TBA Law Blog

Posted by: Seth Norman, Samuel MacMaster & Roland Gray on Mar 1, 2015

Journal Issue Date: Mar 2015

Outcomes and Cost Savings of an Innovative Residential Drug Court Treatment Program for Felony Offenders

By the Hon. Seth W. Norman, Roland Gray, Samuel A. MacMaster and Jeri Holladay-Thomas

There are currently more than 2.2 million incarcerated individuals in the United States, almost all of whom will return to the community.1 Clear links between incarceration and substance use have been established, as an estimated 85 percent of incarcerated individuals have serious substance abuse problems: 1.5 million meet the criteria for substance abuse addiction; another 458,000 inmates had histories of substance abuse, were under the influence of alcohol or other drugs at the time of committing their crimes, committed their offenses to get money to buy drugs, and/or were incarcerated for an alcohol or drug violation.2

Individuals charged specifically with drug offenses constitute the majority of federal prisoners (51 percent), and a significant proportion of state prisoners nationwide (18 percent).3 Additionally, significant proportions of state prisoners (19 percent) and federal inmates (16 percent) reported committing their current offense to obtain money for drugs.4 Unfortunately, despite incarceration, most individuals who are released to the community return to prison within a short period of time. While recidivism rates vary widely by state, within three years, almost half (43.3 percent to 45.4 percent) of all prisoners nationwide return to prison.5 Recidivism rates in the state of Tennessee, the site of the present study, are significantly higher. Three-year recidivism rates in Tennessee are 46.1 percent, and four-year rates are 54.8 percent.6 The financial cost of incarceration is significant, particularly for state governments. Nationwide, the estimated cost of a year of state incarceration is $26,000 per person.7 Last year, states collectively spent more than $51 billion on corrections.8

Alternative to Incarceration
To combat these issues, specialized drug courts have emerged to provide an alternative to repeated incarcerations for substance-dependent individuals. The concept combines substance abuse treatment and the authority and structure of the court system to provide an alternative to the revolving door of continued incarcerations for this population. Initially started in Miami, Fla., in 1989, there are now more than 2,500 drug courts nationwide.9 Drug courts draw together and coordinate the work of the court system, community corrections and community-based substance abuse treatment providers to provide sustained monitoring and consequences for relapse to ensure that individuals engage in, and benefit from, community-based substance abuse treatment. Participants typically participate in community-based residential or outpatient treatment services and are closely monitored by the court both during and after program completion.

The drug court model is based on the principle that sustained monitoring of participants with consequences for relapse is effective for ensuring long-term positive treatment outcomes. This approach has been utilized with physicians for more than four decades,10 and has been shown to be effective with both physicians11 and individuals with alcohol dependence.12

The National Association of Drug Court Professionals (NADCP) suggests that all drug courts share these common characteristics: provision of a minimum of a year of contact during which participants are provided with substance abuse treatment and other services; high levels of personal accountability; regular and random drug tests; frequent court appearances so the judge may review their progress; and rewards for doing well or sanctions when they do not live up to their obligations.13 A significant body of literature has been developed to suggest that drug courts are effective, particularly at reducing recidivism and containing costs. Meta-analyses comparing the outcomes of multiple drug courts have found significant reductions in crime and recidivism for program participants.14

Drug courts have also been found to save significant amounts of money for the communities that have utilized them. In addition to savings on reduced probation costs and future savings on reduced recidivism, costs have been calculated to include reduced spending on child welfare, public health care, food stamps, increased tax payments and reduced mental health and substance abuse treatment costs, with found savings of $2,600 to $13,000 per participant.15
Davidson County Drug Court Residential Program (DC4) operates under the direct supervision of the Division IV Criminal Court in the 20th Judicial District of Tennessee (Nashville/ Davidson County). Established in 1996, DC4 is dedicated to utilizing the criminal justice system to assist offenders in improving their lives and rehabilitating themselves.

The program maintains a 108-bed criminal justice/drug treatment facility — the only drug court program in the country with its own dedicated residential substance abuse treatment facility. Program participants, who are not eligible for community release and would typically be sentenced to prison, agree to participate in a two-year program in which they receive a full continuum of residential, intensive outpatient and transitional treatment and related services. Unlike most other applications of the drug court model, participants are treated in a specialized long-term residential drug treatment facility dedicated solely to individuals who are enrolled in the drug court.

Program Model
The DC4 treatment program is based on a drug court model combined with a modified therapeutic community and relies heavily on a 12-step model and philosophy. The program utilizes a variety of psychological techniques to enhance and modify the 12-step model psycho-educational programming. This includes the use of group and individual interventions based on motivational interviewing, dialectical behavior therapy, cognitive behavioral therapy and rationale emotive therapy, as well as specialized services for individuals identified with mental health or trauma-related needs. All participants are screened for mental health needs and connected with appropriate in-house or community-based psychological services.

The DC4 program adheres to the standardized model of drug court programming to ensure coordination between the court system and treatment providers, with the lone adaptation that substance abuse treatment is provided within a single court-affiliated residential program, rather than multiple community providers. Participants’ progress is supervised through reviews by the drug court team and regular sessions before the judge. The team is made up of the judge, the program director, a public defender, the district attorney responsible for criminal court, DC4’s clinical staff, and representatives from community corrections who are housed within the DC4 facility. The team meets twice a week to review participant progress and each case is reviewed at least weekly. Drug court is held weekly; participants attend weekly during the first three phases of treatment and twice a month in the fourth phase, or aftercare portion, of the program to receive feedback on their progress.

The program is organized into four phases, based on a level system that is individualized to each participant’s needs and progress in his or her recovery. Phases are structured to allow for greater autonomy over time and a slow release back into the community. Participants are closely monitored throughout the process for both behavioral relapses (dishonesty, not attending meetings, etc.) and chemical relapse (a return to any substance use). The clinical team reviews all participants weekly and the program provides individualized and immediate consequences for relapses of either type at weekly drug court sessions.

Phase one is an assessment and orientation phase during which each individual is assessed for clinical and support service needs, and is socialized to the program’s rules and expectations. The transition from the unstructured environment within the county jail to the highly structured DC4 program is completed in four weeks to three months, depending on the time an individual needs to internalize the structure and expectations.

The second phase focuses on stabilization and rehabilitation; in this phase individuals receive a variety of clinical and support services to ameliorate problematic behaviors that underlie their substance use, and begin to build and develop a recovery support system in the community. Individuals are allowed to leave the facility for the first time in this phase for therapeutic reasons: they attend community-based 12-step groups three to four times per week and develop connections to outside resources for trauma, mental health and physical health services.

The third phase of the program is focused primarily on ensuring a positive transition into the community. Individuals are required to obtain employment during this phase and develop a community re-entry plan. Therapeutic services in this phase are offered in the evenings to facilitate employment. Individuals are slowly allowed to return to the community during this phase. Initially, this occurs on day passes in small groups or on a buddy system for employment searches. Once an individual is employed, 24-hour passes are offered to facilitate the transition to the community.

At the completion of the third phase, an individual is transitioned to a community-based sober living facility to begin the fourth and final stage. In this stage, participants have contact with the program three to four times a week: they have two drug screens per week, meetings with probation officers, weekly after-care group sessions, and attendance at drug court sessions. DC4 staff members monitor both houses and employment to ensure individuals are maintaining their recovery.

Integral to the treatment program is the involvement of participants in community service work. This allows individuals to participate in the community in a positive, pro-social manner and is believed to be a key building block in the development of moral character, positive self-esteem and basic employment skills. A variety of opportunities is made available to participants from the time they enter the program. Work crews go out into the community for beautification, routine maintenance and landscaping, as well as picking up trash in public areas or at local schools and nonprofits. Other opportunities allow participants to see how their experiences can benefit others through speaking to schools and community groups about their use and recovery. Individuals participate in community service work 16 hours a week during phases one and two, and four to 12 hours in phase three, depending on their employment schedule. Participants are also involved in a variety of formal and informal interventions to improve job-readiness skills and provide vocational training. Job readiness, including employment assessments, resumé assistance and interviewing skills and preparation, is provided by collaborating organizations. On-site vocational training includes opportunities for participants to learn and practice skills related to fixing small mechanics, painting, upholstery, wood shop, automotive shop, body shop, and wood shop. The facility also has a two-acre garden and a greenhouse, which provides opportunities for participants to grow the produce consumed at the facility. Excess produce is donated to area food banks or canned for consumption during the winter.

All program participants who enter residential services are nonviolent drug-related offenders who are not eligible for community release. Participants have typically been incarcerated within the general population of the county jail for six to nine months prior to entry into the program. Once referred by their legal counsel to the program, an intake assessment is scheduled. In the assessment interview conducted at the county correctional facility, a trained intake person describes the program, reviews and obtains consent to participate, and completes a clinical and legal assessment—based on items from the Addiction Severity Index (ASI).16 If the individual is willing to participate, he or she pleads guilty to the charges and is remanded to the DC4 treatment facility. All program participants are offered an opportunity to participate in the ongoing evaluation during the initial phase of treatment.

Recidivism data is collected annually on all program participants. Each July, NDCSF requests community corrections to review the arrests of every past program graduate. Data for both the local criminal justice information system and the FBI’s National Crime Information Center (NCIC) are reviewed for both arrests and convictions. Data on the type of crime, date and disposition of both arrests and convictions is entered into the local database to track participants’ long-term success post-graduation. This data was analyzed to investigate the effectiveness of the program.

Data was available for nearly 1,500 individuals (1,409) who entered treatment between April 1996 and May 2011. All participants had received residential services; average length of stay was 492 days (s.d.=305). At the time of program entry, participants’ average age was 32.6 years, (s.d.=8.8). As a group, participants were young; nearly two-thirds (63.1 percent) were under the age of 35, and more than a quarter (25.3 percent) were under the age of 25. The majority of participants were male (75.4 percent) and African American (52.8 percent). Caucasians made up most of the remainder of participants’ self-reported race/ethnicity (46.3 percent).

The data is reflective of the DC4 program’s focus on the needs of hard-to-reach, repeat criminal offenders who have long-term histories of criminal justice involvement and chronic substance use problems. Program participants reported significant criminal histories, as the average number of lifetime arrests is 11.9. Participants typically entered the program at the height of their criminal involvement; on average the number of arrests in the past two years is more than four (4.3), constituting more than a third of their lifetime arrests (36.1 percent).

In keeping with the focus of the program, drug offenses made up the majority (61.0 percent) of the offenses that brought individuals to the program, followed by drug-related offenses of theft (12.9 percent), burglary (8.5 percent) and aggravated burglary (8.1 percent). Participants had been sentenced to serve an average of 2,301 days, or about six-and-a-half years. There was significant variability in the length of time sentenced, ranging from six months to 30 years.

Participants also reported significant histories of substance use. On average, participants had used substances for 17.9 years. The majority of participants (59.5 percent) had received substance abuse treatment in the past, but none had been able to initiate or maintain their recovery. Participants were most likely to identify their current drug of choice as cocaine (57.2 percent), followed by marijuana (14.0 percent), methamphetamines (8.6 percent), alcohol (8.2 percent), and prescription pain pills (7.1 percent). Their first average reported drug use was 14.7 years, and most participants (52.1 percent) had used prior to age 14. Participants, at the time of program entry, were not faring well in terms of psychosocial functioning. None of the participants were employed, and nearly half (41.5 percent) had never held the same job for a year. Only a quarter (26.5 percent) currently had a valid driver’s license. As a group, participants averaged 11.3 years of formal education. Nearly two-thirds of participants (61.9 percent) had not graduated from high school, although a significant percentage (21.7 percent) had obtained a GED. Less than a third (30.3 percent) lived in their own home or apartment at the time of their arrest.

In terms of marital status, nearly two-thirds (64.0 percent) had never been married and few (12.8 percent) were currently married. More than one-third of participants (34.8 percent) reported they had a mental illness, and only 12.9 percent had received any mental health treatment in the past year.

In terms of criminal convictions for those individuals completing and graduating from the two-year program, the majority of individuals (61.7 percent) were not convicted for any new offenses. More than two-thirds of program completers (67.8 percent) were not convicted for new violent or drug offenses. Almost all program completers (94.1 percent) were not convicted for new violent offenses, and nearly three-fourths (86.8 percent) were not convicted for new drug-related offenses. Program completers also remained arrest-free at high rates after graduation from the program. Most individuals (87.8 percent) were arrest-free for one year post-graduation. More than three-quarters (75.6 percent) were arrest-free for two years post-graduation, and nearly two-thirds of program completers (64.8 percent) were arrest-free for five or more years after graduation.

Substance Use and Employment
Substance use and employment were monitored throughout the two-year treatment program. As a requirement of graduation, all program participants must be completely abstinent for one year. Substance use is monitored by regular urine drug screens, which were negative at a rate greater than 99 percent. All program participants were employed full-time at the time of graduation and had maintained that employment for approximately a year. This is a significant increase from the time of program entry, during which no one was employed.

Cost Savings
Savings on incarceration were calculated comparing the costs of DC4 versus continued incarceration in jail or prison. These calculations do not account for any of the other potential financial benefits the community may have incurred due to the program, i.e., the number of individuals working and paying taxes, the number of individuals either regaining custody or making financial contributions for their children, and/or the potential cost savings for individuals who are no longer engaged with the criminal justice system.

Costs savings were calculated using three different comparisons: the savings compared to the cost of incarcerating individuals for their complete sentence, the savings compared to the cost of incarcerating individuals for half of their sentence, and the daily cost savings based on housing individuals in DC4 only for the days they were residents.

A day of services at DC4 has been calculated to cost $48 by an outside auditor.17 The cost of state incarceration is reported to be $65/day by the Tennessee Department of Corrections.18 The average length of the sentence for a DC4 resident was 2,301 days. Assuming that each individual served his or her entire sentence, the average total cost to the community would be $149,565 to incarcerate each individual. The average length of time in the DC4 program was shorter, at 492 days, with a total cost of $23,616. Assuming that each individual completed his or her sentence, the community experienced a cost savings of $125,949 per person, or a total of $150,635,004 for the 1,196 individuals who have completed the residential portions of the program, i.e., phases one through three.

The assumption that individuals serve their entire sentence behind bars does not necessarily reflect reality, as individuals often receive reduced sentences as a reward for good behavior. Assuming that on average each individual would have only served half of their sentence —  1,150 days as opposed to 2,301 days —  the community would still realize significant cost savings. Incarceration costs would be calculated to be $74,750 per person, saving the community $51,134 per person or a total of $61,156,264.

At a minimum, the community saved significant amounts of money simply by placing individuals in the DC4 program as an alternative to a county or state criminal justice facility. For the 1,196 individuals who have completed the residential portions of the program a total of 573,756 days have been served at DC4. For these individuals alone, the community has saved a total of $9,753,835. This is an underestimate of the total savings cost, as the significant cost savings for individuals still participating, or who dropped out before completing, are not included in this calculation.

The findings from these analyses may be useful in contributing to what we know about the efficacy of drug court programs and community re-entry services for substance-dependent individuals. While a great deal has been written about the efficacy of drug court programs, little has been documented regarding populations not eligible for community release and the use of specialized residential treatment facilities. The results of this study indicate that individuals who participated in the program showed significant improvements in substance use, employment and criminal justice involvement.

While these results do further our understanding of these issues with respect to previous literature, more study is clearly required. As a non-experimental design, the results are not absolute and are only suggestive of this possibility. Additional research should be conducted with this program, or similar programs of this type, to further evaluate these questions through a study with a more rigorous design.

The success of the approach that combined substance abuse, mental health and support services within a specialized substance abuse treatment center within the criminal justice system is an important finding. Similarly, this study yields data that demonstrate the need for, the willingness and motivation to connect with, and the possible effectiveness of appropriately provided services for a population of individuals who typically cycle in and out of criminal justice facilities.

Although intensive levels of social need are often documented in the research, improvements of these needs and, more importantly, the willingness of members of the population to remain in services, are often less well documented. Without a counter factorial, it is impossible to know what may have occurred without the intervention. Additionally, participants in the program were not randomly sampled; thus the generalizability of these findings is limited. As there was no control group, the results from this study are only applicable to the individuals who participated in the program.

Studies based on this type of sampling run the risk of sampling bias, as individuals who were in the sample may not accurately represent the pool of potential service recipients, i.e., all felony drug offenders. For example, in the current study, the participants were offered the option of participating in the program. Therefore, the program may not be effective for less motivated individuals, as the sample does not represent the total population of potential service recipients and the remaining individuals may differ in their outcomes from the sample in unknown ways. While the sample does represent the majority of all eligible participants, it is important to view the results of this study with this limitation in mind.

Despite these limitations, the results are important. All of the outcome measures indicated significant improvements for the individuals involved in the project. Despite the limitations, these results can be utilized to further develop and/or enhance services to groups of similar individuals in other areas.

The project demonstrated that specialized residential treatment and support services provided within the context of a drug court model may be effective for the target population (i.e., incarcerated substance users with substance use disorders who have histories of chronic drug use and multiple related psychosocial problems). This is a population that has been historically described as difficult to reach and/or noncompliant with traditional services. The finding that these services save significant amounts of money as compared to the status quo alternative of incarceration suggests that these services are extremely cost effective regardless of the participants’ outcomes. When coupled with the findings of the significant life improvements of program participants, the findings are substantial.

Seth W. Norman is judge of Division IV Criminal Court in Nashville. He was elected to the bench in 1990 and reelected without opposition in 1998 and 2006. He founded the Davidson County Drug Court, a long-term residential treatment program for nonviolent felony offenders, over which he presides along with his responsibilities as criminal court judge. The program is the only court-operated residential drug court in the United States. He also presides over the 13th Judicial District Drug Court and the Morgan County Residential Recovery Court. A Korean War veteran, Norman, received his law degree from the Nashville School of Law in 1962 and practiced law in Nashville for 28 years in the law office of Jack Norman Sr. Norman serves on the Governor’s Criminal Justice Committee and the Safe & Drug Free Schools and Communities Advisory Committee for the United States Department of Education.

Roland Gray, M.D., is medical director at the Tennessee Medical Foundation’s Physicians Health Program in Nashville. Since 1997, Gray has worked as the volunteer medical director for the Davidson County Drug Court. In 2004, the court honored Dr. Gray by naming its rehabilitation building the “Dr. Roland Gray Vocational Building.” A practicing pediatrician from 1976 through 2001, he is a fellow of the American Academy of Pediatrics and of the American Society of Addiction Medicine.

Samuel A. MacMaster, Ph.D., is an associate professor of Family and Community Medicine at Baylor College of Medicine in Houston, Texas. He has worked with numerous community-based organizations in the design, development and evaluation of services for substance using populations. He is also the co-founder of JourneyPure, a national substance abuse treatment provider headquartered in Brentwood, Tenn.; where he serves as the executive vice president and chief clinical officer.

Jeri Holladay-Thomas, MCJ, is the executive director of the Nashville Drug Court Support Foundation, a 501(c)(3) community-based nonprofit organization. She has provided assistance to the criminal justice system since 1996. The NDCSF seeks to raise awareness and combat the impact of substance use and related criminal activity on the community. It has been instrumental in working with Judge Seth W. Norman and various state agencies related to the design, development and implementation of a second residential drug treatment/criminal justice facility in Tennessee, the Morgan County Residential Recovery Court, which doubles the number of residential treatment beds in the state.  

The authors report no real or perceived vested interests that relate to this article (including relationships with pharmaceutical companies, biomedical device manufacturers, grantors, or other entities whose products or services are related to topics covered in this manuscript) that could be construed as a conflict of interest.

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