More than 80 percent of state prison inmates have indications of serious drug or alcohol involvement.1 After nearly 15 years of clinical and administrative involvement with offender programs at Gateway Rehabilitation, I have observed that some offenders seemed to need more intensive treatment than they were receiving, while others did not seem to need as much as we provided. I wondered, “Why the mismatch?”
It turns out that the corrections program differed from other Gateway programs because offenders were placed into treatment without the use of any formal clinical assessment or placement criteria. In fact, the only service options available-per a Pennsylvania Department of Corrections (DOC) contract with Gateway-were inpatient, which, other than detoxification, is our highest level of care, and work-release, which offers case management service but is not licensed or recognized as a level of care for addiction treatment. The DOC made the referral with the level of service (either inpatient or work-release) already specified for the offender.
The National Association of Addiction Treatment Providers (NAATP) and the American Society of Addiction Medicine (ASAM) worked together to develop the first ASAM Patient Placement Criteria (ASAM PPC). 2 ASAM was designed to help clinicians and payers use and fund levels of care in a rational and individualized manner. 3 Disturbingly, researchers estimate that:
95 percent of released state inmates with drug abuse histories return to drug use;
68 percent are rearrested;
47 percent are reconvicted; and
25 percent are sentenced to prison for a new crime.4,5
Offenders at high risk for criminal recidivism generally require more structured and intensive treatment interventions (such as residential inpatient treatment or intensive outpatient), while low-risk offenders are better suited for low-intensity interventions (such as outpatient, peer support, or 12-Step groups).6,7 Research from criminal justice literature has shown that when low-risk offenders are mismatched with treatment programs and placed into intensive programming that they do not need, the rate of recidivism increases.7
Addiction treatment research literature has indicated that under-treating offenders is also clinically harmful. In one study, more alcohol-use days were associated with patients who were under-treated in outpatient placement (such as intensive outpatient) after three months of intake.8 In another study, patients who met criteria for inpatient rehabilitation and were correctly matched to treatment showed consistently better short-term outcomes than patients that received partial hospitalization and were mismatched to a lower level of care or under-treated.9
I knew that conducting research at Gateway and determining if offenders were actually being matched into services based on criteria for substance dependence could be beneficial. The research I conducted at Gateway consisted of analysis of over 150 Aliquippa, Penn., corrections program patient records from calendar year 2005.
Evaluations were completed on these records using ASAM PPC. A level of care recommendation was then made based on the clinical information in the record. This clinical recommendation was then compared to the actual referral placement of the offender. I speculated that there would be a substantial percentage of mismatches due to the wide range of treatment options available at Gateway and the limited contracted referral options from the DOC.
The results of the research showed that nearly two-thirds of the offenders referred to services that year were mismatched. The level of care recommendation from the assessment using placement criteria did not match the actual referral placement made by the DOC for the patient. Two main areas of concern emerged from this research:
Among offenders referred to work-release (no treatment), almost 40 percent would have met placement criteria for inpatient treatment (highest intensity). Thus, a substantial percentage of offenders were under-treated, which research has shown to be clinically harmful. (See Table.)
Nearly 40 percent of the offenders referred to inpatient treatment would have met placement criteria for lower levels of care (such as partial hospitalization or halfway house) that were not covered under Gateway's contract with the DOC. (See Table.)
Study results indicate that there are not enough contracted treatment options for offenders. The referral options available-either the most intense level of treatment or no treatment at all-cannot meet the needs of offenders with substance abuse problems, as evidenced by the large number of offenders who were mismatched. Additional research is needed to determine whether these results can be replicated in similar programs across the state. It should be noted that this study was a single-site design and contains no outcome or follow-up data on the offenders subsequent to discharge from the program.