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

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.

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.