Spotlight on Criminal Justice: Observing National Recovery Month – September
Established in September 1989, National Recovery Month honors the millions of Americans who struggle with substance use disorder (SUD) and the service providers committed to using evidence-based strategies to prevent SUD and assist people in recovery. On Aug. 31, 2023, President Joe Biden issued a proclamation celebrating the 20 million-plus Americans who have sought treatment for SUD, recognizing the 100,000-plus individuals who died from drug overdose last year and outlining his commitment to addressing the national overdose crisis. These efforts include billions of dollars dedicated to making mental health treatment more accessible; expanding the nation’s system of Certified Community Behavioral Health Clinics; enhancing Naloxone access; and launching the 988 Suicide & Crisis Lifeline, which connects callers to trained counselors around the clock.
Legal substances like caffeine, tobacco and alcohol are also addicting, as are behaviors like gambling. The Centers for Disease Control and Prevention lists tobacco as the leading cause of preventable death in the United States, with alcohol coming in fourth. Though drug overdoses rise 30 percent year over year, more people die annually from alcohol and cigarette smoke. Rather than diminishing the impact of the opioid overdose epidemic, this serves as a reminder of how widespread substance use dependence is—even as it pertains to legal substances. Dependence and recovery are also important to criminal justice professionals because of the high rates at which these individuals come to the attention of the American legal system.
Substance Use Disorder and Mental Illness
In its Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V-TR), the American Psychiatric Association (APA) defines SUD as “a complex condition in which there is uncontrolled use of a substance despite harmful consequences.” Symptoms are grouped into four categories: impaired control, social problems, risky use and drug effects. According to the National Center for Drug Abuse Statistics, 50 percent of people age 12 or older have used illicit drugs at least once, and 70 percent of those who try an illegal drug before age 13 develop a substance abuse disorder within the next seven years. Repeated substance use changes the brain chemistry and function, which is why the DSM-V-TR classifies it as a mental illness.
The relationship between substance use and mental illness is complex. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), individuals who have a mental health disorder and a co-occurring SUD represent a “significant and growing number of people in the justice system.” The National Institute on Drug Abuse identifies three main pathways that contribute to the dual presence of a mental health disorder and a substance use disorder: 1) common risk factors that contribute toward the development of both; 2) the presence of a mental illness may contribute to substance use and addiction; and 3) substance use and addiction can contribute to the development of a mental illness.
Common risk factors include genetic predisposition and vulnerability; stress; brain development; and environmental influences like stress, trauma and adverse childhood experiences. Certain mental illnesses, like attention deficit hyperactivity disorder, are associated with later substance use dependence. Substance use and addiction can contribute to the onset of mental illness because changes to brain structure may kindle an underlying predisposition toward developing schizophrenia, anxiety, mood disorders or other impulse control disorders. It is important to note that one disease may not have caused the other; rather, the presence of one may exacerbate factors contributing toward the other.
Comprehensive treatment remains underfunded and out of reach in both community and carceral settings, and the general relapse rate for people with SUDs is between 40 and 60 percent. Compared to the general population, persons with mental health disorders and SUDs have higher incidence rates of incarceration in jails and prisons. Though the APA considers medications for opioid use disorder as the “gold standard” standard of treatment, a National Academy of Sciences report found that only 5 percent of people with the disorder in jail and prison settings receive medication treatment. Further, most prison medical directors are unaware of the benefits of medically assisted treatment. Unsurprisingly, inmates with opioid use disorder are at a higher risk for relapse-related overdose following release.
Treatment and Recovery
The complexities of mental health, substance use and dependence make it exceedingly difficult, if not impossible, for people to discontinue use despite harmful consequences like incarceration or death. People are never considered “cured” from the disease of dependence; instead, they are referred to as being in recovery—“a process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential.” Recovery often begins with treatment.
There are a variety of evidence-based approaches to treating SUDs in an effort to assist people in the recovery process. According to the American Society of Addiction Medicine, the proper approach for each individual depends upon a comprehensive biopsychosocial assessment of their acute intoxication and/or withdrawal potential; biomedical conditions and complications; emotional, behavioral and cognitive conditions and complications; readiness to change; relapse, continued use or continued problem potential; and recovery/living environment. The therapeutic process may involve inpatient residential treatment, intensive outpatient, general outpatient, relapse recovery and/or a combination of other individual and group therapies.
Similarly, a variety of recovery programs exist to meet individual needs. These may include clinical treatment, medications, faith-based approaches, peer support, family support, self-care and other approaches. Recovery-oriented systems of care, recovery support services, and social and recreational recovery infrastructures facilitate stability, wellness and resilience. Additionally, the U.S. Department of Labor has created a Recovery-Ready Workplace Resource Hub to help employers support and hire people in recovery.
Education and Prevention
Due to the incidence and prevalence of SUDs among justice-involved persons and the rates of relapse and overdose, there is an increased effort to educate and prevent tobacco, alcohol and other substance use, abuse and dependence. SAMHSA’s Center for Mental Health Services leads the federal effort to develop policies, programs and services to prevent, reduce and delay the onset of use. A comprehensive list of free, evidence-based resources for clinicians, policymakers and the public is available on their website.
In addition to the hundreds of thousands of individuals who die annually from tobacco, alcohol and illicit substances, millions more continue to suffer from dependence. The cost of drug-related crime, criminal justice expenses and victim losses is estimated at more than $100 billion per year. Drug treatment—even in a hospital or carceral setting—is a more effective, less expensive alternative. Research indicates that comprehensive drug treatment for incarcerated individuals can reduce drug use and crime upon release. This approach returns more people to the community better equipped to engage in productive, healthy and socially integrated lives.
As National Recovery Month draws to a close, let this serve as a reminder that investing in recovery is an investment in saving lives, building safer communities and growing our national economy.