Chapter 2-The Relationship of Addiction to Crime, Health, and Other Social Problems

by Jackie Massaro, C.S.W., and Bert Pepper, M.D.
The Information Exchange, Inc.

Addiction to alcohol and other drugs (AOD) has grown to be a far-reaching problem in the United States. It not only has led to a greatly increased crime rate; it is closely associated with increased communicable diseases, mental illnesses, and an over-taxed social services system. This chapter takes a brief look at the issues, emphasizing a need to treat the substance abuser as a means of protecting the innocent.

Addiction and Crime

In 1972 the United States had a total of 196,000 jail and prison cells; by 1991 that number had risen to between 1.1 and 1.25 million, a 600 percent increase. A single State such as New York State increased its jail and prison population from 13,000 in 1970 to about 60,000 in 1992.

Despite the number of people in prisons, the streets are more dangerous than ever. Crime has not been checked although the United States incarcerates more people per capita than any other nation on the planet. It is critical that we begin to develop an alternative to the status quo because this nation cannot afford to continue current rates of incarceration. Alternative sentencing coupled with mandatory treatment must be considered. Figure 2-A compares the numbers of incarcerated persons in American jails and prisons between 1970 and 1991.

What is the relationship of drug use to crime? The statistics are shocking to the general public, but common knowledge to those in the criminal justice and substance abuse treatment fields. The criminal justice data presented in the following paragraphs and Table 2-A reflect a dramatic correlational relationship between drug use and crime. With this knowledge, steps must be taken to identify drug users, treat the problems of chemical dependency, attend to environmental correlates of relapse (lack of job skills, employment, housing, family stresses, etc.) and prevent relapse through continuing care programs (including the use of self-help models). The task seems enormous and expensive, yet it pales when compared with the apparent failure and costs of current methods.

Current research by the United States Department of Justice attempts to clarify the relationship between drug use and crime by surveying and/or performing drug testing on arrestees, probationers, and prison inmates at selected sites through random sampling. Surveys involve interviews, questionnaires, and other instrumentation. Drug testing is done by urinalysis.

Arrestees
The National Institute of Justice Drug Use Forecasting Program (DUF) measures recent drug use by arrestees. The data collected are also used to determine trends in drug use by this population (see Figures 2-B and 2-C for 1992 DUF data). Trained local staff obtain urine specimens and interview booked arrestees. Participation in the program is both anonymous and voluntary. Participation levels are high, with 90 percent of arrestees agreeing to interviews and 80 perecent agreeing to urine testing. In order to obtain samples with sufficient distribution of arrest charges, drug charge and driving offense samples are limited in male arrestees. Juvenile and female samples are not limited because they are fewer in number. Samples for male booked arrestees are taken at 24 sites in major cities across the United States, while samples for females are taken at 21 of those sites and samples for juveniles, at 11 sites.

Probationers
The Bureau of Justice Statistics surveyed felons on probation using a sample of one-quarter of felons sentenced to probation in 1986. The survey used State criminal history files and probation files. The sample was not nationally representative, yet is informative. This survey found that 53 percent of probationers had an identified drug abuse problem(22 percent occasional users, 31 percent frequent users).

The rearrest data for probationers who had been convicted of a drug offense were:

• 27 percent rearrested for drug offense
• 7 percent rearrested for violent offense
• 20 percent rearrested for property offense
• 5 percent rearrested for other offense

Treatment or drug testing:

• 38 percent of probationers were required to participate in treatment (9 percent required to participate in alcohol treatment)
• 48 percent of probationers were required to participate in drug testing
• 42 percent of probationers with known drug problems were not required to be tested for drugs

State prisoners:

• 54 percent reported drug use at time of offense (1986)
• 52 percent reported use during month prior 43 percent reported daily use 46.8 percent of State prisoners were actively involved with illegal drugs either as users or by conviction on a drug charge

Violent offenders:

• 54 percent of violent offenders reported use at time of offense
• 30 percent of victims were perceived to be under the influence
• drug use was highest among those who victimized strangers
• manslaughter was the crime which most involved AOD by offender, victim, or both

Drug offenders and burglary:

50 percent of robbery, burglary, larceny, or drug offenders were daily drug users 40 percent reported use at time of offense (higher percentage than for other offenses) 58 percent of federal inmates (1991) were drug offenders 26.1 percent of State inmates were drug offenders (with no known prior sentence to probation or incarceration).

Past dependency or treatment:

• 28 percent of State prisoners reported past drug dependency
• 30 percent reported participation in a drug treatment program at some time (half received most recent treatment while incarcerated)

1. abstinence from AOD, and
2. reduced recidivism to crime.

In addition, the individuals who populate the nation's prisons and probation or parole caseloads are caught in a web of social problems. These problems also contribute to high rates of recidivism and must be considered in a holistic approach.

Addiction and Health

Addiction to psychoactive drugs has profound affects on the brain and all other organ systems. These changes are caused by direct effects of drugs, the mode of drug ingestion or factors associated with the drug-using lifestyle. For example, heroin itself disrupts the normal patterns of mood; injection of heroin with unsterile needles places the user at risk for developing AIDS, hepatitis and numerous other blood disorders, or infection of internal organs; heroin users are frequently malnourished, compromising the body's ability to ward off disease. It has long been known that alcohol and other drug users were at greater risk of health problems than nonusers. In recent years, however, drug users have become a critical link in the AIDS epidemic and the related resistant tuberculosis epidemic, placing innocent nonusers at risk of developing these potentially fatal communicable diseases.

• Alcohol's direct effects on immune function can compromise the immune system. The immune system is dependent upon vitamins, proteins, and other nutrients to function properly. Alcohol can inhibit the absorption and bio-availability of important nutrients leading to malnutrition.
• The liver is the organ responsible for making nutrients "bio-available" and for metabolizing toxins. Alcohol and some other drugs impair liver function. Liver dysfunction caused by AOD leads to malnutrition as well as increased exposure to toxic substances (for example, contaminants in street drugs).
• IV drug use can cause viral hepatitis, an infection of the liver; alcoholism causes cirrhosis, a scarring of the liver, as well as hepatitis.
• Malnutrition can also be a result of improper diet. Alcohol and other drug dependent people will often use resources (money) for drugs and eat poorly.
• Addicts do not seek proper medical care, fearing contact with legal authorities. As a social group, they are also inexperienced consumers of medical care. Lack of attention to minor medical problems can sometimes lead to major medical problems.
• Addiction sometimes results in poor hygiene; this can result in infection of minor cuts, dental disease, and urinary tract infection, among other problems.
• Prenatal AOD exposure has been clearly linked to the disruption of the normal development and maturation of the brain, heart, skeleton, and immune system. We know that most pregnant drug users are polydrug abusers, most commonly using alcohol, but perhaps using cocaine, marijuana, etc.
• Alcohol and other drugs can act as disinhibitors. When inhibitions are reduced, it is more likely that individuals will engage in high risk behaviors such as unprotected sex, use of multiple drugs (possibly including injectable drugs), or activities that can result in serious accident or injury.
• AOD can impair motor function, making simple activities into high risk activities (i.e., driving, standing on a subway platform, crossing busy streets, swimming, operating machinery). These accidents frequently place others at risk for injury as well.

The sharing of blood contaminated needles, syringes, and works (other instruments associated with IV drug use) is the conduit of the human immunodeficiency virus (HIV), which is responsible for AIDS. IVDUs share equipment for many reasons, including convenience, lack of access to sterile equipment, and the social milieu of drug use.

In addition to the IVDUs, substance abuse-related AIDS cases also include individuals infected through sexual contact and children born to HIV infected mothers. Additional factors associating AOD use with HIV/ AIDS include the following:

• cocaine is associated with increased sexual desire and may lead to unprotected sexual contact;
• the exchange of sex for drugs;
• prostitution for obtaining money for drugs;
• AOD can disinhibit resulting in high risk behaviors; and
• cocaine users often use heroin intravenously to mediate withdrawal.

Tuberculosis (TB) is an infection caused by the bacterial organism Mycobacterium tuberculosis. An infected individual can spread the disease by coughing. The tiny bacteria become airborne and are small enough to be inhaled by another into the lungs. In order for an individual to become infected, prolonged or repeated exposure is usually necessary. The TB bacteria accumulate and multiply in the lung and then spread to the lymph nodes. The infection moves to other organs through the blood stream.

The spread of disease can be rapid in crowded housing, shelters, hospitals, prisons, or other institutions, since the disease is airborne. These settings are associated with the lifestyle of AOD users. In addition, the compromising effects of AOD on the immune system place addicts at high risk for TB infection. Finally, IV drug use and sexual disinhibition place addicts at risk for HIV infection, a high risk factor for the development of active TB.

Treatment of TB with anti-tuberculosis drugs is usually effective, but addiction and alcoholism present complicating factors. For example, many addicts are reluctant to use the health care system, fearful of reprisal. Even when they do seek medical help and are diagnosed with TB, many are not compliant with treatment instructions. They do not take medication or get follow-up care. In addition, they continue to compromise their health through the use of alcohol and other drugs. These patterns in alcoholics and addicts have contributed to a new menace, multi-drug resistant (MDR) tuberculosis, a type of TB that does not respond to the usual anti-tuberculosis medical treatment.

Common tuberculosis and MDR tuberculosis are proving to be more contagious that previously believed, placing millions of non-addicted individuals at risk for a serious and possibly fatal disease.

HIV/AIDS and Tuberculosis
HIV infection weakens the body's immune system and increases the likelihood of the progression of latent TB infection to active TB. In fact, HIV infection is the highest risk factor associated with the development of active TB.

AIDS and Tuberculosis in Corrections
The war on drugs has led to an unprecedented number of individuals with multiple health problems populating the nation's prisons. Overcrowded conditions in jails and prisons contribute to the spread of disease and portend a public health emergency. In jails and prisons nationwide, cells designed for one individual have been accommodating two and three individuals. A 1990 survey indicated that correctional institutions were operating well beyond capacity:

• State prisons by 18 percent to 29 percent over capacity;
• federal prisons by 51 percent over capacity; and
• jails by 104 percent over capacity.

(Source: American College of Physicians, National Commission on Correctional Care, and American Correctional Health Services Association, 1992.)

The incidence of AIDS is 14 times higher in State and federal correctional systems than in the general population, while the incidence of TB in persons with AIDS is almost 500 times that of the general population. In 1985, the Centers for Disease Control and Prevention estimated the incidence of TB among incarcerated persons to be three times the rate in the general population.

This higher incidence of AIDS and TB in corrections is due to the over-representation of persons with histories of high risk behavior, especially intravenous drug use. Mandatory sentencing for drug offenders, who also have high rates of HIV infection and tuberculosis, concentrates infected individuals in prisons and places enormous burdens on prison health care systems.

In many correctional institutions, health care is "demand driven." That is, medical attention is received at the request of the inmate, at sick call. When health care is requested rather than scheduled, infectious disease goes undetected and untreated. Disease then spreads within the institution, straining existing medical services and creating undetermined costs for taxpayers. To complicate matters, individuals released from the institution carry the disease to the community.

The American College of Physicians, National Commission of Correctional Health Care, and American Correctional Health Services Association (1992) recommend a comprehensive assessment of health care needs in corrections. In addition, these organizations jointly outline the following needs in correctional health care:

• increased medical staffing of correctional institutions;
• implementation of primary care and prevention models of health care delivery;
• proactive health care which emphasizes screening, early disease detection and treatment, health promotion, and disease prevention;
• collaborative ventures with academic medical centers and public health services;
• reconsideration of mandatory sentencing laws for drug-related crime; and
• increased funding for AOD abuse/dependence treatment and AIDS prevention with this population.

Other Social Problems

Prenatal drug exposure:

• Eleven percent of pregnant women use drugs.
• The estimated number of drug-exposed infants born each year ranges from 100,000 to 375,000.
• Drug-exposed infants suffer from a wider range of medical problems needing more extensive and intensive care, with costs up to four times greater than non-drug-exposed infants.
• Long-term physical effects of prenatal drug exposure are likely to require continued expensive medical care.
• The number of boarder babies reported by hospitals nationwide has been growing: From 1986 to 1989 the following increases occurred in three large cities: New York City, 268 percent; Los Angeles, 342 percent; Chicago, 1735 percent.
• Four hospitals in major cities reported that 26 percent to 58 percent of drug-exposed infants were placed in foster care (1989).

Child abuse and neglect:

• The Massachusetts Department of Social Services reported that 64 percent of neglect and abuse investigations identified abuse of drugs and alcohol as an important factor.
• The percentage of foster care placements identified as children of substance abusing families were as follows: New York, 57 percent; San Antonio, 40 percent; Los Angeles, 90 percent.
• Hospital officials nationally indicate an increasing number of young children admitted for problems that result from maltreatment from drug abusers.

Education:

• Drug-exposed infants are vulnerable to developmental problems that may affect learning; one researcher estimates that approximately half of these children will require special educational services.
• After birth, children of substance abusers are at risk of experiencing physical abuse, sexual abuse, neglect, or emotional trauma; these abuses often lead to a requirement for special educational services.

Women and crime/addiction:

• More than 1 in 3 women in jails were accused or convicted of drug offenses.
• Forty percent of female arrestees reported daily use; 38 percent were under the influence at time of arrest.
• Two-thirds of women in jail had children under age 18.
• 52,000 children under age 18 had mothers who were in jail (1989).

Treatment services for women:

• Very few treatment programs provide child care or adequate alternatives for women who seek treatment, creating a significant barrier for women who need help.
• Women fear the loss of their children to child protective services if they seek treatment. Horror stories in the media about the fate of some children in foster care increase this fear.
• Fear of criminal prosecution deters addicted women from seeking medical and drug treatment services.
• The House Select Committee on Children, Youth and Families indicated that two-thirds of major hospitals in 15 cities reported that there were no drug treatment programs available to pregnant women (Fink, 1990).
• The U.S. General Accounting Office report on drug-exposed infants (1990) indicates that hospital and social welfare officials in each of five major cities responded that drug treatment services for pregnant addicts were insufficient or inadequate to meet the demand for services.
• Addicted pregnant women were refused service by over half of 78 treatment programs surveyed in New York City; lack of necessary medical and other support services was cited as the primary reason.

This multi-problem individual, at the mercy of other social changes, creates stresses on numerous social services. The 1980s brought the tragedy of irresponsible deinstitutionalization; thousands of mentally ill individuals were removed from institutions and returned to the community. Deinstitutionalization was not accompanied by sufficiently increased community services for the mentally ill and was coupled with a drug abuse epidemic. Now many individuals with severe personal and social handicaps are roaming the streets. They abuse drugs and alcohol; they become involved in crime; they become a danger to our communities. As a result, they have become a great burden on law enforcement and the criminal justice system.

Which comes first, mental/ emotional disorders or drug/ alcohol abuse? The pattern can develop from either starting point. A study by Regier and colleagues (1990) suggests that dual disorders are more prevalent among people in jail than in the general population. Data reported by the National Institute of Mental Health suggest that mental disorder is twice as likely to come first in individuals with dual disorders; that is, for every case of an individual who first abuses substances and then becomes mentally ill, there are two individuals who first have symptoms of mental illness and then abuse alcohol and/or other drugs (F. Goodwin, M.D., personal communication, 1992). Detailed prospective studies on the sequential development of criminality, mental illness, and substance abuse are not yet available.

Chiles and colleagues (1990) did a survey of sentenced prisoners at the time of classification in the State of Washington prison system. They found that 88 percent of the prisoners being classified met criteria for a substantial emotional or psychiatric disorder. Of that group, a full 92 percent also met criteria for alcohol/substance abuse or dependence. If these findings are generalized to the national prison population, an estimated 800,000 or more prisoners have coexisting psychiatric and substance abuse disorders, while lesser numbers suffer from a single disorder. Today there are 10 times as many mentally ill and/or substance abusing persons in jails and prisons as there are in mental hospitals.

The criminal justice system has become the recipient, via "trans-institutionalization," of hundreds of thousands of drug-addicted, mentally ill, and alcoholic persons whose criminal behavior is frequently secondary to their untreated mental illness or substance abuse disorders.

Seeking Solutions: Treatment Works!

The harsh attitude of the 80s was a sharp turn from the more liberal, treatment oriented approach prevalent during the 1960s and early 1970s. During the earlier period behavior was attributed largely to social/environmental factors to the near-exclusion of genetic factors. The criminal justice system tagged clinicians who were well-meaning but had little experience with prison populations as "do-gooders."

In the 90s, with a new under-standing of AOD dependence as a biopsychosocial problem and innovative treatment and relapse prevention approaches, the pendulum will need to swing toward the middle, to include treatment and rehabilitative services as well as incarceration. However, the errors of the 70s must not be repeated with fragmented approaches.

The 90s require linkages between agencies to develop integrated net-works of services that can:

• match individuals to appropriate treatment services;
• divert AOD users from incarceration;
• follow them into the jails and prisons;
• incorporate case management; and
• be available in the community to protect against relapse after release.

Treatment Is Prevention
Comprehensive treatment and appropriate use of social services and supports not only stabilize the individual but serve as prevention strategies to curb crime, infectious disease, and continued alcohol and other drug abuse. Treatment is prevention in the sense that addressing the real problems of the AOD user can interrupt the vicious cycle of the immature, unsuccessful individual who becomes the father or mother of a number of un-parented or under-parented young children who are at high risk of becoming the next generation of adolescents and young adults in difficulty with alcohol and other drugs, the law, and society.

What Do We Know?
A comprehensive biopsychosocial approach to treatment and rehabilitation should be utilized. Services must attend to the broader needs of housing, education, vocational rehabilitation, and vocational opportunities; the multiple health care needs; and the more individualized needs of helping people connect with their extended families of origin, former mates, and children.

Relapse prevention is the key. Untreated alcohol/drug abuse portends relapse to mental/ emotional disorders and criminal behavior; untreated mental/ emotional disorders portend relapse to alcohol and drug use and criminal behavior. Unmet health care needs place the individual at risk for relapse and place others at risk for infectious disease. Persons released from jails and prisons without vocational/educational skills, housing, work opportunities, and other social services are likely to relapse in some way.

Combined treatment is essential. Individuals with dual disorders are unlikely to be successful when treatment is provided for only one of these disorders. Since the majority of persons in the prison population who have a mental health disorder also have a substance abuse disorder, programs for combined treatment are essential.

Mandated treatment does work; that is, it works about as well as voluntary treatment. There is a body of literature indicating the success rates for people mandated into mental health or substance abuse treatment are similar to those in voluntary treatment.

Short-term intensive treatment requires long-term follow-up titrated to the needs of the individual. In the criminal justice system, people released from prison with long-term community supervision and follow-up have greater success than those who have little or no follow-up. At present, community supervision is frequently inadequate because probation or parole officers have caseloads numbered in the hundreds. Inadequate follow-up is a key contributing factor to relapse.

Cognitive-behavioral deficits. The work of Dorothy Otnow Lewis, M.D., indicates that dually diagnosed individuals found in prison populations have a high incidence of minimal brain damage, cognitive behavioral deficits in functioning and neuropsychological impairments. Recent developments in diagnosis allow for identification of these problems more readily than in the past. Innovative rehabilitation techniques for discrete impairments show promising results and should be made available to individuals with dual disorders, including those in the criminal justice system.

Psychoeducation has been used successfully with individuals who have mental/emotional disorders or dual disorders. This approach shows great promise as a component of comprehensive treatment.

Treatment as Part of a Network of Care

Individuals with alcohol and other drug problems are stressing the criminal justice, health care, and other social services systems. The ever-increasing number of full and expensive prison cells cannot provide an effective solution to social problems in this country.

Individuals in the criminal justice system have multiple problems, including drug addiction with coexisting medical problems and mental illness, that keep recidivism rates high. A comprehensive plan which begins at arrest, which realistically deals with public safety, which provides effective mechanisms to capture the individual in a web of controlled, growth-oriented treatment is necessary. Research clearly shows that mandated treatment works, that new and effective techniques of treatment have been developed, and that systems of rehabilitation and relapse prevention in the community must be integrated and accessible to corrections.

In addition, substance abusers must be linked to other community resources to meet the needs that place them at risk of relapse. Job skills training, employment services, health care, and housing must not be neglected.

Criminal justice, mental health, public health, and chemical depen-dency professionals need to merge their valuable experience with new data on innovative approaches toward treatment and rehabili-tation of the multi-problem individual. Criminal justice professionals need to understand the nature and goals of treatment and how treatment and rehabilita-tion can make the criminal justice system work better. Mental health and chemical dependency professionals must understand the nature of criminal behavior and the criminal justice system to which the client is linked. In each profession, a comprehensive plan must be understood by all branches and levels of service.

References

American College of Physicians, National Commission on Correctional Health Care & American Correctional Health Services Association (1992, June). The crisis in correctional health care: The impact of the national drug control strategy on correctional health services. Position paper.

American Council for Drug Education (1992, March). Cocaine fact sheet.

Boodman, S.G. (1992, July). Prison medical crisis: Overcrowding created by the War on Drugs poses a public health emergency. Washington Post.

Bureau of Justice Statistics (1992, April). National update. Washington, DC: U.S. Department of Justice, Vol. I, No. 4.

Califano, J.A. (1992, December 21). Three-headed dog from hell: The staggering public health threat posed by AIDS, substance abuse and tuberculosis. Washington Post, A12.

Centers for Disease Control and Prevention (1990). TB fact sheet. U.S. Department of Health and Human Services.

Centers for Disease Control (nd). Tuberculosis: The connection between TB and HIV (the AIDS virus). Atlanta: Author.

Chiles, J.A., Von Cleve, E., Jemelka, R.P., & Trupin, E.W. (1990). Substance abuse and psychiatric disorders in prison inmates. Hospital and Community Psychiatry, 41(10), 1132-1133.

Cocaine/Crack Research Working Group (1991, October). C/CRWG Newsletter (Issue 2). New York: New York State Division of Substance Abuse Services.

Division of Criminal Justice Services (1992, February). Drug use forecasting (DUF), 1991 first quarter, in Data Abstract.

Fink, J.R. (1990). Effects of crack and cocaine upon infants. Law Guardian Reporter, 6(2).

HIV and substance abuse: An overview (1991, April). Focus on AIDS in New York State, 3(1).

National Council on Alcoholism and Drug Dependence, Inc. NCADD fact sheet: Alcoholism, other drug addictions and problems among women. New York: Author.

National Institute of Justice (1991, August). Drug use forecasting: Drugs and crime 1990 annual report. Research in Action, U.S. Department of Justice.

National Institute of Justice (1993, May). Drug use forecasting (DUF), third quarter 1992 (Research in Brief). U.S. Department of Justice.

Pepper, B., & Ryglewicz, H. (1984, July). The young adult chronic patient and substance abuse. TIE Lines, 1(2).

Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z., Keith, S.J., Judd, L.L., and Goodwin, F.K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse: Results from the epidemiologic catchment area (ECA) study. JAMA, 264(19), 2511-2518.

Roberts, D.E. (1991, October). Associate Professor of Criminal Law and Civil Liberties, Rutgers University School of Law. Personal communication.

Schoenbaum, E. HIV risk factors among IVDUs. AIDS Clinical Care, 2(4).

Tonry, M., & Wilson, J.Q. (Eds.) (1990). Drugs & crime, Vol. 13. Chicago: The University of Chicago Press.

Trans-institutionalization: Substance abuse and mental illness in the criminal justice system (1992, April). TIE Lines, 11(2).

U.S. Department of Justice (1991, March). Violent crime in the United States. NCJ-127855.

U.S. Department of Justice (1991, August). Drugs and crime facts, 1990. NCJ-128662.

U.S. Department of Justice (1992, September). Drugs and crime facts, 1991. NCJ-134371.

U.S. General Accounting Office (1990, June). Drug-exposed infants: A generation at risk. Report to the Chairman, Committee on Finance, U.S. Senate. GAO/HRD-90-138.

Women and Substance Abuse: What Are the Facts? (1992, July). TIE Lines, 9(3).

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