Key Results: Cost-Effectiveness of Substance Abuse Treatment in Criminal Justice Settings
Citations Listed in Key Results
- The majority of studies show that treatment in correctional settings is generally effective in reducing drug relapse and criminal recidivism, but other research suggests these effects may disappear over time.
A number of studies have compared rates of drug relapse and/or criminal recidivism in treated and untreated groups of offenders. Although some results are mixed, a majority of these studies have documented lower rates of drug relapse and rearrest among offenders participating in prison-based substance abuse treatment programs (Wexler et al., 1992; Wexler et al., 1999a, 1999b; Prendergast et al., 2004; Inciardi et al., 1997; Martin et al., 1999; Hiller, Knight, and Simpson, 1999; Knight, Simpson, and Hiller, 1999).
Prison-based treatment can include a variety of treatment modalities such as group therapy, individual counseling, cognitive behavioral approaches, and 12-step programs. However, the most widely applied modality in correctional settings is the therapeutic community (TC), which focuses on providing high-intensity treatment to promote abstinence from drugs; elimination of antisocial activities; and the development of employable skills, prosocial attitudes, and values (De Leon, 2000; Wexler, 1995; Wexler and Love, 1994). Most of the existing economic research on treating offenders is based on the TC model, and little is known about the cost-effectiveness of other types of corrections-based treatment.
Many of the studies confirming the overall effectiveness of prison-based treatment have evaluated TC programs over a relatively short follow-up period - typically 1-2 years post-release from prison. Longer-term evaluations of 3-5 years post-release have produced less consistent results. For example, a 5-year follow-up evaluation of Delawares CREST work release TC found significantly lower rates of drug relapse and better employment outcomes among treated offenders (Butzin, Martin, and Inciardi, 2005). Other analyses of in-prison and post-release treatment for criminal offenders report that rates of reincarceration and drug use between treated and untreated offenders seem to converge over time, particularly after 3 years post-release (Wexler et al., 1999b; Prendergast et al., 2004). There is no consensus on the most reasonable timeline for estimating the economic impact of corrections-based programs. Studies that have conducted benefit-cost analyses of these programs have generally found that, even over a relatively short follow-up, the economic benefits from reduced criminal activity offset the cost of treatment (Aos et al., 2001). Additional research is needed to examine the long-term effectiveness of prison-based programs. Current research agendas are emphasizing the importance of long-term evaluations (3 or more years post-treatment), which reflects an evolving perspective among clinicians, researchers, and policy-makers that recognizes that drug or alcohol dependence is a chronic disease, much like diabetes or hypertension, requiring long-term treatment and characterized by numerous relapses.
- Cost analyses show treatment in prisons is relatively inexpensive compared to residential or outpatient treatment in a community setting.
Estimating the costs of prison-based treatment requires an incremental analysis of resource use, because expenses generated by imprisonment - such as housing, food and security - will be incurred regardless of whether or not a treatment program is in place. Thus, an appropriate estimation for the costs of treatment in prison settings is one that isolates treatment expenses from the standard costs of incarceration.
An assessment of four in-prison therapeutic community (TC) programs in California, Colorado, Delaware, and Kentucky estimated that the average weekly cost (per inmate) ranged from $86 in California to $47 in Kentucky (McCollister and French, 2002). Another study estimated the average costs of various corrections-based treatment programs including cognitive behavioral programs ($370 per participant) and adult prison TC programs ($3,208 per participant) (Aos et al., 2001). These estimates are considerably less than the average weekly cost for community-based programs. For example, the average weekly cost per client for standard outpatient treatment is $140 and for adult residential treatment is $789 (French, Popovici, and Tapsell, 2008). These cost estimates are all expressed in 2007 dollars.
It is important to note that these cost estimates reflect the direct costs of providing treatment in prisons. They do not include ancillary costs associated with post-release treatment or potential resource savings gained from treating prisoners drug abuse, such as reduced prison-management costs.
- Prison-based treatment coupled with post-release aftercare programs is cost-effective relative to no treatment or to prison-based treatment only.
Cost-effectiveness analysis (CEA) is a common tool used for assessing and comparing the costs and consequences of a treatment program. The effectiveness of a prison-based treatment program is typically pegged to a tangible outcome, such as reduced drug use, reduced arrests, or fewer days reincarcerated. Differences in program costs and outcome are compared across two or more programs to determine what program(s) has the lowest cost-effectiveness ratio (i.e., is relatively more cost-effective).
A CEA of an in-prison therapeutic community (TC) and aftercare in Texas compared treatment costs and recidivism rates across groups of high-risk offenders, low-risk offenders, and untreated parolees. Treatment proved most cost-effective for high-risk parolees who completed prison treatment and aftercare, relative to low-risk parolees (who completed treatment and aftercare), parolees who did not complete prison treatment, and the untreated comparison group (Griffith et al., 1999).
One-year and 5-year CEAs of a prison-based TC and aftercare program in California found that offenders who completed both programs had the lowest number of days reincarcerated and were relatively more cost-effective in terms of "cost per avoided incarceration day" than the group of offenders that received in-prison treatment only and the group of untreated offenders (McCollister et al., 2003a, 2004). Similarly, a 1-year follow-up CEA of a specialized work release TC in Delaware found that offenders who participated in the work release TC followed by aftercare had a lower "cost per avoided incarceration day" relative to offenders that only participated in the work release TC (i.e., no aftercare) and standard work release (i.e., no treatment) participants (McCollister et al., 2003b).
Another study used data from the Connecticut Department of Correction and the Connecticut Department of Mental Health and Addiction Services to assess the cost-effectiveness of four levels of treatment for offenders as measured by the likelihood of getting arrested 6, 12, and 18 months post-release. Higher levels of treatment (intensive outpatient, day treatment, and residential treatment) were associated with significantly fewer rearrests for the treatment group relative to the no treatment group. Thus, more intense treatment was relatively cost-effective in reducing rearrest compared to a brief drug education program or no treatment (Daley et al., 2004).
- Post-release programs for offenders play a pivotal role in determining the overall cost-effectiveness of providing treatment to prisoners.
There is a growing body of evidence indicating that providing a continuum of treatment---in-prison services followed by post-release or aftercare treatmenthas the greatest potential to reduce reincarceration and drug relapse among offenders with substance abuse problems. Post-release substance abuse treatment programs are now part of an evolving perspective on rehabilitating offenders with substance use disorders, one that incorporates the need for complementary services such as job training, health care, and family counseling.
A number of research questions related to aftercare for offenders remain unanswered. In most cases, subjects were randomly assigned to in-prison treatment or no-treatment conditions, but participation in aftercare was generally voluntary and at times capacity for this was seriously limited. Thus, there may be some unobserved characteristics, such as an intrinsic motivation for change, in the offenders who volunteered for aftercare that lead to improved treatment outcomes. Second, there is no standard aftercare program. Rather, aftercare involves a variety of parole- and community-based interventions, and it is unclear which models are cost-effective. One recent study found that parolees from prison-based TC programs had similar return-to-prison rates regardless of whether their aftercare involved a residential or outpatient program (Burdon et al., 2007), suggesting that the type of aftercare is less important than the fact that they received services designed to facilitate community re-entry. With community-based residential treatment being more costly than outpatient models, this also suggests that cost-effectiveness of aftercare following prison-based treatment can be improved by using outpatient rather than residential models of continuing care.
Post-release or aftercare for offenders with substance use disorders is clearly important for overall treatment success, and yet there is no clearly defined process for linking offenders with appropriate services after they are released from prison. Aftercare in most cases is defined by whatever services are available when the offender is released. In some cases, offenders who participate in prison treatment enter a formal transitional program to facilitate the reentry process and then step down to less intensive aftercare programs (Pelissier et al., 2007; Hiller, Knight, and Simpson, 1999). However, many offenders do not have access to post-release programs that are specifically designed for parolees. Instead, they are funneled into the existing network of drug abuse services in their communities, which include a wide variety of treatment modalities, treatment clients, types of services, and program expectations. Also, often there can be a lag between release from prison and engagement in treatment, which can leave offenders at risk for drug relapse or rearrest.
- Broader economic evaluations that include other outcomes such as health services utilization, criminal activity, and employment are important for understanding the net benefits associated with corrections-based treatment.
Reduced drug relapse and recidivism may be the most clinically relevant outcomes associated with prison-based treatment, but it is common knowledge that these programs are affecting a number of other areas including employment, health status, relationships with family and community members, and prison management issues. Many of these outcomes are appropriate for a benefit-cost analysis (BCA) of corrections-based treatment.
BCA would estimate the dollar benefits from increased employment, reduced health services utilization, increased child support, reduced dependence on social welfare programs, reduced criminal activity, and reduced costs associated with operating a correctional facility. Collectively, these outcomes represent the economic benefits of corrections-based treatment.
A few studies have attempted to estimate the costs and benefits of treatment programs for criminal offenders by looking at reduced criminal justice system costs, reduced criminal activity, avoided cost of medical care, and improved productivity (Mauser, Van Stelle, and Moberg, 1994; Aos et al., 2001). These studies found that the benefits of treatment far outweighed the costs, with the average benefits ranging from $1.13 to $3.83 per dollar invested in treatment.
In addition, a recent economic analysis of programs at the California Substance Abuse Treatment Facility (SATF) found that compared to non-treatment prison yards, the in-prison treatment yards generated lower administrative costs for disciplinary actions, inmate grievances, and major disruptive incidents resulting in lockdowns. The total savings to the California Department of Corrections and Rehabilitation generated by the in-prison treatment programs over a two-year period ranged from $45,694 (fewer disciplinary actions) to $217,481 (fewer inmate grievances) (Zhang, Roberts, and McCollister, 2009).
Estimating the economic benefits of treatment in criminal justice settings requires the ability to translate outcomes into dollars using monetary conversion factors. For some outcomes (employment, criminal activity, health services) such cost estimates are readily available. Other outcomes (improved family relationships, reduced drug use) are more difficult to estimate in monetary terms. This is an important area for future methodological work.