Prison Country: Prisons, Drugs, and a Way Forward

prison country

It’s an easy thing to be tough on crime in American politics. “Don’t do the crime, if you can’t do the time”, “Three-strikes-and-you’re-out”, and other phrases captured the spirit of the time on crime in America, especially in the 1990s. They were not idle words.

An Individual’s Crime, An American Sin

From 1980 to 2013, America’s prison population had tripled, reports The Economist Magazine.[1] You may read this and wonder, what does that mean? It means that the United States, which presently has about 5% of the world’s population, has 25% of the world’s official prison population. A little less than 1% of Americans are imprisoned at any given time. The US has an incarceration rate so high that multiple newspapers have reported problems, including basic questions about how the prison system will care for inmates with Alzheimer’s.[2] More troubling, perhaps, is a substantial for-profit prison system that has evolved to accommodate an escalating political demand for prisons.

An astute reader may ask further, isn’t this old news? It is, but the past is ever with us and The Economist, The Guardian, The New York Times, and others continue to report on the issue because it is not going away and might actually be getting worse. There wonderful piece in The Economist book review on the politics of wrongful convictions and what it’s like inside private prisons in America today.[3] The Guardian also published a riveting excerpt about how prisons in America are effectively being used as alternatives to hospitalization for the mentally ill.[4] The Article notes that:

“The racial inequity of the criminal justice system has been widely noted: it is estimated that one out of every three African American men and one of every six Hispanic men born in 2001 will be arrested in their lifetimes.

But for Americans with serious mental illness, it is estimated that as many as one in two will be arrested at some point in their lives. It’s not just arrests. One in four of the nearly 1,000 fatal police shootings in 2016 involved a person with mental illness, according to a study by the Washington Post. The Post estimated that mental illness was a factor in a quarter of fatal police shootings in 2017, too.”

 Drugs, African Americans, and Modern Incarceration

Perhaps one of the best books on the War on Drugs and race is The New Jim Crow: Mass Incarceration in the Age of Colorblindness by Michelle Alexander.[5] Alexander’s argument is essentially that The War on Drugs and Tough on Crime policies devastated African American communities. To put this claim in perspective, African Americans represent roughly 40% of the US prison population and are incarcerated at a rate nearly six times greater than non-Hispanic Whites.[6] This is despite the fact that African Americans are 13% of the total population, according to the 2010 Census.[7]

There are two claims that we will examine by Alexander: that the War on Drugs has dramatically expanded the prison population and that the War on Drugs has disproportionately impacted African Americans.

A report by the Brookings Institute shows that drug offenses constitutes the majority of all incarcerations in U.S. prisons. These can be seen with Federal data in Graph 1, although Drug Crime Admissions were declining in the late 2000s. It should be noted while going through these statistics that there is very little in the way of transparency. These Brookings numbers were published in 2015 but are using 1990s and 2000s data.

Graph 1: State & Federal Prison Incarcerations by Offense Type, 1993-2009

Courtesy the Brookings Institute

Having established that most admissions are for drug offenses, why is there any debate? A consequence of lack of transparency is that most people were looking at the left-hand part of the Graph 2. Some experts concluded that since drug offenses comprised only 20% of the prison population at a given time, that the War on Drugs was not an overwhelmingly significant source of incarcerated persons. This is clearly false when one considers the rate at which non-violent drug offenders are processed by the criminal justice system—there are fewer of them in prison at a given time because their sentences are shorter.

 

Graph 2: Percent of Current Inmates by Type of Offense: Stock vs. Flow, 2013 and 2011

Courtesy, The Brookings Institute

The second part of the claim is also easy to validate. Using Bureau of Justice Statistics (BJS) figures, we can clearly see that African Americans are incarcerated at much higher rates than any other racial group. Incidentally, these figures are much higher for Africans Americans aged 18-19 than their peers in other racial groups—11 times as high.[8] It is entirely possible that the decrease in African American incarceration could be attributed to more lenient enforcement and sentencing for minor drug offenses, of which young African American men are hit disproportionately hard.

Graph 3: Prison Admission Rates by Race, 2006-2016

Courtesy the Bureau of Justice Statistics

Do Drugs Cause (Violent/Property Related) Crime?

Now that we have talked about some of the biases of the criminal justice system, we ought to ask ourselves: why might drugs cause crime and do they actually cause crime?

 

We start with the first question because theory better informs facts. In the field of criminology, (spoiler) it is well known that many types of illicit activities are correlated with each other. There are basically two models for thinking about causality: (1) persons who abuse drugs are likely to engage in other crimes to fuel a habit that is costly and (2) the type of person who would abuse drugs will also engage in other crimes because they cannot control themselves.

There is no real consensus as to whether drug abuse causes (non-drug related) crime. The problem is that both theories presented above could be true simultaneously—drugs could be a motivating factor in some crimes but inherent personality traits could be in other crimes. One study suggests that different types of drugs are associated with different crime types: abusers of benzodiazepines and methamphetamines being more likely to commit opportunistic property crime and abusers of alcohol and heroin being more likely to commit violent crimes.[9] In either case, acting under the influence of drugs was noted in over 70% of property and violent crime cases. To top it off, a meta-study found that drug abusers were three to four times more likely to offend than non-drug users.[10]

Conclusions—A Definite Case for Sobriety

Whatever your feelings are on the War on Drugs or substance abuse generally, it is pretty clear that there is a strong case for giving drugs a wide berth in our society. They are strongly associated with large numbers of serious criminal offences even outside the realm of possession. Regardless of causality, if you know or suspect that a friend or loved one is abusing, you should try to intervene as quickly as possible before the situation escalates. The American Criminal Justice System is both massive and often pitiless in the administration of the law, saying nothing of the stigma attached to individuals after release. Should preventative measures fail, your best recourse is to find some sort of alternative sentencing and try to manage your loved one’s dependence.

[1] https://www.economist.com/blogs/economist-explains/2013/08/economist-explains-8

[2] https://www.nytimes.com/2012/02/26/health/dealing-with-dementia-among-aging-criminals.html

[3] https://www.economist.com/news/books-and-arts/21732513-why-criminal-justice-system-so-very-fond-incarceration-problem-prisons

[4] https://www.theguardian.com/society/2018/mar/31/mental-health-care-crisis-overwhelming-prison-jail

[5] http://newjimcrow.com/about

[6] https://www.prisonpolicy.org/reports/rates.html

[7] https://www.census.gov/prod/cen2010/briefs/c2010br-06.pdf

[8] https://www.bjs.gov/content/pub/pdf/p16.pdf

[9] https://www.ncbi.nlm.nih.gov/pubmed/25705014

[10] https://www.sciencedirect.com/science/article/pii/S1359178908000037

The Opioid Crisis in Perspective

Opioid Crisis

The Opioid Crisis in Perspective

Tune into any major news network on any given day and its difficult not to hear something about the Opioid Crisis. More people have died from drug overdoses in 2016 year than the total number of Americans in Vietnam.[1] And opioids represented two thirds of those deaths, according to the Center for Disease Control (CDC).[2] The CDC reports that as of 2014, two million Americans were abusing or dependent on prescription opioids.[3] As one drug rehabilitation expert puts it, “No family has been left untouched by the Opioid Crisis.”

 

Scary numbers but they may leave inquiring minds with basic questions like: What is an opioid? What does an opioid do to you exactly? How can we measure how severe the opioid crisis is? What are major risk factors and signs of use? And what should I do if I suspect a friend or loved one of opioid use? These are questions that we will be exploring this week.

 

What is an opioid and what do opioids do to you?

 

Opioid is a catch all term for opiates, or drugs derived from poppy plants that include morphine, and synthetics opioids that mimic an opiates connection to opioid receptors in your body. Most, if not all, of these drugs have legitimate medical uses, but as the CDC points out there have been problems with dramatic over prescription of these pharmaceuticals across the country.[4] “Providers wrote nearly a quarter of a billion opioid prescriptions in 2013—with wide variation across states. This is enough for every American adult to have their own bottle of pills.”[5] These prescriptions were concentrated in narrow geographic areas, such as West Virginia and Ohio. For our purposes, there are basically three classifications of opioid:

 

  • Prescription Drugs: a broad category of prescription medications that are given out primarily for pain management. Includes drugs such as Oxycodone (OxyCotin®), Methadone, and Hydrocodone (Vicadin®).

 

  • Heroin: an illegal narcotic that is typically mixed with other drugs and thus puts people at risk for overdose. It is typically injected, but can also be snorted or smoked. Also runs the risk of contracting diseases, such as Hepatitis, through unclean needle sharing.

 

  • Fentanyl: a pain medication that is fifty to one hundred times more potent than morphine and is also commonly used in combination with either heroin or cocaine for added effect.

 

These are drugs that connect to Opioid Receptors in your brain, causing a combination of euphoria and sedation. They desensitize these receptors, resulting in an increased tolerance and physical dependency. If left unchecked, these drugs will cause progressively shallower breathing resulting eventually in death from respiratory system distress.

 

How can we measure how severe the Opioid Crisis is?

The commercial value of opioids, both as a medicine and as a narcotic, is well understood. The British, for example, famously fought two wars with China to export the drug into Chinese territories. These wars—essentially state sponsored drug dealing—were creatively called “The Opium Wars”.[6] Recreational use by American servicemen during the Vietnam War is well documented, as we talked about last week. In Central and South Asia, opioids are quite rampant.  U.S. military planners have said that victory over the Taliban in Afghanistan is impossible without first crushing narco-traffickers.[7] Incredibly large numbers of Indians and Pakistanis are addicted to heroin and other opioids.[8] Clearly, it’s big business. Clearly, it’s also destructive.

 

As I just pointed out, the CDC noted that about two thirds of drug deaths in 2016 were attributed to opioids. Below are a map and death counts by region provided by the CDC showing how each category drug is distributed across the country. Do note that there is huge variance by county within a given state—just because your home state has low numbers doesn’t mean there aren’t counties or cities with very high rates of abuse.

 

Table 1: Drug Deaths by Region and Fentanyl Cases Reported by State (2014, 2015)

Courtesy the Center for Disease Control

Opioid Crisis Opioid overdoses
heroin overdose death rates

 

Are other, more clinical accountings of the Opioid Crisis: the economic and logistical costs. Most opioid users are in their mid-twenties to mid-fifties. These are people in the prime of life. When they die or are near death, they cost the tax payers in terms of emergency services allocated to attempt to save a life or investigate. They also cost local, state, and national governments in the form of lost tax payer revenue. The epidemic has been so taxing that an Ohio city councilman, trying to contain the damage to his town and its emergency services, proposed a “three strikes” policy for opioid revivals.[9] Economists report that drug overdose deaths have cost the U.S. approximately one trillion dollars since 2001, with a rapidly growing rate of loss.[10] Although it may be painful to examine such an emotional issue this way, it is instructive to see how else the Opioid Crisis impacts communities.

 

What are major risk factors and signs of use?

The CDC has identified major risk factors for both Prescription Opioid and Heroin use. The Risk Factors are as follows:

 

Prescription Opioids

  • Obtaining overlapping prescriptions from multiple providers and pharmacies.
  • Taking high daily dosages of prescription pain relievers.
  • Having mental illness or a history of alcohol or other substance abuse.
  • Living in rural areas and having low income.

Prescription Opioids and Medicaid Patients

  • Inappropriate prescribing practices and opioid prescribing rates are substantially higher among Medicaid patients than among privately insured patients.
  • In one study based on 2010 data, 40% of Medicaid enrollees with prescriptions for pain relievers had at least one indicator of potentially inappropriate use or prescribing:
    • overlapping prescriptions for pain relievers,
    • overlapping pain reliever and benzodiazepine prescriptions,
    • long-acting or extended release prescription pain relievers for acute pain, and
    • high daily doses.

Heroin

  • People who are addicted to prescription opioid pain relievers
  • People who are addicted to cocaine
  • People without insurance or enrolled in Medicaid
  • Non-Hispanic whites
  • Males
  • People who are addicted to marijuana and alcohol
  • People living in a large metropolitan area
  • 18 to 25 year olds

Major signs of use for non-heroin opioids include, but are not limited to:

 

  • Doctor Shopping—frequent changes in doctors, typically for the purpose of receiving new prescriptions.

 

  • Lack of Motivation—becomes disinterested in work or life more broadly. The lack of motivation is most noticeable in the sense that things that once brought joy are now secondary or below notice.

 

  • Rapid Depletion of Prescriptions—goes through a month’s worth of prescriptions in a few weeks.

 

  • Sickness—often a result from a failure to receive sufficient opioids.

 

  • Social Disconnection—becomes withdrawn from family and friends.

 

 

What should I do if I suspect a friend or loved one of opioid use?

Seek help immediately! Time is your enemy and you need to act quickly to become informed. Below are several government agencies that can better inform you and help decide your course of action:

877-726-4727

888-696-4222

If you are in the LA area, please also consider calling one of our intake counselors. They will help you through the process and will also help refer you to a different provider if needed.

 

855-998-LAST (5278)

 

[1] https://www.vox.com/policy-and-politics/2017/6/6/15743986/opioid-epidemic-overdose-deaths-2016

[2] https://www.cdc.gov/drugoverdose/data/statedeaths.html

[3] https://www.cdc.gov/drugoverdose/opioids/prescribed.html

[4] https://www.cdc.gov/drugoverdose/opioids/prescribed.html

[5] IMS Health, National Prescription Audit (NPATM). Cited in internal document: Preliminary Update on Opioid Pain Reliever (OPR) Prescription Rates Nationally and by State: 2010-2013.

[6] https://www.britannica.com/topic/Opium-Wars

[7] https://www.theguardian.com/news/2018/jan/09/how-the-heroin-trade-explains-the-us-uk-failure-in-afghanistan

[8] https://www.economist.com/news/asia/21701163-states-drugs-problem-life-and-film-pushing-poppies-punjab

[9] https://www.usatoday.com/story/news/nation/2017/06/28/ohio-councilman-suggests-three-strikes-law-halt-overdose-rescues/434920001/

[10] https://www.npr.org/sections/health-shots/2018/02/13/585199746/cost-of-u-s-opioid-epidemic-since-2001-is-1-trillion-and-climbing

Long Term Structured Sober Living

 

long term structured sober living

Today’s blog is something of an inaugural post. We will be bringing in strongly empirical (factual) evidence to thoroughly and simply explore and validate the claims of substance abuse experts. Today’s post, we will be exploring the effectiveness of structured sober living arrangements. The claim that structured sober living arrangements are effective has two core assumptions:

 

  • The longer one is sober, the more likely they are to remain sober; and

 

  • the networks and habits created by structured sober living environments make people more likely to change their behavior and stay sober longer both in and outside of treatment.

 

The Longer You Are Sober, The More Likely You Are to Remain Sober

This first claim makes intuitive sense to most people. It takes a long time to break a habit, particularly when a habit is tied to an addictive activity or substance. Prolonged sober living decreases the brain’s dependence on the substance in question as it becomes more independent in terms of generating and regulating chemicals, such as dopamine. This claim is easy to validate, as empirical research on the matter shows stark drop-offs in attrition as someone recovering approaches the 6-month mark. A meta-analysis from the late 1990s showed that those in long term treatment experienced a 50% reduction in cocaine consumption if in treatment for 6-months or longer.[1] This finding is particularly instructive given the addictive nature and the scale the cocaine and crack cocaine epidemics in the 1990s.[2]

 

Long-Term Care Structured Sober Living Creates Better Outcomes

Having established that duration of soberness is critical to maintaining sobriety (duh), we need to consider a means of extending that soberness: structured care. The idea of structured care is fairly intuitive because it centers around behavioral modification and networks of accountability.  If all your friends are drug users who use regularly, you are more likely to be a drug user. If you engage in risk enhancing behaviors, like smoking when you typically smoke while drinking, you are more likely to abuse a substance. Structured care takes those ideas and works them in reverse to break vicious cycles and create virtuous ones.

 

There are many different factors that put a person at risk for substance abuse and recovery, the most obvious being motivation. By creating a network of like-minded individuals attempting to be sober, everyone’s motivation increases. We all bicycle faster together. Similarly, creating new positive environments to live in reduces dependence on drugs. This has been shown to be empirically true. A famous study with a food and a cocaine dispenser with rats showcased everyone’s worst fear: the rat, when isolated, would continually dispense drugs until starving to death. The second part of the Rat Park Study showed that rats, when allowed to live with other rats, strictly preferred plain drinking water to drug laced water if the drug water was linked to some sort of physical or emotional isolation.[3]

 

This theory, while unpopular at the time, was proven true by the most unlikely of things: the Vietnam War. Soldiers fighting in Vietnam had notoriously high rates of substance abuse, often a form of maladaptive self-care. The fear was that when the G.I.s returned home, there would be massive drug epidemics. The truth, it seems, was that when the soldiers demobilized and returned to less traumatic and more helpful environments, they had levels of drug abuse consistent with the general population.[4] Environment and behavior are extremely important to controlling substance abuse.

 

Conclusions

The efficacy or cost effectiveness of long term treatment for heavy drug users is not exactly news, either. The RAND Corporation, a policy research and analysis firm that typically does work for the Pentagon, released a study for the war on drugs in the 1990s. In its study, RAND found that treatment was more effective and less costly than higher mandatory sentences and other law enforcement measures. The study is so thorough and convincing in its analysis that it is used as a case study for students of public policy across the country to this day.[5] Alas, these demand style approaches have not gained traction for political reasons, to the detriment of everyone from government agents to taxpayers and drug users themselves.[6] The topic of incarceration and treatment is something that we will talk about in greater depth next week.

 

[1] http://psycnet.apa.org/buy/1997-43757-005

[2] http://www.drugfreeworld.org/drugfacts/crackcocaine/a-short-history.html

[3] https://www.summitbehavioralhealth.com/blog/overview-rat-park-addiction-study/

[4] https://www.npr.org/sections/health-shots/2012/01/02/144431794/what-vietnam-taught-us-about-breaking-bad-habits

[5] https://www.amazon.com/Practical-Guide-Policy-Analysis-Eightfold/dp/1568029233

[6] https://www.rand.org/pubs/periodicals/rand-review/issues/RRR-spring95-crime/treatment.html