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.

1 Comment | Addiction, California, Prisons, Public health, drugs | Tagged: , , , , , | Permalink
Posted by jgogek

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.

Leave a Comment » | Addiction, Alcohol, Network Medicine, Obesity, Public health, Tobacco, prevention, substance abuse | Tagged: , , , , , , , | Permalink
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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.

1 Comment | Addiction, Obesity, Public health, prevention | Tagged: , , , , , , | Permalink
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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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Guns: What about the right to health?

June 30, 2008

Opposition to gun control in this country has become so toxic that it’s impossible to have a clean discussion about it. This most recent response to the Supreme Court’s 5-4 vote on gun ownership shows why. As public health experts know (it’s no surprise, despite what the headline says), guns play a significant role in suicides.

By MIKE STOBBE, AP Medical Writer
Mon Jun 30, 9:18 PM ET

ATLANTA – The Supreme Court’s landmark ruling on gun ownership last week focused on citizens’ ability to defend themselves from intruders in their homes. But research shows that surprisingly often, gun owners use the weapons on themselves.

Suicides accounted for 55 percent of the nation’s nearly 31,000 firearm deaths in 2005, the most recent year for which statistics are available from the Centers for Disease Control and Prevention….

And, no, it’s not true that people who would commit suicide would simply find some other way to do it if no gun is available.

… More than 90 percent of suicide attempts using guns are successful, while the success rate for jumping from high places was 34 percent. The success rate for drug overdose was 2 percent, the brief said, citing studies.

“Other methods are not as lethal,” said Jon Vernick, co-director of the Johns Hopkins Center for Gun Policy and Research in Baltimore.

Gun control opponents argue that other countries have higher suicide rates with less availability of guns. True. But we’re not talking about other countries. The data does not back up the contention that U.S.  gun suicides would always find some way to kill themselves. That’s conjecture.

The right to bear arms isn’t the only policy issue here. The right to health and safety is even more important. Suicide, homicide and gun violence are serious health and safety issues. But look what’s happened to thwart honest policy analysis. The gun lobby in Congress (and in the hallways of Congress) has blocked data collection about gun violence. Same story:

…Both sides agree there has been a significant decline in the last decade in public-health research into gun violence.

The CDC traditionally was a primary funder of research on guns and gun-related
injuries, allocating more than $2.1 million a year to such projects in the mid-1990s.

But the agency cut back research on the subject after Congress in 1996 ordered that none of the CDC’s appropriations be used to promote gun control…

The anger-filled aggressiveness by the gun lobby and gun enthusiasts has succeeded in stopping reasoned discussion — and even scientific data collection! The result is that we can’t even have a rational discussion on guns and health in this country.

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Posted by jgogek