Substance Abuse, Lack of Treatment, Prejudice and Incarceration A Community Health Problem

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Substance abuse and poor mental health form some of the biggest concerns of society. People of all ages especially the young are influenced by substance abuse. Child and spousal abuse, school failure, teen pregnancy, becoming infected by sexually transmitted diseases including AIDS, frequent disruptions in the family, personal life and work and incarceration have complicated the lives of the involved. The impact on the health indicators is tremendous. Drug abuse is the non medical use of a drug and would mean that a person is using a drug without proper prescription contrary to the labeling instructions or using an illicit drug.

Incarceration

Incarceration is one of the consequences of inadequate treatment of co-occurring substance abuse and mental disorder. Inmates who have a double diagnosis are usually more likely to be homeless and would have been charged with violent crimes unlike other inmates (McNiel, 2005). There are 2.2million people behind bars. 95% of them would be leaving prison at some time in their lives and two thirds of them would be re-arrested. They would have difficulty integrating into society due to their substance abuse and addiction (Gever, 2007). Lack of proper treatment inside and outside the prison makes them vulnerable to failure. They would have difficulty in securing housing and jobs. Substance abuse would have made them commit crimes. A large number of crimes would have been committed like peddling drugs apart from using them, indulging in drunken driving and causing accidents and fatalities, stealing to buy drugs and wreaking violence. 81% of the inmates are usually five-time offenders with regular drug use (weekly use for one month at least) and 41% would be first time offenders (NCASA). These inmates also had the misfortune of remaining in jail for longer periods. It is evident that many people who need treatment badly are in jail. Multiple service delivery is the essential requirement here.

Women

There has been a dramatic increase in the number of women entering prison for drug offences (Zlotnick, 2002, p.2). The lack of viable treatment for these women is a problem. Incidents of interpersonal violence were reported from them. A higher rate of recidivism was also reported from these women who were subject to increased incidences of physical and sexual abuse (Zlotnick, 2002, p.2). The illicit drug use and interpersonal problems were the main ones in their lives. Post traumatic stress disorder was the commonest of the mental illnesses affecting these women inmates. The rates of PTSD were 3 times that in the general population. Childhood abuse is strongly related to PTSD (Zlotnick, 2002, p. 3). A high level of co-occurrence of PTSD and substance abuse is seen in incarcerated women and a severe course is a result. PTSD predisposes the women to 5 times more incidence of substance abuse than those women without PTSD. The women with both showed lesser compliance with treatment, a worse course of substance abuse, more medical illnesses and more admissions for treatment, greater recidivism and exhibit greater criminal behavior (Zlotnick, 2002, p.3). Most of the women with both PTSD and substance abuse were associated with the more severe drugs. They also showed greater sleep disturbances than those with only substance abuse. Those with co-occurring PTSD and substance abuse were found to have poorer psychosocial functioning due to interpersonal problems, homelessness, unemployment and child maltreatment (Zlotnick, 2002, p. 4).

Reentry and the requirement of treatment

Treatment has reduced addiction which has been a major cause of re-entry into jail and lowered the numbers returning to jail for a new offense which again would be related to substance abuse and addiction. The inmates who had been involved in a residential treatment program in prison had a 9-18% lesser chance of recidivism than the other inmates who received no treatment (Gever, 2007). Drug relapse rates were lower by 15-35% (Reentry Policy, 2005). These figures improved when treatment was continued outside prison without break. Prisoners who completed the residential program and then continued with a community based after- care program had lesser rates of re-incarceration. The re-incarceration rate for prisoners who continued treatment was 25% only when compared to the group which never had any care and had 42% re-incarceration while the group which participated in some care but dropped out had a 64 % rate (Re-entry Policy, 2005). Some studies have shown a 50% lower rate for those who continued treatment when compared to those who did not. Successful treatments are sufficiently long in duration and help offenders effectively change their behaviors with the criminal justice system helping to ensure compliance with treatment (Taxman, NDCIR). Several barriers limit the inmates access to treatment. These are identified as lack of treatment, lack of access to public benefits and lack of employment (Gever, 2007).

Lack of treatment

All prisons may not have available treatment. Only 40% of all correctional facilities had this treatment. However only a dismal figure of 10% institutions participated was between 70-85% people needed it. This comes to the figures of 150000 and 680000. There is also no follow-up. It is easy for a released prisoner to go back to his old habits of drugs and crime. Severe addiction problems require in-patient services. A system whereby the prisoners on parole or if convicted for some types of crimes cannot avail of social service or benefits for assistance stops them from taking appropriate treatment (Gever, 2007). Some states have refrained from enforcing this law. Preventing access to public houses could interfere with their access to treatment. Public housing is not available to ex-offenders. Many of them are homeless. Finding work is another obstacle. Their poor education is a problem but those who secure jobs remain out of jail. One study found that 70 % of parolees were unemployed. 21% had full time jobs (Gever, 2007).

Alternatives are being investigated for the prisoners who face re-incarceration for substance abuse problems. The drug court has been set up for the treatment of non-violent offenders. If the treatment is completed successfully, the dismissal of charges or a reduced sentence results (Gever, 2007). Discussion is on for treating substance abuse outside the correctional facility. It can be concluded that treatment outside and inside the prison lowers the incidence of recidivism. The most effective services are yet to be implemented. Evidence based treatment programs can be effective in slowing recidivism.

Strained budgets are hampering effective services (Gever, 2007).

Healthy People 2010

The Healthy People 2010 programme has addressed the major health indicators of public health concerns in the United States (Healthy people 2010, 2000). Strategies and action plans have been drawn up for each of the indicators. The objective is to create healthy people in healthy communities. Substance abuse and mental health form two of the many indicators of health addressed. However there is only a passing reference to the problem of co-occurring substance abuse and PTSD in women inmates. The proportion of inmates receiving substance abuse treatment in correctional facilities is to be increased (Healthy People, 2000, p. 26-43). The goal of Healthy People 2010 for substance abuse is to reduce substance abuse to protect the health, safety and quality of life for all especially children

Data to highlight the community problem 100000 deaths have been related to alcohol consumption (McGinnis, 1993). Another 12000 deaths have been attributed to drug abuse and AIDS. Annual economic costs have been estimated to be running to the tune of $167 billion from alcohol abuse and $110 billion for drug abuse in 1995 (Harwood, 1992). This would amount to saying that every citizen has to spend $1000 for meeting the cost of health care, vehicle crashes, crime, productivity loss and other undesirable outcomes like poor mental health associated with substance abuse.

20% of the population is estimated to have mental illness, mostly depression. This amounts to 19 million people having mental ill health. Only 23% of these people received treatment. Two thirds of the suicides have been accounted for by people with depression (Healthy people 2010, Leading health indicators). 78% of all inmates in the U.S jails have been found to have co-occurring substance abuse and a mental disorder (McNiel, 2005).

The hospital approach for treatment would have been due to drug use for reasons of dependence, suicide or psychic effects. The commonest motives were found to be suicidal attempts and dependence, each accounting for 35 %. 55% of these events occurred in the age group 16-34 and 44 % in the higher age group beyond 35 years. Whites answered 54% of the episodes and African Americans to 25% (HHS, 1999). The alcohol-related visits due to drug abuse accounted for 2.4 % of all emergency department visits or 2.2 million visits. The two commonest diagnoses were dependence and abuse (Li, 1998). There was a suggestion that most of the young and with trauma were intoxicated (Barnett, 1998). To reduce these alcohol-related visits, policy measures that help to diminish the number of vehicle crashes and violence may help.

Health risk behaviors are usually initiated in principle at the impressionable period of adolescence, developed into youth and established in adulthood. Hispanic students had the greatest likelihood of driving with a person who had been drinking. State surveys of the Youth Risk behavior Surveillance System showed a median of 34.1% of adolescents who had driven in the last 30 days with a driver who had been drinking. Local surveys showed a median of 31.4% (HHS, 1999).

Literature indicated that an average of 60% of homicide offenders committed the offence while drinking (Murdoch, 1990). Drugs and alcohol had been behind many firearm-related deaths (Pacific Center for Violence Prevention, 1994). In 1996, many of the arrestees for violent offences like robbery, assault and using weapons were under the influence of drugs. Two thirds of intimate partner violence victims revealed the influence of alcohol. 75 % of spousal violence victims spoke of alcohol abuse. 31% of victimized strangers claimed that alcohol had been used by the offender (US Department of Justice, 1997).

Female inmates showed drug possession convictions which were higher by 41% and drug trafficking by 34% (U.S.Department of Justice, 1999a). 40% of the female inmates were under the influence of drugs while only 32% of men were so. The prevalence rates for drug dependence in women prisoners were about 26 to 63% while alcohol dependence ranged from 32 to 36%. The current rates are 30-52% for drug dependence and 17-24% for alcohol dependence (Zlotnick, 2002, p.2). The women in prison are 5 times more likely to abuse alcohol and 10 times more likely to abuse drugs than those in the general population.

Epidemiological model

The epidemiological model is set in a community based format. The vision is Healthy People in a Healthy community. The aim is to teach the people to build a community coalition to build a healthier and happier place to live, work and play. A healthy community enables people to maintain a high quality of life and productivity (Healthy People in Healthy Communities, 2001). Key organizations and individuals would be mobilized to help build the coalition community. Various health problems are to be tackled with community help. Health indicators and their targets have been put together and the means of achieving these targets have also been suggested in the Healthy People 2010 Program. The problem of incarcerated women with co-occurring

substance abuse and PTSD could also be handled in a similar manner through community effort while outside jail and with cooperation of jail authorities while in prison.

Sex race, ethnicity and age distribution

Substance abuse appeared to affect all races, ethnic and economic groups alike.

Alcohol was the most commonly used and was similar for race and ethnicity (p.26-6). Next in incidence came tobacco use and then illicit drug abuse. The usage among the adolescents showed that the whites and Hispanics used more alcohol (35.1 and 29.4%) than the African Americans (22.3%). Tobacco was most used by the whites (26.9%) in comparison to the other two groups which showed the incidence of 20.4% and 16.2% respectively. Illicit drugs were most used by whites (16.9%) and Hispanics (17.4%) than African Americans (14%).

It has been found that initiation to substance abuse began at 13.1 years for both alcohol and drugs and is common for all communities (p.22). The objective of the Healthy People program is to increase the age of initiation to 16.1 for alcohol and 17.4 for drugs and proportion of adolescents who remain free of alcohol to 29% from the 19% of 1998 and of drugs to 56% from the 49% of 1998 (p.23).

Influence of education, income and poverty levels

Disparities in income and education and socio-economic status do not apparently affect substance abuse and mental health problems. However they affect the incarcerated people who are homeless, do not have the privileges of citizens for health care and who go into the habit of re-incarceration.

Major risk factors for poor health outcomes

Older adolescents and adults who had co-occurring substance abuse and mental disorder needed appropriate treatment for both. When treatment is designed for either, the chances of the affected getting appropriate treatment is less as they would be shunned by both departments (Healthy people, p.26-7). The older age group above 65 had a higher risk of alcohol-related problems even though their consumption was much less. Problems also could arise from alcohol-drug interactions in this group of people as they would be taking medications for many illnesses. Alcoholism could lead to memory deficits and dementia (p.26-7). The adolescents who started before 14 years of age had the risk of falling into dependence later. A family history of alcoholism predisposed adolescents to follow suit. Excessive drinking increased the risk of alcohol-induced disorders depending on the amount, duration and patterns of consumption and a vulnerability to alcohol related consequences (Healthy People, p.26-3).

Morbidity and mortality

High blood pressure, heart arrhythmias, heart muscle disorders and stroke are some of the illnesses that could be caused by long term alcoholism. Morbidity can also be seen as cancers of the oesophagus, mouth, throat and larynx. Cirrhosis and other liver disorders have been associated with alcoholism. The outcome for patients with hepatitis C is worsened with cirrhosis. The risk for developing cancers of the colon and rectum is increased. The risk of women developing breast cancer is increased if they take 2 or more drinks daily. Sexually transmitted diseases including HIV are rampant.

Mortality is increased when injuries and deaths occur from alcohol-related motor vehicle crashes, falls, fires and drownings. Homicide, suicide, domestic violence, child abuse and high-risk sexual behavior have been associated with alcoholism. Delayed mortality can be attributed to the progress of cancers, cirrhosis and HIV.

Drug-induced deaths are caused by psychosis, dependence, suicide and poisoning from intentional and accidental reasons. Mere declining initiation or the number of cases or the intensity of abuse are not the only factors that influence the reduction in the statistical figures. Prevention of suicide, accidental poisoning and the knowledge of fatal interactions between drugs are also contending factors for saving lives.

One of the leading causes of cirrhosis is sustained alcohol consumption and cirrhosis is one of the 10 leading causes of death (Hasin D., 1990). It is the replacement of healthy liver tissue with scarred tissue and thereby disturbing the normal functions of metabolism. Better treatment availability and better management have reduced the cirrhosis deaths since 1973. The costlier beverages also must have deterred many.

Levels of prevention for the substance abuse and mental health problem

Concerted efforts through the enforcement of the laws pertinent to alcohol abuse have reduced the incidence. These laws are the raising of the minimal drinking age to 21 years, revoking of licenses of those who drive while drunk, lowering the level of blood alcohol limits for youth and adults and raising the prices for alcoholic drinks. Combined community programs involving the city departments and private citizens have also contributed to the diminished incidence (Healthy People, 2000).

The Healthy People aims to reduce the deaths and injuries caused by alcohol and drug-related motor vehicle crashes. Alcohol related deaths are to be reduced from 5.9 in 1998 to 4 per 100000 in 2010 and the alcohol-related injuries from 113 in 1998 to 65 in 2010. Another initiative of Healthy People is to reduce cirrhosis deaths from 9.5 per 100000 in 1998 to 3 in 2010. The number of drug-induced deaths is to be reduced from 6.3 per 100000 population in 1998 to 1 in 2010. Emergency department visits for substance abuse-related events are to be reduced by 35 % from 542544 visits in 1998 to 3500000 visits by 2010. Alcohol-related hospital emergency department visits are also to be reduced. Ensuring that adolescents are not driven by a driver who had been drinking is essential in reducing alcohol-related deaths by vehicle crashes and injuries. The target aimed at is to reduce the present statistics of 33 % in 1999 to 30 %. Intentional injuries are to be reduced through the effort of the local communities and their surveillance systems. Prevention and treatment programs may be directed at violence related to substance abuse. Reducing the cost of lost productivity by implementing the various policy measures and being stringent with laws is another goal of the Healthy People Program. Efforts would be made to increase the age at first use of both alcohol and drugs. The main aim is of course to take children from adolescence to adulthood without indulging in alcohol or drugs. Prevention activities would concentrate on strengthening the ability of children to reject these substances while in adolescence so that the chances of carrying these favored skills and attitudes into adulthood are high. Once in adulthood, they are no longer amenable to suggestions and family constraints (p. 24). The number of children who reported that they were free from alcohol and drugs is rising due to prevention activities. The proportion of adolescents not using alcohol or illicit drug in the past one month is to be increased from 79% to 89%. The Healthy People Program aims at increasing the proportion of persons with co-occurring substance abuse and mental disorder who receive treatment for both (Healthy people, p. B18-15) Interventions TIP 17 Drug courts have found that the previous method of punishing for substance abuse has not made an impact on the drug problem. The criminal justice system believes in using long term therapy for controlling the drug problem (TIP).

The Best intervention for Substance Abuse and Mental Illness in incarcerated women

Integrated treatment for co-occurring substance abuse and PTSD would offer better results and provide relief for both faster (Zlotnick, 2002, p.4). The dual diagnosis causes a more severe course and is involved with greater psychosocial impairment than when either occurs singly. PTSD needs to be addressed earlier so as to elicit a better outcome. Not doing so may carry the risk of relapse and recidivism.

Four approaches have been described. Abuegs 12 session relapse prevention model is used for the therapy of elderly patients with alcoholism (1994). A coping-skills model is the form of therapy suited for dual diagnosis. A 25-session cognitive behavioral psychotherapy called Seeking Safety may be used here (Najavits, 2002). It has a combination of coping skills and exposure. Relapse prevention is also involved. Brady and his colleagues also used coping skills and (in vivo and imaginal) exposure model (2001). Substance dependence PTSD Therapy was a combination of relapse prevention and in vivo exposure (Triffleman et al, 1999).

Incarcerated women are not offered the therapy which has exposure. They may drop out or exhibit increased distress. Incarcerated women have drawbacks in self soothing and affect regulation. History of childhood abuse may be behind the problem. Male and female incarcerated inmates require different therapies (Zlotnick, 2002, p.6). Seeking Safety intervention appears to be the best for incarcerated women. Problems like impulsiveness, anger, maladaptive lifestyles are targeted and skills to manage these behaviors are taught. Cognitive behavioral therapy of substance abuse, treatment of PTSD, treatment of women and educational research are the four aspects dealt with in Seeking Safety intervention. The therapy aims at abstinence from substances and personal safety from self harm, HIV risk and domestic abuse. Sessions concentrate on subjects like honesty, asking for help, setting boundaries, integrating the split self, compassion, and taking good care of yourself. Past relationships are discouraged to eliminate the possibility of retraumatization. The patients sense of control is restored (Najavits, 2002). The patient is followed up for months. Change in severity of abuse is checked at intervals. Various instruments are used to check the patient at intervals to understand the progress with therapy. Seeking safety has a high degree of acceptability among incarcerated women. Half the women no longer met the criteria for PTSD at 3 months. Therapy did not exhibit an obviously positive outcome for substance abuse as the women were still in prison. The retention rate was higher than in other studies (Zlotnick, 2002, p.16). However many of the women returned to prison. A continuum of therapies would have provided significant relief.

Incarcerated women must also be provided reproductive health services (Clark, 2006). There could be high risk of sexually transmitted diseases including HIV, pregnancies, inconsistent birth control, inconsistent condom use, multiple partners and unplanned pregnancies. These ladies, probably living in abject poverty would not be having insurance or welfare help for their needs. Incarceration may be the only way they can secure some general health care, reproductive health care and preventive health care. They still are not liable to get preventive services like Pap tests for cervical cancer detection, STD screening, family planning or preconception counseling (Clarke, 2006).

Jail diversion and the role of the police

The role of the police is significant when a disordered person is taken into custody for a crime. The policeman has to decide whether the individual is just eccentric or not mentally fit to be placed in a cell. He has to coordinate with the local mental health facility to decide what to do with the person. Managing the mentally ill would require hospitalization. The police department and the mental health facility have a written agreement for maximum cooperation. Police realize that alcoholics and addicts are not received well in hospital. The attitude of the health facility is prejudiced. Sometimes persons who can be sent home easily and have not done anything serious are informally disposed of (Steadman, p.2). The persons if found not having much of a mental problem may be arrested. The third option is to divert a mentally ill person who needs therapy badly to a mental health facility after securing their diagnosis. This is jail diversion. Early detection, diversion, targeted crisis intervention, stabilization and linkage all mean that safe pre-trial detention occurs (Steadman, p.7).

Healthy People 2010 Advice

The treatment gap is to be reduced (Healthy people, 2000, 26-43). This gap is the difference between the number of people who need treatment for substance abuse and the number who are already on treatment. Efforts need to be taken at the National level to correctly estimate the treatment gap, develop plans to increase the capacity and eliminate the barriers which are preventing access. Adolescents, females and the elderly must be addressed. The proportion of inmates in correctional institutions who are to take treatment must be increased. The number of people who are incarcerated for drug offences like possession, trafficking and violence crimes has increased. (Healthy People, 2000, 26-43). Without treatment they have a greater risk of repetition. Increasing the number of admissions of substance abuse patients for injection drug use is one method of reducing cases. The target is 200000 admissions by 2010. Reducing the treatment gap for alcohol is another method to control the incidence.

Current Best Practices

Empirically oriented scholars are attempting to integrate practice and research.

(Rubin, 2007, 406). Evidence-based practice is the process by which practitioners ensure that their clients receive the best and the latest and most effective interventions. Taking into account various parameters like diagnosis, age, gender, ethnicity and problems, the practitioner formulates an answerable question regarding the needs of the client. The next step would involve the search for the best evidence available to answer the question. The scientific validity and the usefulness of the evidence are then appraised (Rubin, 2007, 406). The treatment options are delineated and based on the practitioners experience, some practical adjustment is made. This is then applied and the outcome is assessed. The community approach to the goals of Healthy People 2010 greatly involves the nursing profession which rubs shoulders with the community. They are the ones who can influence the community and bring the needy for treatment interventions (Rubin, 2007, 406).

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