Karen Cropsey, PsyD
Conatser Turner Endowed Professor of Psychiatry, University of Alabama at Birmingham
Dr. Cropsey has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: Could you tell us a bit about your background in working with people with addiction in the criminal justice system? Dr. Cropsey: I am a clinical psychologist and professor in the Department of Psychiatry at the University of Alabama at Birmingham. I conduct research and provide clinical care to patients with addiction within the criminal justice system.
CATR: Clinicians often worry about what treatment their patients get during incarceration. Are addiction services routinely provided? Dr. Cropsey: Unfortunately, across most jails, there is not much active treatment. Jails are different than prisons. Jails are for short-term periods of incarceration (generally less than 12 months), often before going to trial. People are in and out of jails, and it’s more of a chaotic environment, because there is a lot of movement. Oftentimes people come in and they may be high on something, but they are not going to see a doctor or even probably a nurse, and they’ll just end up withdrawing on their own unless someone notices something and decides that they need medical attention.
CATR: Is the situation different in prisons? Dr. Cropsey: Yes. There usually isn’t as much active use by the time people are in prison, although we do know that people smuggle in substances. There also is more of an opportunity to intervene in prisons, but it varies by system and by state, and most states still don’t provide opioid agonist treatment with buprenorphine or methadone.
CATR: That’s unfortunate, given that these lifesaving medications are the standard of care. Dr. Cropsey: Sadly, in states that have failed to extend Medicaid, even people in the community can’t access these treatments. With recent programs like SAMHSA’s SOAR (SSI/SSDI Outreach, Access, and Recovery), there is increased access to disability benefits, and people are starting to be able to access treatment. But if you live in a rural community, there often are no methadone clinics or buprenorphine providers. And overall, if you don’t have insurance, more than likely you really don’t have access to agonist treatment. Again, the community standard varies dramatically from state to state, and that’s also reflected in the prison systems.
CATR: You mentioned access to illicit drugs. Are they easy to access? Dr. Cropsey: It’s hard to say. I’ve heard people who say, “Yeah, we can’t get anything in this place,” and then others tell you, “Yeah, you can get any drug you want.” It is hard to know how much illicit drug use goes on or how the drugs get into prison as there have not been many studies on these issues. But anecdotally, some prisoners will report using drugs during incarceration.
CATR: Any thoughts about the kinds of drugs that are most available in jails and prisons? Dr. Cropsey: Prisoners will ferment fruit or grain to make alcohol, which is often called “hooch.” And it can be relatively easier to smuggle marijuana or any other drug that can be mixed into tobacco. But even that varies, and smoking is not allowed in some systems, which also cuts down on illicit drugs because you then can’t hide them in tobacco. In addition to illicit drugs, prisoners will also trade or sell prescribed drugs that are not commonly diverted on the streets, like diphenhydramine or gabapentin.
CATR: We sometimes hear from clinicians that certain patients would be better off incarcerated, because they can’t stay sober in the community. Others respond that no one is better off incarcerated. What are your thoughts? Dr. Cropsey: I’m of the opinion that we shouldn’t be incarcerating people for drug use. Incarceration should be saved for violent offenders. Putting people in for a few ounces of marijuana or cocaine seems a bad use of resources and is not a medically indicated way to address substance use. If we believe addiction is a medical disease, we need to treat it as such instead of a moral failing or a criminal behavior. This means you’ve got to accurately diagnose and treat the disorder. And treating the disorder is not about separating people from society and disallowing them to work or engage in other activities.
CATR: Perhaps some believe that if people spend enough time away from society or away from substances, then they can get cured from their addictions. How would you respond to that claim? Dr. Cropsey: People generally don’t receive much treatment in prison. Resources are tight. Again, there are better ways to treat people in the community. Instead, we warehouse people, and then they come out, and it’s hard for them to earn a decent living—and then we get upset when they go back to dealing drugs. It’s a setup for failure. I can tell you that with tobacco, up to 98% of people relapse back to using tobacco after release (Frank MR et al, J Smok Cessat 2017;12(2):76–85). The high rate of opioid overdose following release from prison also suggests that merely removing people from drugs for a period of time is not an effective intervention for drug use (Merrall EL et al, Addiction 2010;105(9):1545–1554).
CATR: Could you tell us more about the challenges people face after release from incarceration? Dr. Cropsey: People come out with a felony on their record, which makes it extremely challenging to get a job, and certainly a good-paying job. They also go right back into the same environment that they were in (https://www.prisonpolicy.org/reports/outofwork.html). None of that is a recipe for success. And they also need to find a place to live, reconnect with family and friends, maybe try and get their kids back, or maybe try to go finish education. Now some will finish their education in prison. But again, there are better ways to address this issue than warehousing people in prison with violent offenders.
CATR: This is all important information. What can clinicians do to help with reentry after incarceration? Dr. Cropsey: It’s important to help people reconnect to treatment. Let’s say someone has schizophrenia and was on medication in the prison system; often the person will be discharged with a limited amount of medications—maybe a 30-day supply at best. And so, it’s important to make sure that the person can get connected back into the community and get followed by a prescriber. The same is true with every medical condition, and it’s especially challenging because the person may have lost Medicaid or private insurance coverage. Some states do a better job of bridging people and doing release planning, but it varies. Another issue that people may need help with is housing. When they leave prison, they need to have an identified place to go live. Sometimes if states can’t get that sorted out in time, they may just end up giving the person a bus ticket and a little bit of money.
CATR: Clinicians sometimes run into a situation where their patients are still seeing them but have a trial date after which they are expecting to be incarcerated. Is there any advice we can give patients facing this situation? Dr. Cropsey: In this situation, you can give them a list of their medications, so the people who do their check-in will have that information. The patient is likely not going to get any controlled substances, so if you have someone on a benzo or stimulant, the prison is not going to fill those, and there is a limited formulary within jails and prisons. So, it would make sense to simplify the regimen and consider tapering down controlled substances. Of course, that’s assuming you know about the incarceration in advance. The problem is that you often don’t find out patients have been put in jail until they don’t show up for their appointment.
CATR: I’ve had patients on buprenorphine who say, “I can stay on the medication for just a couple of weeks, because then I have my trial date, and I’m pretty sure I’m going to prison,” and I get worried. I don’t want to leave them vulnerable to overdose, and I know that the prison system will likely not provide that medication. So, we end up tapering in the last couple of days, and I tell them to come back and reconnect right after release. Dr. Cropsey: Yes, it’s challenging. Prison systems are probably more willing to give people a shot of naltrexone on the way out, because it’s not controlled, but it’s very costly so a lot of systems aren’t going to want to do that either. Follow-up to get this shot again is challenging, especially if the person doesn’t have insurance. There is a 3-fold to 8-fold increased risk of post-release overdose in the 2 weeks following release (Merrall EL et al, Addiction 2010;105(9):1545–1554). We need more attention to this problem. There is a recent SAMHSA publication on the need to treat opioid use disorder in the criminal justice system (https://store.samhsa.gov/system/files/pep19-matbriefcjs.pdf). Unfortunately, addiction is not generally viewed as a medical disorder, and we have a long way to go in providing adequate treatment and release planning.
CATR: Clinicians sometimes run into a situation where people with opioid use disorder have been incarcerated for years without using opioids. Should they be offered buprenorphine or methadone? Dr. Cropsey: You want to evaluate them, of course, but there shouldn’t be a problem starting them on buprenorphine or methadone. And we do know from the work that Doyle and Binswanger and others have done that the time immediately after release from prison is very risky, and most deaths occur within the first two weeks or month of being released (Merrall EL et al, Addiction 2010;105(9):1545–1554). You could also talk to them about extended-release naltrexone if it’s clinically appropriate. Also, training people to recognize signs of a opioid overdose and administer naloxone would also be important prior to release.
CATR: Let’s switch gears a bit and talk about drug courts. What are they, and how do they work? Dr. Cropsey: I’ll give an example to illustrate the issue. In Alabama we have what’s called TASC, which stands for Treatment Alternatives for Safer Communities; there are equivalent programs in every state. TASC is an umbrella term that encompasses criminal justice diversion and community corrections. Community corrections refers to people who are on parole after leaving prison and are serving the rest of the sentence in the community. There’s also probation, which is for people with a criminal conviction who are serving their time in the community rather than in jail or prison. And then you have different types of courts: drug courts, veterans’ courts, mental health courts, domestic violence courts. These are court systems where people are generally charged with a felony and are mandated to receive treatment. They also have a set of requirements that they have to do, such as urine drug screening or paying certain fees.
CATR: What happens once those requirements are met? Dr. Cropsey: If they meet those requirements and do what they’re supposed to do, then after 6–12 months their charges are basically dropped. If they fail to do what they are supposed to do, then the judge can make the determination that they need to go and serve their time in prison or jail depending on the length of sentence.
CATR: One thing that comes to mind is that not everyone who uses substances has a substance use disorder. How does the court know when there is a disorder that needs clinical attention? Dr. Cropsey: There are addiction counselors that work with the court, and so they do an evaluation which determines whether the person meets criteria for a substance use disorder, and the counselors are the ones who talk to the judge about those issues. But sometimes the judge will just say, “You got caught with cocaine in your car, so we’re going to send you to treatment.” And the person may say, “This is the first time I tried it” or, “I only do it once a month.” And the person will still get looped in for treatment sometimes.
CATR: So ultimately treatment decisions still are at the judge’s discretion, is that correct? Dr. Cropsey: Right, and judges will sometimes make poor decisions. For example, they may say, “Okay, this person can’t take pain medication for their cancer because they have a history of drug use.” Or they’ll say, “They can’t be on buprenorphine, because it’s an abstinence-only program.” Or, “They can’t be on methadone and be in my drug court.” And then the person ends up using and overdoses. All this is very unfortunate, because judges are not clinicians and they should defer to experts when it comes to making these kinds of decisions.
CATR: But that’s embedded in the system, correct? Judges have a lot of leeway, and perhaps patients don’t have that much recourse when it comes to getting the right treatment. Dr. Cropsey: That’s very true. It’s how our legal system is, unfortunately, from police officers all the way up to judges. Police officers are making decisions too that may involve medical issues. And there is a lot of racial bias involved, where African Americans are disproportionately put in prison or jail, and that includes for drug use as well as other crimes (eg, Friedman SR et al, Int J Drug Policy 2016;32:11–16).
CATR: That’s very unfortunate. Do people suffer from a certain degree of PTSD related to their experiences in the corrections system? Dr. Cropsey: Yes, it’s very common. I see people coming back from prison who’ve had sexual and physical trauma while there. The prison environment is very isolating and violent. And support is very limited—you can’t talk to a friend or a family member whenever you want, and calls are monitored.
CATR: The term “corrections” implies a certain level of rehabilitation, but it looks like we often don’t see this in practice. Dr. Cropsey: Yes, unfortunately. Because of the expensive warehousing of so many people, there is not much rehabilitation that goes on. But it depends on the prison. Some people will get their GED, or do the substance misuse classes, or maybe will get better mental health treatment on the inside because they can actually access medical care. For a long time, people would say they got better HIV treatment on the inside because at least they had access to their medications and they weren’t missing doses. When they came out in the community, it was hard to access medical care, and medications were expensive. Now I think most of that has gotten better. But unfortunately, the focus for corrections is on warehousing and public safety and not as much on rehabilitation.
CATR: Do you have any additional words of advice for clinicians? Dr. Cropsey: I think it’s important to do a thorough evaluation for people who’ve been in prison or caught up in the criminal justice system. These are folks who are at higher risk for infectious diseases such as HIV and hepatitis C—diseases that should be on our radar anyway with drug use. And we also need to asses for other common medical problems. For example, people may have been getting antihypertensives in prison, and now they can’t access that care and they are not necessarily going to tell you unless you ask. We should always think about trauma when evaluating patients, and you will have people who present with symptoms of PTSD but will deny experiencing trauma in prison until you win their trust. They may not be ready to discuss sexual trauma, for example.