The Need for Continuity of Care in the Criminal Justice System
People with mental health and substance use disorders who would benefit from treatment are overrepresented in the criminal justice system. It has been reported that 63% of individuals in jail and 58% of individuals in prison meet the criteria for having a substance use disorder, and 36% of the population serving a state prison sentence were being treated for a mental health disorder, which is 17% higher than the general population in Tennessee. Justice- involved individuals with mental health and substance use disorders have a higher risk of recidivism, especially when they lack access to medications and behavioral health treatments both during and after incarceration. However, despite this heightened prevalence and treatment need, criminal justice entities rarely have the resources needed to ensure at-risk individuals receive continuous evidence-based care. Given Tennessee’s incarceration rate has risen to 10% above the national average, and almost half of all incarcerated individuals are rearrested within three years of release, it is critical for individuals to have access to continuous care both during incarceration and at reentry into the community.
To begin addressing the gaps in treatment for mental health and substance use disorders within the criminal justice system, it is important to first understand why these individuals enter the justice system to begin with. Substance use disorders often increase risk for criminal behavior. According to the Tennessee Bureau of Investigation, it is estimated that 80% of all crimes in Tennessee have a drug-related nexus. According to the National Institute on Drug Abuse, although initial substance use is typically considered voluntary, substance use disorder is a disease that can develop in anyone with continued use, and risk factors have been identified. This disease changes the physical structure and function of the brain, and over time leads to impaired judgment and an inability to control behavior, increasing the probability of engagement in behaviors that prompt incarceration.
In addition to substance use, research findings also show that there is a link between childhood trauma and involvement with the criminal justice system. Adverse childhood experiences (ACEs) involve things such as experiencing neglect, abuse, or violence (among others) and have a detrimental impact on developmental trajectories. Although studies on the rate of ACEs in incarcerated adult populations in the United States are severely limited, there is extensive work showing “disturbingly high rates of ACEs” among justice-involved youth, and such individuals are significantly more likely to continue offending into adulthood. Experiencing ACEs is linked to long-term mental health disorders like major depressive disorders and post-traumatic stress disorder (PTSD), and it has been known for over half a century that victimization, either as a child or adult, has been linked to increased aggression and criminality. Trauma can prompt people to adopt a perspective that the world is unsafe and unpredictable, and in turn, disregard laws and social norms. In turn, alcohol and substances are often used to cope with trauma, which further increases criminal risk. While these are not the only reasons people commit crimes, they are very common among justice-involved people and require treatment to effectively manage.
Treatment in Jails & Prisons
The criminal justice system provides a unique opportunity to intervene and address the cycle of beliefs, behaviors, mental illness, and addictions that lead to criminal behavior. Evidence-based treatment for mental health and substance use disorders delivered during incarceration reduces symptoms and disciplinary problems, improves post-release adjustment, and decreases recidivism risk. For example, Rhode Island, one of the first states to strategically prioritize treatment in jails and prisons, actively promoted referrals to medication-assisted treatment for individuals with opioid use disorders and maintained treatment regimens for those who had become reincarcerated. The effects of this model led to a significant and clinically meaningful reduction in post-incarceration overdose deaths following the implementation of their model. However, there is a disconnect between our knowledge of what treatments are effective at reducing risk and which treatments are delivered to justice-involved people. For example, the Tennessee Department of Corrections provides numerous programs for incarcerated people that aim to address behaviors and reduce criminal risk, but these resources are not always available during incarceration and are dependent on custody level (e.g. jail versus state prison) and location (e.g. rural versus urban). Urban facilities, for instance, offer a wider variety of services and more aptly address substance use disorders during incarceration than rural facilities, despite comparable rates of substance use disorders . Unfortunately, it is Tennessee’s rural jail population that has grown at a greater rate over the last decade due to a variety of factors.
Reentry is notorious for being a challenging time period, especially for people with substance use or other mental health problems. Many incarcerated people do not have access to programs, funds, housing, or social structures that will enable them to be successful upon returning to their communities. This, in turn, often leads them to return to using substances and/or re-engage with the type of criminal behavior that led to their original incarceration. Post-release programming that is consistent with services delivered during incarceration is vital for reducing recidivism and reintegrating justice-involved individuals back into their communities. According to the Substance Abuse and Mental Health Services Administration:
- Treatment for justice involved people should be consistent throughout their involvement with the justice system and should not end upon reentry into the community.
- Evidence-based treatment, curtailed to the individual’s needs, should ideally be coordinated between corrections and community-based facilities prior to release from jail to ensure there are no gaps in care.
- A reentry plan for each justice-involved individual should be developed by a qualified clinician upon incarceration and should address the person’s social determinants of health and comorbidities.
- Upon reentry, this plan should be monitored by the Community Supervision Officer to ensure compliance, if the release has community supervision requirements. Unfortunately, many incarcerated people are released back into the community with little to no transitional preparation or treatment, and since many are being released from county jails instead of state prisons, there is often a disproportionate lack of resources available to them.
- Warm handoffs upon release, such as being provided transportation to services directly upon release, often leads to better outcomes.
In sum, research shows that if treatment is effectively started during incarceration and continued after reentry with a developed treatment plan, outcomes improve for justice-involved individuals struggling with substance use or other mental health disorders.
|Jefferson County – A Rural County Making a Change
Jefferson County, a rural county in East Tennessee with a population of about 55,000 people, is the only county in the state currently initiating treatment with medications for opioid use disorder during incarceration at the county jail. The program, championed by the Honorable Duane Slone of TN’s Fourth Judicial District, Dr. Stephen Loyd of Cedar Recovery, and Candace Allen of the McNabb Center, was implemented in October 2021 and has had over 50 incarcerated people enrolled. At intake, all incarcerated people are assessed for the presence of opioid use disorder. If indicated, treatment is initiated via telehealth by Dr. Stephen Loyd. Treatment includes medication, either buprenorphine or naltrexone, as well as behavioral therapy and counseling, which is provided by the McNabb Center. Medications for opioid use disorder are administered to incarcerated people using the same process as other medications within the jail, and a correctional officer is present during distribution to decrease the risk of medication diversion. Planning for continued treatment and linkage to wraparound services upon release is essential and begins when treatment is initiated. This program is funded through state and federal grants and is being evaluated by the Tennessee Department of Health. Because this program was recently implemented, data to fully evaluate the success of the program is not yet available, but preliminary data is promising.
Program information obtained from Kristen Zak, Deputy Director, Opioid Response Coordination, Tennessee Department of Health
Policy Brief Authors:
Jason Trautwein, UT Knoxville Law Student
Kelly Moore, PhD, Assistant Professor, East Tennessee State University
James Hart, Jail Management Consultant, UT Institute for Public Service
Rick Dierenfeldt, PhD, Assistant Professor, UT Chattanooga
Honorable Duane Slone, Fourth Judicial District of Tennessee
Jeremy Kourvelas, MPH, SMART Initiative
Jennifer Tourville, DNP, Executive Director, SMART Initiative
SMART Policy Network Steering Committee Members