecution and sentencing phases of the criminal justice process 

to determine suitable treatment programs that meet the offender’s 

needs. Through drug courts, diversion programs, pretrial release 

programs that are conditional on treatment, and conditional probation 

with sanctions, the offender can participate in community-based drug 

FREQUENTLY ASKED QUESTIONS
17

abuse treatment while under criminal justice supervision. In some 

instances, the judge may recommend that the offender participate 

in treatment while serving jail or prison time or require it as part of 

continuing correctional supervision post-release.

3. How effective is drug abuse treatment 

for criminal justice-involved individuals?

Treatment is an effective intervention for drug abusers, including 

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

effectiveness of drug treatment depends on both the individual and the 

program, and on whether interventions 

and treatment services are available 

and appropriate for the individual’s 

needs. To alter attitudes, beliefs, 

and behaviors that support 

drug use, the drug abuser must 

engage in a therapeutic change 

process, which may include 

medications to help prevent relapse. 

Longitudinal outcome studies find 

that those who participate in community-based drug abuse treatment 

programs commit fewer crimes than those who do not participate 

(Prendergast et al. 2002; Butzin et al. 2006; and Kinlock et al. 2009).

4. Are all drug abusers in the criminal justice 

system good candidates for treatment?

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

abuse treatment. Offenders who meet drug dependence criteria 

should be given higher priority for treatment than those who do 

not. Less intensive interventions, such as drug abuse education 

or self-help group participation, may be appropriate for those not 

meeting criteria for drug dependence. Services such as familybased interventions for juveniles, psychiatric treatment, or cognitivebehavioral interventions for changing “criminal thinking” may be a 

higher priority for some offenders, and individuals with mental health 

problems may require specialized services (see FAQ Nos. 6 and 12).

Outcomes can be 

improved when criminal 

justice personnel work 

in tandem with treatment 

providers.
18

Low motivation to participate in treatment or to end drug abuse 

should not preclude access to treatment if other criteria are met. 

Motivational enhancement interventions may be useful in these 

cases. Examples include motivational interviewing and contingency 

management techniques, which often provide tangible rewards in 

exchange for meeting program goals. Legal pressure that encourages 

abstinence and treatment participation may also help these individuals 

by improving retention and prompting longer treatment stays.

Drug abuse treatment is also effective for offenders who have 

a history of serious and violent crime, particularly if they receive 

intensive, targeted services. The economic benefits in avoided crime 

costs and those of crime victims (e.g., medical costs, lost earnings, 

and loss in quality of life) may be substantial for these high-risk 

offenders. Treating them requires a high degree of coordination 

between drug abuse treatment providers and criminal justice 

personnel to ensure that the prisoners receive needed treatment and 

other services that will help prevent criminal recidivism.

5. Is legally mandated treatment effective?

Often, the criminal justice system can apply legal pressure to 

encourage offenders to participate in drug abuse treatment; or 

treatment can be mandated through a drug court or as a condition 

of pretrial release, probation, or parole. A large percentage of those 

admitted to drug abuse treatment cite legal pressure as an important 

reason for seeking treatment. Most studies suggest that outcomes 

for those who are legally pressured to enter 

treatment are as good as or better than 

outcomes for those who entered treatment 

without legal pressure. Individuals under 

legal pressure also tend to have higher 

attendance rates and remain in treatment 

for longer periods, which can also have a 

positive impact on treatment outcomes.

Legal pressure can 

increase treatment 

attendance and 

improve retention.

FREQUENTLY ASKED QUESTIONS
19

6. Are relapse risk factors different in 

offender populations? How should drug abuse 

treatment deal with these risk factors?

Often, drug abusing offenders have problems in other areas. 

Examples include family difficulties, limited social skills, educational 

and employment problems, mental health disorders, infectious 

diseases, and other medical issues. Treatment should take these 

problems into account, because they can increase the risk of drug 

relapse and criminal recidivism if left unaddressed.

Stress is often a contributing factor 

to relapse, and offenders who are 

re-entering society face many 

challenges and stressors, 

including reuniting with family 

members, securing housing, and 

complying with criminal justice 

supervision requirements. Even 

the many daily decisions that most 

people face can be stressful for those 

recently released from a highly controlled prison environment.

Other threats to recovery include a loss of support from family or 

friends, which incarcerated people may experience. Drug abusers 

returning to the community may also encounter people from their 

lives who are still involved in drugs or crime and be enticed to resume 

a criminal and drug using lifestyle. Returning to environments or 

activities associated with prior drug use may trigger strong cravings 

and cause a relapse. A coordinated approach by treatment and 

criminal justice staff provides the best way to detect and intervene with 

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

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

could lead to relapse.

Treatment staff should identify the offender’s unique relapse risk 

factors and periodically re-assess and modify the treatment plan 

as needed. Generally, continuing or re-emerging drug use during 

treatment requires a clinical response—either increasing the amount 

or level of treatment, or changing the treatment intervention.

Returning to environments

associated with drug use 

may trigger cravings and 

cause a relapse.
20

7. What treatment and other health services 

should be provided to drug abusers involved 

with the criminal justice system?

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

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

time, various combinations of treatment services may be required. 

Evidence-based interventions include cognitive-behavioral therapy to 

help participants learn positive social and coping skills, contingency 

management approaches to reinforce positive behavioral change, and 

motivational enhancement to increase treatment engagement and 

retention. In those addicted to opioid drugs, agonist/partial agonist 

medications can also help normalize brain function, and antagonist 

medications can facilitate abstinence. For juvenile offenders, 

treatments that involve the family and other aspects of the drug 

abuser’s environment have established efficacy.

Drug abuse treatment plans for incarcerated offenders can facilitate 

successful re-entry into the community by incorporating relevant 

transition plans and services. Drug abusers often have mental and 

physical health, family counseling, parenting, educational, and 

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

often crucial components of successful treatment. Case management 

approaches can be used to provide assistance in obtaining and 

integrating drug abuse treatment with community services.

8. How long should drug abuse treatment last for 

individuals involved in the criminal justice system?

While individuals progress through drug abuse treatment at 

different rates, one of the most reliable findings in treatment 

research is that lasting reductions in criminal activity and drug 

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

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

treatment completers achieving the greatest reductions in drug 

abuse and criminal behavior. Again, legal pressure can improve 

retention rates. 

FREQUENTLY ASKED QUESTIONS
21

A longer continuum of treatment may be indicated for individuals 

with severe or multiple problems. Research has shown that 

treatment provided in prison and continued in the community after 

release can reduce the risk of recidivism to criminal behavior as well 

as relapse to drug use. 

Early phases of treatment help the participant stop using drugs and 

begin a therapeutic process of change. Later stages address other 

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

learn how to self-manage the drug problem.

Because addiction is a chronic disease, drug relapse and return 

to treatment are common features of recovery. Thus, treatment may 

need to extend over a long period across multiple episodes of care.

9. How can rewards and sanctions 

be used effectively with drug-involved 

offenders in treatment?

The systematic application of behavioral management principles 

underlying reward and punishment can help individuals reduce their 

drug use and criminal behavior. Rewards and sanctions are most 

likely to change behavior when they are certain to follow the targeted 

behavior, when they follow swiftly, and when they are perceived as fair. 

It is important to recognize and reinforce progress toward responsible, 

abstinent behavior. Rewarding positive behavior is more effective 

in producing long-term positive change than punishing negative 

behavior. Indeed, punishment alone is an ineffective public health 

and safety intervention for offenders whose crime is directly related to 

drug use (Leukefeld et al. 2002). Nonmonetary rewards such as social 

recognition can be as effective as monetary ones. A graduated range 

of rewards given for meeting predetermined goals can be an effective 

strategy. 

Contingency management strategies, proven effective in community 

settings, use voucher-based incentives or rewards, such as bus 

tokens, to reinforce abstinence (measured by negative drug tests) 

or to shape progress toward other treatment goals, such as program 

session attendance or compliance with medication regimens. 

Contingency management is most effective when the contingent 

reward closely follows the behavior being monitored. An intervention 
22

tested by CJ-DATS researchers, called “Step’n Out,” used a 

contingency management approach whereby criminal justice staff 

monitored specific behaviors (e.g., abstinence, employment searches, 

and counseling attendance) and rewarded individuals who met 

agreed-upon goals with social acknowledgement (e.g., congratulatory 

letter from parole supervisor) and small material incentives (e.g., 

partial payment for clothes for job interviews). This approach improved 

parolees’ attendance at integrated community parole and addiction 

treatment sessions, as well as increased use of treatment and 

individual counseling services (Friedmann et al. 2009). 

Graduated sanctions, which invoke less punitive responses for early 

and less serious noncompliance and increasingly severe sanctions 

for more serious or continuing problems, can be an effective tool 

in conjunction with drug testing. The effective use of graduated 

sanctions involves consistent, predictable, and clear responses to 

noncompliant behavior. 

Drug testing can determine when an individual is having difficulties 

with recovery. The first response to drug use detected through 

urinalysis should be a clinical one—for example, increasing treatment 

intensity or switching to an alternative treatment. This often requires 

coordination between the criminal justice staff and the treatment 

provider. (Note that more intensive treatment should not be considered 

a sanction, but rather a routine progression in health care practice 

when a treatment appears less effective than expected.)

Behavioral contracting can employ both 

rewards and sanctions. A behavioral contract 

is an explicit agreement between the 

participant and the treatment provider 

or criminal justice monitor (or among all 

three) that specifies proscribed behaviors 

and associated sanctions, as well as 

positive goals and rewards for success. 

Behavioral contracting can instill a sense of 

procedural justice because both the necessary 

steps toward progress and the sanctions for violating the contract are 

specified and understood in advance.

It is important to 

recognize and 

reinforce progress 

toward responsible, 

abstinent behavior.

FREQUENTLY ASKED QUESTIONS
23

10. What is the role of medications in 

treating substance abusing offenders?

Medications can be an important component of effective drug 

abuse treatment for offenders. By allowing the brain to function more 

normally, they enable the addicted person to leave behind a life of 

crime and drug abuse. Although some jurisdictions have found ways to 

successfully implement medication therapy, addiction medications are 

underused in the treatment of drug abusers within the criminal justice 

system, despite evidence of their effectiveness.

Methadone transfer 

on release

Methadone referral only

Methadone preand post-release

Methadone treatment before and after 

release from prison increases treatment 

retention and reduces drug use

Source: Kinlock et al. 2009.

At 12 months post-release, offenders who had received methadone 

treatment in prison and continued it in the community were significantly 

more likely to enter and stay in treatment and less likely to test 

positive for opioid and cocaine use than participants who received 

counseling and referral to methadone, or those who received 

counseling with transfer to methadone maintenance upon release.

In CommunityBased TxOpioid Test 

Positive

Cocaine Test 

Positive

Percentage

20

40

60

80

100

0

17.3

36.7

65.6

48.7

25

71.9

66.6

43.2

0
24

Effective medications have been developed for treating addiction to 

opiates/heroin and alcohol:

• Opiates/Heroin. Long-term opiate abuse results in a desensitization 

of the brain’s opiate receptors to endorphins, the body’s natural 

opioids. Opioid agonist/partial agonist medications, which act at 

the same receptors as heroin, morphine, and endorphins, tend to 

be well tolerated and can help an individual remain in treatment. 

For example, methadone, an opiate agonist, reduces the craving 

that otherwise results in compulsive use of heroin or other illicit 

opiates. Methadone treatment has been shown to be effective in 

decreasing opiate use, drug-related criminal behavior, and HIV risk 

behavior. Buprenorphine is a partial agonist 

and acts on the same receptors as morphine 

(a full agonist), but without producing the 

same level of dependence or withdrawal 

symptoms. Suboxone is a unique 

formulation of buprenorphine that contains 

naloxone, an opioid antagonist that limits 

diversion by causing severe withdrawal 

symptoms in addicted users who inject it to 

get “high.” It has no adverse effects when taken 

orally, as prescribed. 

 An alternative approach, in previously detoxified opiate users, is 

to use an antagonist medication that blocks the effects of opiates. 

Naltrexone has been available for more than 2 decades, but 

poor compliance in the face of severe cravings and addiction has 

undermined its benefits. An extended-release injectable formulation 

of naltrexone (Vivitrol) was recently approved by the U.S. Food 

and Drug Administration (FDA) for treating opioid addiction. Vivitrol 

requires dosing every few months rather than daily, which stands to 

improve treatment adherence.

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

therapy that induces nausea if alcohol is consumed. Acamprosate, 

a medication that helps reduce alcohol craving, works by restoring 

normal balance to the brain’s glutamate neurotransmitter system. 

FREQUENTLY ASKED QUESTIONS

Medications can 

be an important 

component of 

effective drug 

abuse treatment 

for offenders.
25

Naltrexone (and now Vivitrol), which blocks some of alcohol’s 

pleasurable effects and alcohol craving, is also approved by the FDA 

for treatment of alcohol abuse.

11. How can the criminal justice and drug 

abuse treatment systems reduce the spread 

of HIV/AIDS, hepatitis, and other infectious 

diseases among drug abusing offenders?

Individuals involved in the criminal justice system have 

disproportionately high rates of substance use disorders and infectious 

diseases, including HIV/AIDS. In fact, 14 percent of HIV-infected 

individuals in this country pass through the criminal justice system 

each year (Spaulding et al. 2009). Other infectious diseases, such 

as hepatitis B, hepatitis C, and tuberculosis, also are pervasive in the 

criminal justice system. 

This overrepresentation also provides an opportunity to integrate 

treatment and improve outcomes for both substance use disorders 

and infectious diseases. Research shows that treatment for drug 

abuse can lessen the spread of infectious diseases by reducing 

high-risk behaviors like needle-sharing and unprotected sex (Metzger 

et al. 2010). Identifying those who are 

HIV+ and starting them on HAART 

treatment could not only improve 

their health outcomes but also 

decrease HIV spread (Montaner 

et al. 2010). 

It is imperative that offenders 

with infectious diseases be linked 

with community-based medical 

care prior to release. Offenders often 

have difficulty negotiating access to health services and adhering to 

complex treatment protocols following release from prison and jail. 

One study found that simply helping HIV-infected inmates complete 

the paperwork required to get their prescriptions filled upon release 

significantly diminished treatment interruption, although improvement 

was still needed, since fewer than half had filled their prescriptions 

within 2 months of release (Baillargeon et al. 2009). 

The prevalence of AIDS

is approximately five 

times higher among 

incarcerated offenders 

than in the general 

population.
26

Community health, drug treatment, and criminal justice agencies 

should work together to offer education, screening, counseling, 

prevention, and treatment programs for HIV/AIDS, hepatitis, and other 

infectious diseases to offenders returning to the community.

12. What works for offenders with co-occurring 

substance abuse and mental disorders?

It is important to adequately assess mental disorders and to 

address them as part of effective drug abuse treatment. Many types of 

co-occurring mental health problems can be successfully addressed 

in standard drug abuse treatment programs. However, individuals 

with serious mental disorders may require an integrated treatment 

approach designed for treating patients with co-occurring mental and 

substance use disorders. 

Much progress has been made in developing effective medications 

for treating mental disorders, including a number of antidepressants, 

antianxiety agents, mood stabilizers, and antipsychotics. These 

medications may be critical for treatment success with offenders 

who have co-occurring mental disorders such as depression, 

anxiety disorders, bipolar disorder, or schizophrenia. Cognitivebehavioral therapy can be effective for treating some mental health 

problems, particularly when combined with medications. Contingency 

management can improve adherence to medications, and intensive 

case management may be useful for linking severely mentally ill 

individuals with drug abuse treatment, mental health care, and 

community services. A specialized type of treatment—Modified 

Therapeutic Communities (MTCs)—incorporates features of traditional 

Therapeutic Communities with a special focus on addressing 

co-occurring mental health conditions.

13. Is providing drug abuse treatment to 

offenders worth the financial investment?

In 2007, it was estimated that the cost to society of drug abuse 

was $193 billion (National Drug Intelligence Center [NDIC], 2011), a 

substantial portion of which—$113 billion—is associated with drugrelated crime, including criminal justice system costs and costs borne 

by victims of crime. The cost of treating drug abuse (including health 

FREQUENTLY ASKED QUESTIONS
27

costs, hospitalizations, and government 

specialty treatment) was estimated to be 

$14.6 billion, a fraction of these overall 

societal costs (NDIC, 2011). Drug abuse 

treatment is cost effective in reducing 

drug use and bringing about related 

savings in health care. Treatment also 

consistently has been shown to reduce 

the costs associated with lost productivity, 

crime, and incarceration across various settings 

and populations. The largest economic benefit of treatment is seen 

in avoided costs of crime (incarceration and victimization costs). 

Providing methadone treatment to opioid-addicted prisoners prior to 

their release, for example, not only helps to reduce drug use but also 

avoids the much higher imprisonment costs for drug-related crime 

(see figure).

Even greater economic benefits result from treating offenders with 

co-occurring mental 

health problems 

and substance use 

disorders. Residential 

prison treatment is 

more cost effective 

if offenders attend 

treatment postrelease, according 

to research (Martin 

et al. 1999; Butzin 

2006). Drug courts 

also convey positive 

economic benefits, 

including participantearned wages and 

avoided incarceration 

and future crime 

costs.

$4,700

Cost of Treatment

$24,000

Cost of Incarceration

Treating addiction in the criminal justice 

system is cost-effective

The cost of methadone treatment averages 

around $5,000 a year, compared to approximately 

$24,000 for State and Federal prisons to keep 

people confined. Reducing the number of people 

incarcerated for drug use can net huge savings in 

economic and social costs.

Sources: Zarkin et al. 2008 and Warren et al. 2008.

The largest 

economic benefit 

of treatment is 

seen in avoided 

costs of crime.
28

14. What are the unique treatment needs 

of women in the criminal justice system?

Although women are incarcerated at far lower rates than men, 

the number and percentage of incarcerated women have grown 

substantially in recent years. Between 2000 and 2008, the number 

of men in prisons and jails grew by only 5 percent, while the number 

of incarcerated women grew by about 15 percent (Sabol et al. 2010). 

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

needs than men, presenting particular treatment challenges that may 

call for tailored approaches (Greenfield et al. 2007) (figure).

Incarcerated women in treatment are significantly more likely 

than incarcerated men to have severe substance abuse histories, 

co-occurring mental disorders, and high rates of past treatment for 

both; they also tend to have more physical health problems (Staton 

et al. 2003; Messina et al. 2006). Approximately 50 percent of female 

offenders are likely to have histories of physical or sexual abuse, and 

women are more likely than men to be victims of domestic violence. 

Past or current victimization can contribute to drug or alcohol abuse, 

depression, post-traumatic stress disorder, and criminal activity.

Treatment programs serving both men and women can provide 

effective treatment for their female patients. However, genderspecific programs may be more effective for female offenders, 

particularly those with histories of trauma and abuse (Pelissier 

et al. 2003). Female offenders are more likely to need medical 

and mental health services, child care services, and assistance 

in finding housing and employment. Following a comprehensive 

assessment, women with mental health disorders should receive 

appropriate treatment and case management, including victim 

services as needed. For female offenders with children, parental 

responsibilities can conflict with their ability to participate in drug 

treatment. Regaining or retaining custody of their children can also 

motivate mothers to participate in treatment. Treatment programs 

may improve retention by offering child care services and parenting 

classes.

FREQUENTLY ASKED QUESTIONS
29

15. What are the unique treatment needs 

of juveniles in the criminal justice system?

The U.S. Department of Justice’s Office of Justice Programs 

reports a high rate of drug use among juvenile detainees. One study, 

for example, found that 77 percent of criminal justice-involved youth 

reported substance use (mainly marijuana) in the past 6 months, and 

nearly half of male and female juvenile detainees had a substance use 

disorder (McClelland et al. 2004a; McClelland et al. 2004b).

Arrest rates for drug-related crimes also remain high among 

juveniles. A recent report showed that of the estimated 2.1 million 

juvenile arrests in 2008, approximately 10 percent were for drug abuse 

or underage drinking violations (Puzzanchera 2009).

Juveniles entering the criminal justice system can bring a number 

of serious problems with them—substance abuse, academic failure, 

emotional disturbances, physical health issues, family problems, and 

Incarcerated women have high rates of 

substance abuse, mental disorders, 

and other health problems

Any drug problem

*Multiple drugs

*Alcohol

*Cocaine

Any mental health

Depression

Anxiety

Dental

Reproductive health

Trauma/injury

Cardiovascular

STDs

Substance abuse Tx

Mental health Tx

Psychotropic medications

Source: Staton et al., 2003.

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

and cocaine, which are the percentage reporting use in the 30 days prior to 

incarceration. (N=60)

0 20 40 60 80 100

Percent
30

a history of physical or sexual abuse. Girls make up nearly one-third 

of juvenile arrests, a high percentage of whom report some form of 

emotional, physical, or sexual abuse. Effectively addressing these 

problems requires their gaining access to comprehensive assessment, 

treatment, case management, and support services appropriate 

for their age and developmental stage. 

Assessment is particularly important, 

because not all adolescents who have 

used drugs need treatment. For those 

who do, there are several points 

in the juvenile justice continuum 

where treatment has been integrated, 

including juvenile drug courts, 

community-based supervision, juvenile 

detention, and community re-entry.

Families play an important role in the recovery of substance abusing 

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

substance abuse or criminal involvement, physical or sexual abuse 

by family members, and lack of parental involvement or supervision 

are all risk factors for adolescent substance abuse and delinquent 

behavior. Thus, the 

effective treatment of 

juvenile substance 

abusers often requires a 

family-based treatment 

model that targets 

family functioning 

and the increased 

involvement of family 

members. Effective 

adolescent treatment 

approaches include 

multisystemic therapy, 

multidimensional family 

therapy, and functional 

family therapy. These 

interventions show promise in strengthening families and decreasing 

juvenile substance abuse and delinquent behavior.

FREQUENTLY ASKED QUESTIONS

Effective treatment 

of juvenile substance 

abusers often requires 

a family-based 

treatment model.

Juvenile offenders

Virtually every juvenile offender should 

be screened for drug abuse and mental 

disorders, and receive an intervention:

• Treatment for those who are dependent on 

alcohol or drugs, or mentally ill.

• Drug abuse prevention for those who are not. 

• HIV prevention or treatment as needed.
31
32

RESOURCES

Many resources 

are available on the 

Internet.

The following are useful links:

General Information

NIDA Web site: www.drugabuse.gov

General Inquiries: NIDA Public Information Office 301–443–1124

Federal Resources

Bureau of Justice Assistance (BJA)

Substance Abuse Programs

www.bja.gov/Topic.

aspx?Topic_ID=8

Bureau of Justice Statistics (BJS) 

Statistics on Drugs and Crime

www.bjs.ojp.usdoj.gov/

content/dcf/contents.cfm

Center for Substance Abuse 

Treatment (CSAT) 

Substance Abuse and Mental Health

Services Administration (SAMHSA)

www.beta.samhsa.gov/

about-us/who-we-are/

offices-centers/csat
33

Federal Resources (continued)

Federal Bureau of Prisons (BOP)

Substance Abuse Treatment

www.bop.gov/inmates/

custody_and_care/substance_abuse_treatment.

jsp

National Criminal Justice

Reference Service (NCJRS)

www.ncjrs.gov

National Institute on Alcohol Abuse

and Alcoholism (NIAAA)

www.niaaa.nih.gov

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

National Institute of Justice (NIJ) www.nij.gov

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

Office of Applied Studies (OAS)

Substance Abuse and Mental Health

Services Administration (SAMHSA)

www.samhsa.gov/data

Office of Justice Programs (OJP) www.ojp.gov

Office of Juvenile Justice and

Delinquency Prevention (OJJDP)

www.ojjdp.gov
34

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Paar, D.P. Accessing antiretroviral therapy following release from prison. 

JAMA 301(8):848–857, 2009.

Binswanger, I.A.; Stern, M.F.; Deyo, R.A.; Heagerty, P.J.; Cheadle, A.; Elmore, J.G.; 

and Koepsell, T.D. Release from prison—a high risk of death for former inmates. 

New Engl J Med 356(2):157–165, 2007.

Butzin, C.A., O’Connell, D.J., Martin, S.S., and Inciardi, J.A. Effect of drug treatment 

during work release on new arrests and incarcerations. J Crim Justice 34(5):557–

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Chandler, R.K; Fletcher; B.W.; and Volkow, N.D. Treating drug abuse and 

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Cooper, M.; Sabol, W.J; and West, H.C. Prisoners in 2008. Washington, DC: 

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Friedmann, P.D.; Rhodes, A.G.; and Taxman, F.S.; for the Step’n Out Research 

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Out study. J Exp Criminol 5(3):227–243, 2009.

Glaze, L.E., and Herberman, E.J. Correctional Populations in the United States, 

2012. Washington, DC: U.S. Department of Justice, Office of Justice Programs, 

Bureau of Justice Statistics, 2013.

Greenfield, S.F., Brooks, A.J., Gordon, S.M., Green, C.A., Kropp, F., McHugh, R.K., 

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DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile 

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For More Information

For more information about other research-based publications 

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

www.drugabuse.gov, or contact the DrugPubs

Research Dissemination Center at 877–NIDA-NIH 

(877-643-2644; TTY/TDD: 240–645–0228).
1

NIH Publication No. 11-5316

Printed September 2006,

Revised September 2007,

November 2009, January 2012, April 2014