“Falling Through the Cracks:” Young Adults, Drugs, and Incarceration

Follow-up on: Welty LJ, Harrison AJ, Abram KM, et al. Health disparities in drug- and alcohol-use disorders: a 12-year longitudinal study of youths after detention. Am J Public Health. 2016;106(5):872–880.

As a clinician working with high-risk youths in New York City, many of whom are justice-involved and substance users, I applaud Welty et al.¹ for their illuminating article in the May issue of AJPH. Their study revealed many noteworthy findings, including the declining prevalence of substance-use disorders (SUDs) among justice-involved youths from about 50% at baseline to nearly 20% 12 years later.¹ However, that level of involvement remains substantially higher than the 8.4% of Americans in the general population with SUDs.²

Sustained involvement with alcohol and drugs may be an important factor predisposing individuals to continued engagement in criminal activities. Approximately 30% of the more than two million adults incarcerated in the United States were arrested as juveniles, and more than 84% report involvement with substances.³

Given the extraordinary economic burden of mass incarceration on society—not to mention its profound effects on the individual, their family, and their community—it is critical that we examine strategies to address factors contributing to reducing recidivism, including effective substance abuse treatment.

Furthermore, we need to also be mindful that substance use is often comorbid with other health problems. I run a program called Project STAY (Services to Assist Youth) that provides comprehensive medical and psychosocial services to youths at risk for, or living with, HIV. The following case is illustrative of the syndemic connections between substance use, incarceration, and other health issues:

Ricky is a 19-year-old African American male who was arrested on a robbery charge and sent to a New York City jail. Prior to incarceration, he reported substantial involvement with multiple drugs (marijuana, cocaine, and ecstasy), as well as alcohol. He was screened for sexually transmitted infections and HIV while incarcerated, and initial tests were negative. He was discharged with no specific aftercare plans. Upon reentry into the community, he quickly reengaged in alcohol and substance use to reduce “stress.” Additionally, he had unprotected sex with multiple partners (male and female) and subsequently developed a penile discharge. He was seen at the New York City Department of Health and Mental Hygiene clinic and was found to have gonorrhea, for which he was treated. A rapid HIV test done at this time was positive, and he was referred to Project STAY for comprehensive disease management.

While this is a solitary case, review of the literature suggests that there may be many more “Ricky’s” falling through the cracks in our legal, correctional, social service, educational, and health systems. Previous work by Teplin et al. revealed that 63% of detained youths with SUDs engaged in five or more sexual risk behaviors that enhance vulnerability for acquiring sexually transmitted infections and HIV.⁴ Furthermore, SUDs are often comorbid with mental health conditions, which may complicate and prolong treatment regimens.⁵

Therefore, failure to address SUDs and comorbid conditions may have substantial health consequences. Conversely, providing appropriate services may reduce community burden of disease and provide a stabilizing effect on communities. However, available evidence suggests that assessment for SUDs among justice-involved youths is inconsistent. For example, in a national survey of 141 juvenile institutional and community corrections facilities, only 47.6% used standardized substance use assessments.⁶ Similarly, delivery of services is limited; 44.5% of facilities provided substance abuse treatment, often only in the form of group counseling sessions. Only 51% of substance-using youths in residential facilities and 31% in jail were referred to community-based treatment facilities upon discharge.⁶

Recommendations for improving assessment and service delivery have been developed by the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration. They reflect findings in addiction research that substance abuse is a chronic condition that often requires long-term intervention. For individuals involved in the justice system, recommendations include “intercepting” individuals with behavioral and substance use issues at key points along the carceral continuum (at prearrest, arrest and early detention, and reentry from detention, jails, and prison back into the community). These recommendations also call for more flexibility within the judicial system in identifying individuals with mental health and substance use problems, and diverting them, if possible, to community-based programming or linking them with targeted services following incarceration to prevent further involvement with the judicial system.

Additionally, the National Center on Addiction and Substance Abuse at Columbia University (CASA) suggests the importance of providing health care, education, and job training to assist in stabilizing justice-involved youths throughout the process of substance use treatment. However, closing gaps in care requires structural changes in communication between service providers, along with better coordination and integration of services. Furthermore, it requires an infusion of resources to establish, maintain, and evaluate. The Affordable Care Act will enhance insurance coverage, and Medicaid redesign efforts, coupled with the development of patient-centered medical homes, has potential to improve services for vulnerable populations. But a concerted focus on justice-involved youths is needed to ensure that they benefit from these initiatives.

Furthermore, concern is raised about the capacity to meet the needs of justice-involved youths with SUDs. It is estimated that more than 800 000 of these young people need treatment, but that figure is six times greater than the number of available treatment slots.⁷ Therefore, there is a concomitant need to recruit and train more substance use treatment and mental health professionals, arm them with evidenced-based assessments and interventions, and develop opportunities for them to work with youths, families, and interdisciplinary teams of other professionals and service providers.

Ideally, we also need to develop primary upstream interventions aimed at improving social determinants of health and reducing the number and severity of adverse childhood experiences or ACEs that may contribute to SUDs and delinquency, while simultaneously addressing factors contributing to the hyperincarceration of minority youths. In the interim, youths presenting at the various doorsteps of the justice system are in need of, and deserve, a second chance to turn their lives around.

Clearly, this will be expensive. However, the estimated annual costs to society attributed to substance-using, justice-involved youths is between 27.5 and 42.2 billion dollars.⁸ These include costs for law enforcement, detention, probation, and providing services for victims of juvenile felonies. And, just as clearly, the current standard of care is failing young men like Ricky.

Conversely, it is estimated that if all substance-using juvenile and adult offenders were provided evidence-based treatment services during confinement and upon release back into the community, the annual costs may be upward of 12.6 billion dollars.³ While this represents a significant investment in resources, we would recoup our costs if just 11% of these individuals remained substance-free, out of jail or prison, and gainfully employed for one year. Further benefits to society accrue if these patterns continue over time—at levels reaching more than $90 000 per inmate per year with respect to savings in decreased crime, lower incarceration rates, and improved health coupled with the benefits of employment.³

At the Incarceration and Public Health Action Network—a coalition composed of schools of public health and other academic institutions concerned about the impact of mass incarceration on the health of our communities—we look forward to working with community advocates, governmental and private funders, and others in the judicial, correctional, legal, educational, vocational, and health sectors to develop creative solutions designed to enhance health outcomes for individuals involved with the justice system. Since his referral to our program, Ricky’s viral load is undetectable, his substance use is reduced, he is employed, and he is going to college. But it took getting HIV for him to get the type of coordinated, integrated services needed to stabilize his life. We can, and must, do better.