A study from Rhode Island Hospital has found that collaborative behavioral management may be effective in reducing substance abuse among convicted marijuana users who are paroled. The findings have important implications for the management of a substantial proportion of the U.S. community correctional population. The study is published in Addiction and is available online in advance of print.

In the U.S., over 700,000 inmates leave prisons each year and over two-thirds of those inmates have a drug problem. The return of these inmates to the community is a critical issue for public health and safety. Relapse following release contributes to the re-arrest of more than two-thirds of parolees and re-incarceration of over half of inmates in the three years after release. While treatment can reduce relapse, drug-involved ex-inmates give limited priority to addiction treatment. Surveillance with the threat of sanction by parole officers is the traditional method of following parolees, yet many ex-offenders fall into the same pattern and are arrested again.

Knowing that contingency management can be an effective treatment for drug abuse and addiction, researchers at Rhode Island Hospital and nationwide, led by Peter D. Friedmann, M.D., performed a clinical trial called “Step ‘n Out” to determine whether collaborative behavioral management would be effective in reducing substance abuse, crime and re-arrest among drug-involved parolees. This study was funded by the National Institute on Drug Abuse of the National Institutes of Health.

Friedmann, a physician and an addiction health services researcher at Rhode Island Hospital, explains, “Because of the so-called War on Drugs, an unprecedented number of people have been put in prison for drug use and the great majority of them return to the community. Community reentry is a difficult period – having a criminal record makes it hard to get a job and you usually return to the same environment you came from with the same people and temptations. Thus, a large proportion of drug-involved ex-offenders return to drugs and crime.”

Addiction treatment during the transition period can reduce relapse, but competing priorities such as the need for housing and finding work often limit ex-offenders willingness to participate in treatment. Parole and probation are supposed to encourage treatment and prevent a return drugs and crime, but they are poorly designed to do so. Probation and parole are based on supervision and punishment for bad behavior. For example, if a parolee tests positive for drugs, he/she might be returned to jail.

Behavioral theory holds that effective reinforcers or punishments must be both immediate (close in time to the behavior) and reliable (happen every time the behavior happens). “Any parent knows that punishment alone is not the optimal way to motivate behavior – it is best to have both carrots and sticks,” Friedmann says. “The problem is that punishment is neither immediate nor reliable - in part because of due process, but also because surveillance is imperfect and offenders have a disincentive to get caught. Conversely, drug use produces both immediate and reliable reinforcement, where a user gets a good feeling with every use.”

Friedmann explains, “The everyday reinforcers of daily life such as a good job and good family life can’t compete – they are delayed and not guaranteed.” Thus, behavioral theory explains what we see – the reentry period is extremely challenging and many ex-offenders end up returning to drugs and crime.”

Through the Step’n Out study, the researchers developed a system of “bridge reinforcement” to provide incentives for good behavior. Weekly over 12 weeks, officers, treatment counselors and clients worked together to agree on a behavioral contract in which there were three target behaviors. If the client met the behaviors then they were rewarded through a system of points that led to positive social reinforcers or material reinforcers like gift cards. A computer program helped track and manage the points and reinforcers. The motto of the study was “Catching People Doing Things Right” because the clients now had a reason to report their successes and the parole officers to recognize them. This intervention was studied in a randomized clinical trial in six parole offices in five states.

The Step ‘n Out trial reported that collaborative behavioral management worked to reduce primary drug use among “non-hard drug” users, primarily marijuana. Since marijuana users comprise a large proportion of individuals arrested for drug use, this study suggests that this behavioral approach to community corrections might reduce drug use and ultimately reincarceration. The findings, however, could not demonstrate benefit among parolees who preferred stimulants or opiates.

Friedmann notes, “Since the majority of drug violation arrests in the U.S. are for marijuana, these findings have important implications for the management of a substantial proportion of parolees. The study shows that an intervention grounded in behavioral science is feasible and effective in real-world correctional settings.”

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Friedmann’s principal affiliation is Rhode Island Hospital, a member hospital of the Lifespan health system in Rhode Island. He also has an academic appointment at The Warren Alpert Medical School of Brown University. He is also a physician with University Medicine Foundation http://www.umfmed.org/ and the Providence Veterans Affairs Medical Center. Other researchers involved in the study with Friedmann include Traci C. Green, Faye S. Taxman, Magdalena Harrington, Anne G. Rhodes, Elizabeth Katz, Daniel O’Connell, Steven S. Martin, Linda K. Frisman, Mark Litt, William Burdon, Jennifer G. Clarke and Bennett W. Fletcher for the Step ‘n Out Research Group of the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS).

CJ-DATS is funded through a cooperative agreement from the National Institute on Drug Abuse, National Institutes of Health (NIDA/NIH), with support from the Center for Substance Abuse Treatment; the Centers for Disease Control and Prevention; the National Institution on Alcohol Abuse and Alcoholism (all part of the U.S. Department of Health and Human Services) and from the Bureau of Justice Assistance of the U.S. Department of Justice.

About Rhode Island Hospital:

Founded in 1863, Rhode Island Hospital in Providence, R.I., is a private, not-for-profit hospital and is the largest teaching hospital of The Warren Alpert Medical School of Brown University. A major trauma center for southeastern New England, the hospital is dedicated to being on the cutting edge of medicine and research. Rhode Island Hospital receives nearly $50 million each year in external research funding.

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Nancy Jean
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Lifespan