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Treatment for mental illness and other conditions related to mental functioning presents significant challenges to clinicians, administrators, and custody staff within correctional facilities. In this chapter, the term refers to police lockups, jails, and prisons. The distinctions are important considerations in the provision of mental health care because of the varying lengths of stay. In one way or another, the mission of all correctional facilities usually includes: 1. Custody 2. Maintenance of order, safety, and control 3. Punishment “Rehabilitation” is found in some correctional mission statements, along with references to restoring an individual to function in the community. In even fewer mission statements is there a reference to medical care or “treatment.” These functions are rarely considered part of the intent of confinement in a correctional setting. The mission statements of health care providers and health care organizations are different. They usually include: 1. Focus on individuals and their health needs 2. Humane and responsive care and treatment 3. Confidentiality 4. Consent 5. Provision of treatment in the least restrictive environment

A number of factors explain the influx of inmates with co-occurring disorders to jails and prisons. These include the closing and “downsizing” of state mental hospitals, adoption of restrictive civil commitment criteria, inadequate access to community support services, widespread availability of relatively cheap and rapidly addicting street drugs, and law enforcement efforts to eliminate drug use and drug-related street crime. Studies examining persons with mental disorders in community settings indicate that having co-occurring disorders increases the risk for community violence and for arrest (Monahan et al., 2001, 2005). Once arrested, persons with co-occurring disorders are more likely to be incarcerated, and once incarcerated, these persons remain in jail significantly longer than other inmates, and are more likely to receive a sentence that involves a period of custody (Bureau of Justice Statistics, 2006; Peters, Sherman, & Osher, in press). This chapter explores emerging and innovative approaches for treatment and reentry of offenders who have co-occurring disorders in jails, prisons, and diversion settings. Key areas highlighted in this chapter include evidence-based models of treatment, program features and principles, reentry approaches, and program outcomes. Several challenges to correctional program implementation and funding are also explored, and implications are discussed for policy development and future research.

The aim of this chapter is to review a much-neglected area of correctional health care: the pharmacological treatment of substance abuse. The particular focus of this review will be on the evidence, prospects, and barriers to implementation among the five federally approved and currently available medications for the pharmacological treatment of substance abuse: methadone, naltrexone, buprenorphine, disulfiram, and acamprosate. We will discuss each of these, as well as provide additional insights into the prospects for treatment of cocaine and methamphetamine abuse. These two additional conditions are also serious public health concerns and are highly prevalent among incarcerated populations (Cartier, Farabee, & Prendergast, 2006; Miura, Fujiki, Shibata, & Ishikawa, 2006). It is likely that over the next decades we will see the advent of several new drugs to adequately treat these chemical dependencies, and when that time comes, it will be important to build from a successful foundation of correctional experiences with other pharmacotherapies of substance abuse.

While most people make staying out of jail and prison a priority, a growing number of researchers are eager to get into correctional facilities in order to study the criminal justice system, the causes and consequences of incarceration, and the role of corrections in our society. For health researchers and their collaborators, the audience for this chapter, correctional facilities offer several unique advantages: a population at high risk of many health problems including infectious and chronic diseases, substance abuse, and mental health problems; social and physical environments that can enhance or impede well-being; a setting that is a focal point for the class, racial/ethnic, and gender differences that divide the United States; a site where health and mental health services and prevention programs are offered and can be evaluated; a controlled environment for administration of treatments such as directly observed therapy for tuberculosis; and a stopping point in the cycle of incarceration and reentry that so profoundly affects community well-being.

One of the most profound challenges facing American society is the reintegration of more than 650,000 individuals who leave state and federal prisons and return home each year. The fourfold increase in incarceration rates over the past 25 years has had far-reaching consequences. Four million citizens have lost their right to vote. One and a half million children have a parent in prison. Men and women leave correctional facilities with little preparation for life on the outside, insufficient assistance with reintegration, and a high likelihood of return to prison for new crimes or parole violations. Nationwide, over half of released prisoners are expected to return to prison within 3 years (Langan & Levin, 2002), and some states experience even higher rates of recidivism. This cycle of incarceration and return of large numbers of adults, mostly men between the ages of 18 and 35, creates specific health needs and risks for returning prisoners, their families, and the community at large.The challenges to improve the health profile of the prison population and protect the health of their families and communities to which they return are numerous. Persons released from prison are disproportionately afflicted with illness and tend to be sicker, on average, than the U.S. general population (Davis & Pacchiana, 2003). The prevalence of chronic, communicable, and mental illnesses is often higher among prisoners than in the general population due, in part, to higher levels of socioeconomic disadvantage and substance use compared to the average American (National Commission on Correctional Health Care [NCCHC], 2002). It is also common for many in the prisoner population to have multiple, co-occurring health conditions (Davis & Pacchiana, 2003).

More than a generation ago, the mentally ill began to flood our jails and prisons. Correctional institutions were not prepared for the influx of mentally disordered offenders and numerous reports have graphically detailed deficiencies in the provision of needed services (Center for Mental Health Services, 1995; National Commission on Correctional Health Care, 2002a, b; The Correctional Association of New York, 2004). However, little attention has been focused on the problems related to transitioning this population to the community and the provision of outpatient-based mental health services. Though the quality of institutional care remains woefully inadequate in many jurisdictions, it has become increasingly apparent that community-based care is an urgent necessity. Parallels between the current state of correctional mental health services and the civil public psychiatric system can be drawn. For many years, the public sector struggled with the problem of the “revolving door”: following discharge from inpatient care, many mentally ill individuals were unable to function in the community, relapsed, and were readmitted. In most jurisdictions, efforts to address this problem have relied on an increased emphasis on discharge planning for patients transitioning from state civil hospitals to community-based treatment and, once in the community, aggressive support services. There is now universal recognition that these measures are essential ingredients to maintaining many of the seriously mentally ill in the community. At present, correctional care systems have not broadly adopted such services, with predictable results. A study from the state of Washington illustrates the consequences. A cohort of mentally ill individuals convicted of felonies was followed postrelease. In the first year in the community, only 16% received any form of mental health treatment; by the end of year three, nearly 40% had been rearrested (Lovell, Gagliardi, & Peterson, 2002).

The reality is that sex offenders constitute a heterogeneous population of individuals and there is neither a single theory to explain their behavior nor one universal system of managing them. Most sex offenders do not live in prisons or hospitals. Those who are convicted are often sentenced to probation; almost all of those who are incarcerated are eventually released to live in the community; and, most importantly, many will never come to the attention of authorities. Because of this, it is important to understand the best ways in which the public can be educated about this population of individuals, hypotheses about why some individuals begin to commit sexually deviant behavior, how to best treat that behavior, which offenders should be incapacitated, and how to manage offenders once they are released to the community. Research on sexual offenses and offenders is generally discussed in the fields of criminal justice, law, sociology, and psychology, not in the arena of public health. However, as Gene Abel and his colleagues have noted (Abel, Lawry, Karlstrom, Osborn, & Gillespie, 1994; Abel & Osborn, 1992), sexual offenders, particularly those who abuse children, constitute a public health problem. They describe it as such because of the high rate of sexual victimization among adult males and females, and because of the high rate of victimization in organizations that supervise or are charged with working with children (e.g., schools, places of worship, youth organizations) (Abel et al., 1994). The effects of sexual victimization are often long-term and traumatic, and may put the victim at a higher risk of suicide, depression, and sexually transmitted diseases (“Perceptions,” 1995).

The electronic health record system (EMR or EHR) has become a foundation principle in every modern solution offered as a method for improving health care. Despite encouragement from the federal government (Bush, 2004a, b, 2005), few state departments of corrections have implemented electronic medical records systems. This parallels the free world where paper medical records continue to predominate (Moore, 2006; Oliner, 2002). It is not clear why medical systems have been slow to adopt electronic medical records. Cost remains a substantial impediment for most correctional facilities but it cannot be expense alone. Hospitals possess elaborate computerized financial departments and correctional facilities commonly employ computerized booking and commissary programs, thus there is no objection to the use of computerized records in these settings. Indeed, hospital and clinic managers would see as foolhardy any attempt to run a health care business without a computerized financial system. The loss of a misplaced paper billing record would be seen as catastrophic, but surprisingly scant attention is given to the deplorable state of most paper medical records. When a paper chart cannot be recovered, we simply create another one-a process common enough that it is considered normal. This practice would be unacceptable in any other area of the medical business enterprise.

Since the majority of inmates are eventually released back to their communities, public health officials have begun to recognize the tremendous public health opportunity within corrections and the potential to benefit the community with reduced illness rates, financial savings, improved public safety, and better use of the existing health care system and resources (Travis, Solomon, & Waul, 2001) From a policy perspective, inmates’ health care and their reintegration back into the community began to take on new importance with the increasing number of HIV/AIDS cases identified in correctional settings (Conklin, Lincoln, & Flanigan, 1998) Collaborations between corrections, community, and public health programs at both federal and state levels have increasingly been developed to take advantage of the incarceration episode to decrease the burden of illness on those incarcerated and the greater community

Highly active antiretroviral therapy (HAART) has remarkably transformed HIV disease into a chronic condition such that when patients completely suppress viral replication, they can expect to live a normal life expectancy. Unfortunately, many of those who might benefit most from HAART (e.g., illicit drug users, the mentally ill, and the socially and medically marginalized) are less likely to receive it, and when they do, less likely to adhere to treatment. Many of these individuals do not interface consistently with health care institutions in the community setting, yet when incarcerated, have an important opportunity not only to be identified as being HIV-infected, but also to initiate HAART if medically indicated. The prevalence of HIV infection among prisoners is five to seven times greater among incarcerated persons compared to the general population (Crosland, Poshkus, & Rich, 2002; Spaulding et al., 2002). Prisons and jails house individuals with HIV who have not traditionally benefited from access to HIV care and antiretroviral therapy in community settings. Specifically, prisons are comprised of HIV-infected individuals with comorbid medical conditions such as substance use disorder and serious psychiatric illnesses and are socially marginalized through relapsing homelessness, poverty, and unstable living circumstances. HIV care has resulted in impressive reductions in mortality in the New York prison system (CDC, 1999) and HIV/AIDS is no longer the leading cause of prison-related mortality nationally (Linder, Enders, Craig, Richardson, & Meyers, 2002). In nearby Connecticut where 98% of prescribed HAART regimens were within the Department of Health and Human Services guidelines, impressive increases in CD4 count and reductions in HIV-1 RNA levels were observed. Indeed, 59% of these prisoners achieved a viral load below the level of detection prior to release. Despite these successes, the one-quarter of subjects who were reincarcerated lost the viral load and CD4 benefits within 3 months after release to the community (Springer et al., 2004).