How NOT to do prison reform

September 18, 2009

How many could avoid prison with drug treatment?

How many could avoid prison with drug treatment?

For decades, people in California have talked about prison reform. Even while we were locking up record numbers of young Californians with laws such as Three-Strikes-and-You’re-Out, Democrats and Republicans (well, not the troglodytes) alike have been talking about how we need to divert nonviolent offenders to rehabilitation programs instead of simply jailing them. And California did have some innovative programs to do just that. Only, they were pilot programs. They never became institutionalized. And they were never really supported by the all-powerful prison guards’ union, because they didn’t create enough prison jobs.

It’s long been known that most criminal offenders are substance abusers; most of them are untreated addicts, hence the high recidivism rate. They get out of prison with no treatment, go score their drug of choice – whether its alcohol, crack or crystal – then get loaded and commit new crimes. It ain’t rocket science to prevent this. Oodles of research and pilot projects show that providing treatment and aftercare to addicted offenders reduces recidivism and criminal justice costs. The famous CALDATA study from the early 1990s found that every $1 spent on drug and alcohol treatment saved $7 in taxpayer money, mostly because of reduced crime.

Meanwhile, California’s Little Hoover Commission continually over the years urged more drug courts, treatment, rehabilitation, education and training for both youth and adult prison inmates to reduce overcrowding and huge taxpayer costs.

But, we didn’t do it, not in any meaningful way. A meaningful way would have been to divert incarceration dollars to treatment and rehabilitation programs and push most inmates and parolees into treatment and long-term aftercare for their addiction. But the prison guards’ union wouldn’t allow that, and neither would conservative politicians — or most liberal politicians who either didn’t want to be seen as soft on crime or who just didn’t think it was very important. The state’s prison budget has increased fivefold since 1994. But we didn’t see fit to use that money to transform our corrections system so that it would stymie recidivism.

Now, it’s too late. The federal government is forcing the State of California to release 45,000 inmates – the size of a small city – because of overcrowding and inadequate health care in prisons. The State Legislature recently passed bills called prison reform, but they were really just ways to cut a billion dollars from the prison budget with some window dressing to try to fool people into thinking that lawmakers were doing something positive.

The state says that it will be sending these released prisoners to local programs. But they’re being cut by the state revenue raid of

California prison population outta control

California prison population outta control

local government and cuts to state-funded treatment and rehabilitation, like the deletion of  Proposition 36 funding. So those local programs, such as probation, jails and rehabilitation, actually have less capacity then they did six months ago, yet the state is sending more offenders to local jurisdictions. All these problems will only get worse as California’s budget problems grow next year.

The moral to this story is…well, there is no moral. People give lip service to prison reform, but I’ve never seen it really done, not in California or anywhere else in the United States. We could be diverting huge numbers of offenders from our prisons. But the truth is — we don’t really want to.

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Posted by jgogek

Arnold Schwarzenegger and Jerry Brown try to shoot the messenger of California’s prison disaster

February 2, 2009

California Gov. Schwarzenegger and Attorney General Jerry Brown are california_prisons_1_4001
firing blanks at the messenger heralding the disaster that California prisons have become. Both the governor and attorney general asked U.S. District Judge Thelton Henderson to remove J. Clark Kelso, who was appointed receiver of prison healthcare three years ago by Henderson, and return inmate medical care to state control. Schwarzenegger and Brown complain that Kelso is going to spend $8 billion to build a gold-plated health system. However, their ploy to remove Kelso probably won’t work.

Let’s set aside whether Kelso’s $8 billion plan is a good one or not and instead look at how we got into this mess and whether we’re anywhere near getting out of it. The last question is easy to answer. Judge Henderson appointed Kelso because prison healthcare in California was terrible. There’s no evidence to show that it’s improved, nor that it will any time soon, considering the state’s multibillion-dollar deficit. Why would Henderson suddenly remove the receiver when nothing has changed?

How did we get into this mess? That’s easy, too. The politicians and people of California created it by foolishly thinking that they could punish crime away — without giving any consideration to the ultimate cost and impossibility of such a plan.

With rehabilitation almost nonexistent – the public and politicians never wanted to pay for that – recidivism remains at more than 66 percent. Two out of every three people released from California prisons go back – the highest rate in the nation.  Politicians and the public thought they could scrimp on health care, drug treatment, rehabilitation, education – anything that might benefit the lives of inmates once they were released because, well, they’re inmates and they deserve only the worst. Only 7 percent of inmates receive alcohol treatment, although 42 percent have a high need for it. And only 2.5 percent of inmates who have a serious need for drug treatment actually get it. And even for those who get treatment in prison, aftercare programs when they’re on parole are wholly inadequate.

The fact is that inmates are wards of the state and the people of the state are responsible for their welfare – all 172,000 of them. The people of California have volunteered to take care of as many inmates as possible, and now they’re complaining about the cost. Maybe Californians should have thought of that before they embarked on their prison-building binge while incarcerating as many people as possible. Since 1977, about 1,000 laws have been passed increasing penalties for all sorts of crimes. California politicians run for office by touting how they got tough on crime by increasing prison sentences. And the public eats it up.

Crime rates are lower in California than they were when we started our prison building and people punishing obsession. But they are lower
everywhere, including in states that didn’t try to throw everybody behind bars. Nobody’s exactly sure why crime goes up and down.

But one thing is sure: Californians chose an impossibly expensive way to fight crime. And now, we don’t want to pay for the program we chose and we don’t have the political will to create real change. The result will be continued billions of dollars in costs for prisons (more than we pay for higher education), continued high recidivism rates and large-scale inmate releases as the system we chose collapses.

That collapse is upon us. A panel of three judges is considering whether to cap the population and release up to 52,000 inmates – with almost no rehabilitative or re-entry programs in place for them.

This whole thing is dumb public policy, folks. A child could devise a better plan.

Recommended read on prison reform on the California Progress Report.

1 Comment | Addiction, Alcohol, California, Prisons, Schwarzenegger, substance abuse | Tagged: , , , , , | Permalink
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President Obama and cigarettes: If he quits, he can help reverse the global tobacco epidemic and save millions of lives

January 17, 2009

barack-obamaWith the country is facing an economic disaster and crises throughout the world, it may not seem very important whether President Obama smokes cigarettes. The public response to his struggle to quit seems to be: Give the guy a break.

But, tobacco smoke kills 440,000 a year in the United States and 5.4 million each year worldwide. That number will reach 8 million by 2030, with 80 percent of those deaths in developing countries. Tobacco will kill 1 billion people this century. It’s the most preventable cause of death, in rich and poor countries alike. President Obama can save millions of these lives by joining the fight against this global epidemic. But unless he can quit smoking and stay quit, he might actually hurt the cause.

The international tobacco industry spends tens of billions each year pushing its message that smoking is normal and desirable. A charismatic world leader who is an inspiration to young and old — and who smokes –would be a godsend for the industry. But if the same world leader publicly quits, and supports changes that help others to quit and children never to start, he could turn the tide on this epidemic.

Smoking in the United States has declined in recent decades; leveling off at about 20 percent of the adult population. Meanwhile, the global reality is much worse. Countries with low or moderate per capita incomes are particularly at risk because of low tobacco prices, lack of awareness and aggressive tobacco marketing.

Indonesia is a tragic example. Over 60 percent of adult males smoke. So do a quarter of teenage boys under 16. The rate among young girls is rising fast. Tobacco advertising is rampant and, like most developing countries, Indonesia has few of the controls that can reverse the tobacco epidemic. Treatment for tobacco dependence and anti-smoking messages are rare. Tobacco advertising is everywhere. And, tobacco taxes, and hence prices, is low.little-kid-smoking-cigarette-copy21

It’s also a country where President Obama is very popular, having spent some of his childhood there. By speaking out as an honored world leader who has quit smoking, he could help countries like Indonesia overcome tobacco industry muscle and enact desperately needed anti-tobacco measures. Africa is another region with a growing tobacco epidemic where President Obama can help.

While tobacco prevalence in Africa is still relatively low, it’s a vast new marketplace for the tobacco industry because of lax controls and young populace. President Obama could spur tobacco controls there, too, and help save millions of lives.

Reversing the global tobacco epidemic is not complex. It doesn’t require breakthrough cures or heroic medical treatment, just policy changes that already have been tested, plus enforcement. A recent World Health Organization report laid out the path countries must take by using the acronym MPOWER: Monitor tobacco use and prevention policies; protect people from tobacco smoke; offer help to quit smoking; warn about the dangers of tobacco; enforce bans on advertising, promotion and sponsorship; and raise taxes on tobacco. These are well-researched and proven methods. If adopted by all countries, these policies would save hundreds of millions of lives.

mpower_report_2008_cover1The tobacco industry vigorously opposes the MPOWER measures. And many countries have yet to develop the political prowess to resist the industry’s powerful influence and sophisticated tactics. President Obama can help by supporting global adoption of these policy changes. He could begin by getting the United States to ratify the World Health Organization’s Framework Convention on Tobacco Control. This treaty is blueprint for reducing the worldwide supply of and demand for tobacco. While 161 nations are parties to the treaty, the United States isn’t one of them.

President Obama will battle unemployment, the real estate collapse, worldwide recession, climate change, a broken health care system, the Israeli-Palestinian conflict and crises still beyond the horizon. But he should not ignore the planet’s greatest preventable health threat. Because he’s admired throughout the world and because he himself struggles with addiction to cigarettes, President Obama could be instrumental in reversing the global tobacco epidemic.

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A new idea in health care that’s been around for awhile

December 5, 2008

Hands togetherIt’s called Network Medicine. Instead of treating the individual on the cellular level, you treat the individual on the social level. You probably remember the evidence, because each research report made the news. First it was obesity, then smoking cessation and very recently, happiness (well-being is associated with improved health). Very credible research in the New England Journal of Medicine and the British Medical Journal show that your health can be influenced by the company you keep – whether it’s your group of friends in your neighborhood or your buddies across the country. Through the amazing research into human networks by UC San Dienejm2go political scientist James Fowler, and his colleague Nicholas Christakis, a Harvard MD and sociologist, we are finding that we can start improving human health by fostering healthy communities. Not communities so much in a physical sense, but communities in a network or system sense.

This idea, of course, has been the essence of public health prevention for years. Now that it’s in NEJM and BMJ, it seems to have more cache. But in 1998, Harold Holder made a similar finding in his book “Alcohol and the Community: A Systems Approach to Prevention,” in which he wrote that alcohol problems are not just a matter of an individual’s misuse of alcohol.

Instead, elements include “what one’s friends and relatives do, and what one believes to be socially expected, as well as such tangible factors as alcohol availability, how much money one has to spend, and the cost of alcoholic beverages…” He points out that you can’t reduce the problem by only intervening in one facet of the problem.

This should be a lesson learned for dealing with other public health problems that involve societal behavioral such as obesity and smoking. Finding the obesity gene and developing a drug to treat it won’t solve the obesity problem. Nor will providing cessation services to individual smokers. Those things may be important, but taken alone, they won’t create real change in the society-wide problem.

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America’s obesity problem: The rugged individualist weighs 350 pounds

August 6, 2008

We know how to combat obesity. But our knowledge can’t help us. What’s required is collective, multi-faceted public health action on a federal, state and local level. And the United States has no infrastructure to accomplish that.

The Centers for Disease Control and Prevention has laid out a straightforward way to solve obesity. Nothing in this plan is new: increased physical activity, increased fruit and vegetable consumption, decreased consumption of sugar-sweetened drinks high energy-dense food. Individuals can accomplish this. But as of yet, we have no societal mechanism to do it on a large enough scale that could make a difference. Some states are making attempts in that direction, but it’s not close to enough.

We have plenty of national centers for research into treating  diseases and disorders, but very few for prevention. The CDC — Centers for Disease Control and Prevention — makes a valiant try but is underfunded and too politically hamstrung to launch truly effective national prevention efforts. So, when it comes to obesity prevention, we’re on our own. That’s where medicine focuses — individual treatment such as obesity surgery and diets. Meanwhile, researchers look to for a cause through genetics, though how that might solve the problem on the population level isn’t clear.

The obesity vector is the American obsession with individualism. Government-sponsored, society-wide programs to change behavior are despised — even if the behavior is killing us. And so, the rugged individualist gets bigger and bigger and bigger, now weighing 350 pounds and riding one of those electric carts through the snack aisle in the grocery store.

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Mental health (including addiction): Parity in policy… how about parity in practice?

July 15, 2008

Sometime in the near future, the United States will achieve parity in insurance coverage for all health disorders. Whether you have a disorder of the heart or of the brain, you’ll get the same coverage. Limited parity was passed by Congress about a decade ago, and the Wellstone Mental Health and Addiction Equity Act is now moving through Congress to patch up past loopholes. Wellstone may not solve all the problems, but it will move us closer to parity in coverage.

But parity in practice will still elude us. Health care professionals — particularly in primary care and emergency rooms — continue to give unequal diagnoses and treatment to disorders of the brain. Diagnoses that are widely missed include substance use disorders, most notably nicotine use disorder and alcohol use disorder. Depression is another diagnosis that is commonly missed in primary care, even though there are well-researched strategies for screening.

Alcohol use disorders are often missed by both physical health and mental health practitioners. A big difference could be made here. Brief interventions in primary care are consistently shown to reduce alcohol consumption.

Parity in diagnoses of patients admitted to emergency rooms could save lives and money. Researcher Larry Gentilello, professor of surgery at the University of Texas Southwestern Medical Center in Dallas, found in a study that 27 percent of all injured adult patients suffer from alcohol use disorder.

“Patients are most likely to consider changing a harmful behavior when that behavior has caused a crisis or a severe problem in their lives… an injury makes patients with an alcohol problem much more responsive to counseling. If brief interventions were offered routinely to these patients nationwide, the annual net savings to hospitals and insurers could be up to $1.82 billion.”

Tobacco-related disorders also lack parity in diagnoses. Family Practice practitioners aren’t taking the opportunity to help their adolescent patients avoid tobacco. Dentists have an excellent opportunity to intervene against smokeless tobacco use. In general, primary care is a place of missed opportunity when it comes to diagnosing and treating nicotine use disorder: Says one reseacher:

Clinicians do not inquire about tobacco usage, do not use available interventions, are under time constraints and may not believe the effort of tobacco cessation intervention is worth the benefit to the patient. United States medical schools inadequately teach tobacco intervention skills. There is a lack of integration of tobacco dependence information throughout all four years of medical school curricula.

There are plenty of resources on how primary care practitioners can help these patients. But until parity in practice becomes as important as parity in policy, we will never properly treat preventable killers such as nicotine use disorder, alcohol use disorder and depression.

1 Comment | Addiction, Alcohol, Parity, Public health, Tobacco, drugs, mental health, substance abuse | Tagged: , , , , , , , , | Permalink
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Department of Dangerously Uninformed Ideas: Lowering the 21 drinking age

July 3, 2008

Arguments in favor of lowering the drinking age are perfect for Internet and blogosphere — all opinion and myth, no facts. The truth is that research overwhelmingly supports leaving the drinking age at 21, and so do the top global researchers on alcohol. Robert Voas, who has been studying alcohol impacts for four decades, and who just won a Lifetime Achievement Award from the Research Society on Alcoholism, stated it eloquently in an op-ed in the Christian Science Monitor:

It’s startling that anybody – given the enormous bodies of research and data – would consider lowering the drinking age…

…This is extremely frustrating. While public health researchers must produce painstaking evidence that’s subjected to critical scholarly review, lower-drinking-age advocates seem to dash off remarks based on glib conjecture and self-selected facts.

One of the worst myths is the idea that there’s some “European Model” that teaches kids how to drink responsibly. The truth is that Europe has much worse youth drinking problems than the United States. In fact, every European country except for Turkey has worse youth binge drinking rates than the United States. Binge drinking is known to increase the risk for serious social problems such as fighting, assault, sexual assault, theft and burglary. So Europe, with its allowance of youth drinking, has created serious problems for itself.

There are plenty of other myths and misinformation:

Old enough to go to war, old enough to drink.

The military takes in youngsters particularly because they are not yet fully developed and can be molded into soldiers. The 21 law is predicated on the fact that drinking is more dangerous for youth because they’re still developing mentally and physically, and they lack experience and are more likely to take risks. Ask platoon leaders and unit commanders, and they’ll tell you that the last thing they want is young soldiers drinking.

The drinking-age law just increases the desire for the forbidden fruit.

…The opposite is true. Research shows that back when some states still had a minimum drinking age of 18, youths in those states who were under 21 drank more and continued to drink more as adults in their early 20s. In states where the drinking age was 21, teenagers drank less and continue to drink less through their early 20s.

I did it when I was a kid, and I’m OK.

Thank goodness, because many kids aren’t OK. An average of 11 American teens die each day from alcohol-related crashes. Underage drinking leads to increased teen pregnancy, violent crime, sexual assault, and huge costs to our communities. Among college students, it leads to 1,700 deaths, 500,000 injuries, 600,000 physical assaults, and 70,000 sexual assaults each year.

And on and on. Yeah, you can find a few researchers who claim otherwise. But they’re like the denialists who claim that global warming isn’t true. Do a Google Scholar search of youth, drinking, alcohol, etc. Look at the evidence in respected peer-reviewed journals. There’s no good argument for lowering the drinking age.

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