Evaluating the Implementation & Impact of a Seamless System of Care for Substance Abusing Offenders: The HIDTA Model

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The author(s) shown below used Federal funds provided by the U.S.Department of Justice and prepared the following final report:

Document Title: Evaluating the Implementation & Impact of a

Seamless System of Care for SubstanceAbusing Offenders: The HIDTA Model

Author(s): Faye S. Taxman Ph.D. ; James M. Byrne Ph.D. ;Meridith H. Thanner M.A.

Document No.: 197046

Date Received: October 28, 2002

Award Number: 96-CE-VX-0017



PROPERTY OFNationalCriminal Justice Reference Service (NCJRS)Box6000Rockville,MD 20849-6000 .S@"--

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University of Maryland Center for Applied Policy Studies

Bureau of Governmental Research

Evaluating the Implementation & Impact of a Seamless System

of Care for Substance Abusing Offenders- The HIDTA Model

By:

Faye S. Taxman, Ph.D.

James M. Byrne, Ph.D.Meridith H. Thanner, M.A.



Table of Contents

Executive Summary ........................................................................ i

Introduction and Overview ................................................................. 1

1. The Link Between Drug Treatment and Offender Control: A

Review of the Research ............................................................2

2. The HIDTA Model ................................................................. 6

a. Continuum of Care ......................................................... 8b. Supervision .................................................................. 10

c. Urinalysis Testing ........................................................... 10

d . Com pliance Measures and G raduated Sanctions ...................... 11

3. The HIDTA Demonstration Project .............................................. 12

4. Data and Method ................................................................... 13

5 . A Profile of HIDTA Participants ................................................. 16

6. Assessing Implementation ......................................................... 18

Area 1: Implementing Continuum of Care .............................. 20



Diagram

Diagram 1 : The HIDTA Model............................................................. 13

Tables

Table 1. Twelve HIDTA Sites and Size .................................................. 14

Table 2. Client Descriptive Statistics ..................................................... 17

Table 3. Characteristics of 1997 HlDT A Sample ...................................... 18

Table 4 . Continuum of Care Models in the HIDT A Sites ............................. 21

Table 5.Treatment Duration & Completion of First Phaseof Treatment ........................................................................ 23

Table 6.Drug Testing Protocols .......................................................... 24

Table 7. Dru g Testing Results for Various Jurisdictions .............................. 25

Table 8. Graduated Sanctions Protocol ................................................... 27

Table 9. Comparison of Actual Rearrest Rate at 6 and 12 Month

Follow-up Period .................................................................. 31



EXECUTIVE SUMMARY

Introduction

By the end of th e year 2000, more than 6.5 million adults were under the supervision of the

correctional system, and more than half of these offenders are estimated to have significant

substance abuse problems.

Traditional, boundary -laden treatment and control strategies have been unable to change offend er

drug use and criminal behavior. Amo ng the state probation populations, the proportion of

offenders wh o successfully complete their supervision has dropped from seventy (70) percent to

sixty (60) percent in the past decade, due in large part to offenders’ failure to abide by the

conditions of their release related to abstinence from druglalcohol use and/or participation in

treatment. In 1999 alone, fourteen (14) percent of the probation population (244,700) and forty

two (42 ) percent of the parole population (17 3,800) were retur nea sen t to prison for a rule



0offenders, specifically the formulation of a new m odel of incorporating treatment within the

criminal justice system - he Seamless System of Care. The HIDTA Model was designed to

target hard-core, substance abusing offenders who are both difficult clients for treatment

providers and difficult offenders for com mu nity supervision agents. Part of this demonstration

project was the restructuring of the treatment a nd supervision delivery systems for criminal

justice offenders within the High Intensity Drug Trafficking Areas (HIDT A) program in the

Washington, DC - Baltimore corridor. Each of the 12 participating jurisdictions (VA:

Alexandna City, Arlington County, FairfaxRalls Church, Loudon County, Prince William

County; MD: Baltimore City, Baltimore County, Charles County, Howard County, Montgom ery

County, Prince W illiam County, and the District of Colum bia) developed a seamless system

tailored to their own socio-legal environm ent which included system reforms consistent with the

core components of the HlD TA model.

The HIDTA model is based on the concept of the boundaryless system that “transcend s the



Evaluation Data and Methods

This evaluation report provides a detailed examination of the development, implementation, an d

initial impact of the High Intensity Dru g Trafficking Areas (HIDT A) Model, based on a multi-

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site (12 jurisdictions) analysis of the program. Using a sim ple pre-post, non-experimental

design, data were collected at each of these twelve sites on the total population of offenders

admitted to the HID TA program in 1997 (N=1,216). By using a non-experimental design to

conduct our initial review, we could prov ide preliminary ou tcome data to jurisdictions while

focusing our evaluation resources on the critical question of level of implementation. Data w ere

collected on the following: (1) demographic and criminal history, (2) treatment placement an d

movem ent through treatment, (3 ) criminal justice supervision and services, (4) drug testing

results, and (5) the use of g raduated sanctions by either the treatment agency or the criminal

justice agency. The integration of records from treatment providers and criminal justice agency

providers w as critical to assessing the im pact of the HlDT A M odel on the offenders included in

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this study.



offender is a low-level drug dealer who deals to support hi sh er addiction to drugs. Th e drug of

choice for these offenders is either crack/cocaine (28.2%) or heroin (19.8%), consum ed by

smoking (39.2%), injection (12.7%), or some other oral means (17.4%). Although th e treatment

histories of H IDTA offenders are often unknown at the time of HIDTA intake, it appears that the

majority of these offenders are addicts who have been in treatment before but w ho remain -

based on their own self-report response - addicted to drugs. In fact, one of every three HID TA

offenders reported daily drug use at the time of their arrest. Clearly, there is significant overlap

between the addiction careers and the criminal careers of these offenders.

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Level of Program Implementation

Th e purpose of our implementation (or process) evaluation is two-fold: first, to determine the

extent to which th e HIDTA model was implemented as designed; and second, to document

changes in each jurisdiction’s response to offenders during the pre-post comp arison period.

Overall, the HIDTA m odel was not fully implemented in 8 of the 12 jurisdictions. How ever,

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based treatmenvoutpatient m odel. On ly one jurisdiction (Montgomery Coun ty) developed a

continuum of care system that incorporates all four modalities. Overall, the average successful

completion rate for H D T A treatment participants was 64 percent, which was much higher than

anticipated given the target population selected. The average time in treatment for H D T A

participants w as 20 8 days (range 1 72-265 days).

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Drug Testing Implementation.Drug testing sched ules varied considerably across the twelve

jurisdictio ns we exam ined: one site used random drug testing; three sites tested offenders three

times per m onth; one site tested offenders w eekly; and seven sites conducted drug tests twice per

week . Thirty-five percent of HIDTA participants tested positive for drugs between the time of

arrest and the time of intake to treatme nt. During this pre-treatment period, the drug of choice

was cracWcocaine ( ll % ) , marijuana (6% ), and heroin (5%). Overall, 18 percent of HIDTA

participants tested positive for drugs during the treatment period. When com pared to the pretest

results, this represents a 49 percen t declin e in the test positive rate (from 35 percent to 18

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Graduated Sanction Implementation. Each jurisdiction we reviewed had a different graduated

sanction protocol, including both judicial and adm inistrative systems. Overall, jurisdictions had

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difficulty responding to the first, second, an d third positive drug tests using progressively more

stringent sanctions. It appears that neither certainty (of response) nor progressiveness (of

response) have been im plemented at the test sites.

The Impact of the HIDTA Model on Offending

Th e average re-arrest rate for a new offense is 1 1 percent at a 6-month follow-up and 16percent

at the 12-m onth follow-up (from intake). At the twelve-month follow-up, there is significant

inter-jurisdictional variation in arrest rates, from a low of 6 percent to a high of 32 percent.

Offenders w ere typically arrested for drug offenses including possession, distribution or

possession with intent to distribute. Based on our review of the previous patterns of offending

among HIDT A offenders, th e overall predicted re-arrest rate for these offenders is 52 percent.

This represents a 70 percent reduction from the base rate (52% vs. 16% re-arrested). Estimates

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Implementation Barriers and Recommendations

During the planning, implemen tation, and evaluation stages of the HIDTA seam less system three

key compon ents of the system were identified as needing to be addressed in order to successfully

implemen t the current and future systemic case management systems. Specifically, the need to

appropriately target the n eeds and risks of offenders and identify what stage in their add ictions

and criminal career they are in , so as to adequ ately meet their treatment and other needs. Second ,

the need to offer various types of high quality treatment prog rams and phases to ad dress specific

needs and to promote longer treatment stays. Need to offer treatment in a convenient and safe

place as a team, for example on location at a parole and probation joint run by supervision and

treatment staff. Und erstand that treatment is a process not an episode and that mo re than one

treatment program or stay may be needed. Important to address whole needs of offender and to

prepare the offender that behavior changes are needed from them. Third, need to develop and

consistently administer joint responses to no ncomp liance in a sw ift and certain w ay. To continue

the impact, more attention is needed on providing a more rigorous application of the san ction and

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Future A nalyses: The Need for an Experimental Design

Although these initial findings are promising, we mu st emphasize that they are preliminary, non-

experimental an d in need of further review. W ith such small sample sizes and without a contro l

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group(s) of non-HIDTA offenders, it is certainly premature to claim that participation in the

HIDTA program w as the primary factor explaining these positive outcomes. Future analyses

stress the importan ce of using a controlled experiment.

Implications

Th e present study has a num ber of potential im plications for theory, research and policy

in the area of dru g use and criminal behavior. First, it does appear that the “boundaryless

system” concept has merit, especially when the target population is the hard-core drug user.

Seco nd, it is certainly possible that the age of the offender, in conjunction with the extent of the

offender’s addiction and crim inal career path to placement in the HIDTA program, may be

at least partially responsible for the findings reported here. Perh aps older addicts are at the state

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Introduction and Overview

Th e following report provides a detailed examination of the development,

implementation and initial impact of th e W ashing tonB altimo re High Intensity Drug Trafficking

Areas (HIDTA) Model, based on a multi-site analysis of the program. The HIDTA M odel

represents an excellent e xample of the type of intra- and inter-system collaboration that m ost

experts agree is critical to the success of drug treatment and control strategies in this country

(Taxman, 2001,Taxman & Bouffard, 2000). At its core, the HlD TA M odel represents a unique

collaboration between agencies and organizations responsible for the provision of drug treatment

services and the agencies and organizations responsible for the community controZ of offenders.

Th e report begins by providing an overview of the em pirical evidence supporting the key

elements of the HlDT A seamless system of drug treatment and control. The HIDTA M odel is

then described, focusing on the following four program elem ents:

1. continuum of care;

2. offender supervision strategies;3. drug testing protocols; and,



1. The Link Between Drug Treatment and Offender Control: AReview of the Research

In 2000, nearly 6.5 million people were under som e form of correctional control in this

country. About seventy (70) percent of our correctional population was under comm unityi

supervision, while thirty (30) percent were in prison or jail (Bureau of Justice S tatistics, 2001).

It is conservatively estimated that over half of these offenders have significant substance abu se

problems (Drug Policy Strategies, 1997), underscoring the link between addiction careers a nd

criminal careers (Anglin & Hser, 1 990). Am ong state prisoners, it is estimated that 83.9% of the

offenders released from prison in 1999 were alcohol or drug involved at the time of the offense

(Bureau of Justice Statistics, 2000). Am ong the state probation populations, the proportion of

offenders wh o successfully complete their supervision has dropped from seventy (70) percent to

sixty (60) percent in the past decade, due in large part to offenders’ failure to abide by the

conditions of their release related to abstinence from drug/alcohol use and /or participation in

@



within institutional and com mu nity correctional settings appears to be the most ob vious course of

action.

Several emp irical studies have illustrated the positive impac t of drug treatment services

on offender criminal behavior and d rug use (Sim pson, Joe & Brown 1997; Lipton, 1995;

Taxm an, 1998; Simpson, Wexler & Inciardi, 1999). Specifically, these studies demo nstrate that

offenders participating in drug treatmen t services are less likely to be rearrested or return to jail

or prison than similar offenders wh o are not participating in drug treatment services.

Participation in treatment services not only contributes to reductions in the incidence of criminal

behavior but also to increase in th e overall length of crime-free time for offenders. Tax ma n and

Spinner (19 97), in their study of offenders w ho participated in a jail-based treatment prog ram

that included a continuum of care, found that 38.5% of treatment participants were rearrested

within 24 m onths after release from jail com pared to 48.7 % of the comparison group.

Additionally, the average offender participating in jail and co mm unity treatment took an averag e

of 282 days to be rearrested comp ared to 201 days for the compa rison grou p, an almost three



Carlson, 1996), particularly for the criminal justice offender (Duffee & Carlson, 1 996; Falkin,

199 3; Scarpitti, Inciardi & Martin, 1994; Wexler, Lipton & Johnson, 1988). In addition, the

prevailing view by criminal justice agents that offenders are undeserving of treatment and that

drug treatment should not be an integral part of the su pervision sentence further impedes the

development of collaborative efforts between supervision agents and drug treatment service

providers.

For a client on criminal justice supervision required to participate in su bstance abuse

treatment services, collaboration between treatment and control is critical for a variety of

reasons. First, the leverage of the criminal justice system can be an important mean s of reducing

treatment dropou ts by establishing credible punitive contingiencies. Second, supervision and

monitoring can augment treatment by enhancing treatment goals and pursuing long-term

outcomes. Finally, the use of criminal justice sanctions for offenders has been evaluated and

recent results from a drug court evaluation in Washington,DC demons trate that offenders who

receive san ctions are four times less likely to continue drug use than typical supervision clients



e.g., MacK enzie & Souryal, 1994; Cowles, Castellano & Gransky, 199 5), and day reporting

centers (see e.g., Parent et al., 1995).

Despite these findings, program developers often lament the man y difficulties associated

with providing treatment to offenders, particularly drug users under com mu nity supervision.

First, drug users often have a num ber of problems related to physical health and/or men tal health

that make “treatment” planning much m ore difficult. In most instances, it should be recognized

that drug users are “m ultiple problem” offenders w ith a variety of treatment needs. Unless a

comprehensive treatment assessment strategy is developed, it is likely that these offenders will

“fail” in drug treatment. Second, resource constraints often limit drug treatment availability

(resulting in inappropriate treatment placements) having an adverse effect on treatment quality.

A num ber of recent reviews of the drug treatment literature have docum ented such problems as

inadequate service levels (Dennis, 1990), the use of inapp ropriate services (Andrew s et al.,

1990a,b), th e short duration of treatment programs (Pendergast et al., 1994), lack of staff training

(Gustafon, 199 1), and lack of essential program compon ents (Gendreau, 1996). Any discussion

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problems as low statistical power, small sam ple sizes, lack of treatment integrity, and/or poor

implementation of treatment procedures.

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2. The HIDTA Model

Case managem ent has been promoted as a critical component of any treatment system. It

involves outreach, assessment, case planning, monitoring, reassessment, coordination, treatment Iplanning, brokering services, treatment m onitoring, discharge planning, advocacy, an d o r clinical

interventions (Anglin et al., 1996; Martin & Inciardi, 19 96; Metja et al., 1994). The con text and

nature of case management practices varies considerably (Anglin et al., 1996) with tremend ous

uncertainty as to the actual functions performed by case managers (Shw artz et al., 1997). A series

of studies on the effectiveness of case management have generated inconclusive and occasionally

negative findings (e.g., Anglin et al., 1996; Martin, Inciardi, Scarpitti & Nielsen, in press; Taxman

et al., 1997), due in part to the large variance in se rvices rendered under the category of “case

management.” As it is most often practiced, case management relies on the individual manager to

make informed decisions and scramble for the needed resources and services. Unfortunately, the



justic e sy stem brokered treatment services from the treatment sy stem under the assumption that

the treatment system had unlimited resources. By brokering treatment services in this way, the

crimina l justic e and treatment sy stems offered separate programs and services, and main tained

separate budgets. Under this mod el, the criminal justice system assumed no su pervisory role

while the offender was in treatment.

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Under the ration ingtriage service delivery model or seamless system, however, service

integration defines the relationship between the criminal justic e and treatment systems. Ro les

are specifically defined for crim inal justice and treatment staff members, as too are jointly

identified goals for offenders under supervision participating in treatment. Joint decisions

regarding treatment selection, placement, monitoring, responses to positive drug tests, and

discharge are predetermined by the supervision agent and treatment provider and serv ices

focusin g specifically on offe nder outcomes are offered by both sy stems. Like many system

reform efforts, systemic case management provides a s tructure to ensure that critical functions

are performed by removing the barriers of coordination and having policy makers restructure

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and discharge. Th e HIDTA seamless system includes the following components: (1) continuum o f

care, (2) supervision, (3) urinalysis testing, a nd (4) compliance measures and graduated

sanctions. Eac h of the four key system elements is described below:

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a. Continuum of Care. Research continues to dem onstrate that length of time in

treatment is influential in determining positive outcomes (Conde lli & Hubbard, 1994; Hubbard e t

al., 1989; Simpso n et al., 19 97a). W ith the tendency in the treatment field to provide short-term

services (Etheridge et al., 1997), the continuum of care requires that the offender participate in

tw o levels of care-typically a more intense service followed by aftercare or counseling. The

concept of a continuum is to mo ve the client through the treatment delivery system consistent

with h is he r progress. Underlying the concept of a continuum is that treatment placemen t

decisions should be affected by the offender's risk level to determine the am ount of control and

structure needed to augment treatment and crim inal justice outcom es (Andrews et al., 1990a,b).

For ex ample, higher risk offenders may need a residential setting for six months because of the

propensity to engage in criminal activity. Th e residential setting provides external controls on

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treatment is usually four to nine months w ith most programs lasting six months in duration.

Offenders continue in com mu nity treatment after release from the resideritial facility as they

mov e through the different stages of recovery.

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Intermediate Care follo wed by Outpatient Services. In this model, the offender is placed

in a 28-day treatment program and then in a six-mon th outpatient program. The program within

the intermediate care usually focuses on treatment readiness and preparation for change in the

comm unity. Th e goal of the 28-day residential program is to prepare the offender for change by

using a variety of psychosocial educational modules and to begin the preparation for return to the

community. Part of the discharge planning is to develop action plans that can guide the offender

to change his he r behavior in the community. This model is being implemented in Montgome ry

County M aryland. In the District of Columbia, the Assessme nt Orientation Center (AOC)

provides an intermediate care environment to em phasize developing the offender’s motivation to

change by focusing on pre-contemplation and contemplation phases of recovery. Th e AOC uses

the period of tim e to assess and diagnosis the offender to determine a ppropriate placement in the

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Jail-Based Programming followed by Ou tpatient Services. Many offenders are in jail

prior to release to the com munity. Incarceration provides an opportunity to begin th e recovery

process w ith a focu s on continued treatment after release from the facility. Jail based

progr amm ing includes cognitive skill development and relapse prevention as the two treatment

strategies to address the offender's com mitm ent to recovery. Jail based program min g usually

runs three to six mon ths in duration and the em phasis is on maintaining the offender in treatment

in the com mu nity after release. In some jail-based programs (after release from jail), offenders

are placed in wo rk release programs after release from the jail where treatment services are

continued. In such cases, the work release program emphasizes work ethic and employment as

part of the recovery process.

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b. Supervision. Mo nitoring and oversight are vital to the man agem ent of offenders in

a the comm unity and remains the primary com pon ent of supervision services. Supervision

facilitates the treatment proces s by enforcing treatment co nditions, and verifying and v alidating

the progress of th e client. Essentially, supervision consists of 1) case managem ent (including



a important that the drug testing information be shared and used to support mutual treatment and

public safety goals. I

d. Compliance Measures and Graduated Sanctions. Both treatment and supervision

agencies share a com mon problem of com pliance with program requirements. S impson et al.,

(1997b) report that over half of the clients do not com plete drug treatment programs and Taxman

and Byrne (1994) estimate that at least half of th e offenders do not comply with basic

/

I

supervision requirements. Not surprisingly, noncom pliance with probation requirements

constitutes on e of the main reasons for new prison admissions each year. Of course, the use and

application of sanctioning (or the leverage of the criminal justice system) tends to vary

considerably in practice, in both the treatment and criminal justice arenas. Recent ad vancements

have promoted the use of b ehavior modification app roaches, referred to as graduated sanctions in

the criminal justice literature, to provide swift, certain, and appropriate responses to com pliance

problems (Harrell et al., 2002;Harrell & Cavanaugh, 1996; Kleiman, 1997). Similar to

contingency management, graduated sanctions ho ld clients accountable for their behavior



3. The HIDTA Demonstration Project

Th e Office of National Drug Control Policy (ONDC P) provides for regional approaches

to drug problems, prim arily drug trafficking issues. Mo st of the HIDTA s are involved in law

enforcement specific activities. Th e Washington-B altimore con ido r was designated as a special

HIDTA in 1994 by the ON DC P (Lee Brown was the Director at this time). ON DC P funde d the

HIDTA initiative to address both d emand and supply issues. On the demand side, the g oal was

to improve the service delivery system for treating chronic substance abusing offenders. Each of

the 12 participating jurisdictions (Virginia: Alexandria C ity, Arlington County, Fairfax/Falls

Church, Loudo un Cou nty, Prince William County; Maryland: Baltimore City, Baltimore Cou nty,

Charles County, Ho ward Cou nty, Mo ntgomery Coun ty, Prince William County, and the District

of Colum bia) developed a seam less system tailored to their own socio-legal environment w ith

th e system reforms co nsistent with the core components, as shown in the following diagram an d

1

system model. Each jurisdiction has d eveloped the supporting policies and procedures to ensure



requires that policies should be developed and put in place to ensure a change in the daily

operations. In order for the model to be developed and implem ented, policies must be developed

and supported by procedures. Th e line staff will then be clear as to the new operational proced ures

and the working relationship among the different agencies.

Diagram 1: The HIDTA Model

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moliciesPrinciples -

/ Treatment Placement

OoerationsProcedures -

Treatment Transitions Contin uum of

Treatment Discharge

* Graduated SanctionsDrugTesting DrugTesting

-Intra-and Inter-

Graduated

4. Data and Method

Twelve separate jurisdictions agreed to participate in this evaluation, including six



Table 1. Twelve HIDTA Sites and Size

12. Washington, D C

I TOTAL:

Site

1 . Alexandria City

2. Arlington Coun ty3. Fairfax County4. Prince William County

5. Loudoun County

6. Baltimore City

7. Baltimore County

8. Howard County9. Charles Coun ty

10.Mon tgomery County11. Prince G eorge’s County

Target

CohortSize

58

59362822

545

2937

44

5366

276

1,216

It should be noted at this point that both case flow and the total num ber of HlD TA

participants identified at each test site were likely affected by th e availability of funding f or this



years. How ever, since the final decision on eligibility criteria was left up to the individual

jurisdiction, it is not surprising that there is considerable inter-jurisdictional variation in the

instant offense, criminal histories, and drug use patterns of the target population identified here.

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For each offen der identified as HIDT A-eligible, data were collected to document the offender’s

movem ent through th e “seamless system” described earlier in this report. Regardless of the

offender’s status in the criminal justice system at the time of intake &e., pretrial release,

probation, parole), data were collected on the following: (1)demog raphic and criminal history,

(2) treatment placement and mov eme nt through treatment, (3) criminal justice supervision and

services, (4) rug testing results, and (5) the use of graduated sanctions by either the treatment

agency or the criminal justice agency. Th e University of Maryland has developed an autom ated

tracking database (H ATS ) that allows criminal justice and treatment agencies to enter and share

offender and client information. This information includes progress across various

organizational networks while maintaining all of the federal protections for confidentiality. The

integration of records from treatment providers and criminal justice agency providers is critical

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implementation level, four of these twelve sites have been selected for participation in a separate,

multi-site randomized field experiment (Baltimore County, Mon tgom ery Coun ty, Prince William

County an d Alexandria City). On e of the problems with field experiments conducted in the past

by criminal justice researchers is that they often jum p the gun, attempting to evaluate the impact

of a program before it has been fully implemented. By using a non-experimental design to

conduct o ur initial review, we can provide preliminary ou tcome data to jurisdictions while

focusing our evaluation resources on the critical question of level of implementation. To the

extent that we can identify an initial link between the level of implementation of the HIDTA

Model an d lower o ffending rates (our impact m easure), there is further justification fo r providing

a more comprehen sive, randomized field experiment on the subgrou p of full implementation

sites. Parenthetically, this is the strategy recomm ended in a recent review of th e research on

drug treatment in criminal justice settings (National Research C ouncil, 2002).

5. A Profile of HIDTA Participants

Th e HIDTA M odel has been designed to target hard-core, substance abusing offenders

II



criminally active for several years: the typical offen der averaged a little over one arrest per year

fo r the past nine years. These offenders are currently in th e criminal justice system becau se of

their drug problem. Nearly 45% of these offenders had a drug charge with half of the ch arges

involving distribution or possession with intent to distribute. It appears that the typical HlDT A

offender is a low-level drug dealer who deals to support hi sh er addiction to drugs. Th e drug of

choice fo r these offenders is either cracWcocaine (28.2%) or heroin (19.8%), consumed by

smoking (39.2%), injection (12.7% ), or some other oral means (17.4%) including inhalation.

Although the treatment histories of HlDTA offenders are often unknown at the time of HlD TA

intake, it app ears that the majority of these offenders are addicts who have been in treatm ent

before but who remain -- based on their ow n self-report response -- addicted to drugs. In fact,

one of every three H D T A offenders reported daily drug use at the time of their arrest. Clearly,

there is significant overlap between the addiction careers and the criminal careers of these

offenders (NOTE: see Table 3 and Appendix A for a site-specific profile of these offenders).

Table 2. Client Descriptive Statistics



Table 3. Characteristicsof 1997 HIDTA Sample

402. Washington, DC 276

Site

1. Alexandria City2. Arlington County3. Fairfax County4. Loudoun County5. Prince William

County6. Baltimore City7. Baltimore County

8. Charles County9. Howard County10. Montgomery

County

11. Prince George’sCounty

81%--

SampleSize

585936

22

285452944

37

53

6685% 20%

Mean

Age

353736

35

3435333434

32

35

18% 1.3

%

Male

82%62%87%

35%

71%71%

70%85%98%

92%

81%

9i

African-American

77%70%49%

45%

36%57%36%39%53%

38%

72%

9%

Employed

44%

24%52%

47%

61%17%14%10%27%

48%

4%

%

PossessionDrug

31%7%

14%

33%

39%23%17%6%

12%

52%

20%

MeanArrests

Per Year

1.oo.81.761.5

1.1

1.51.1

,75.73

1.1

1.2

A%YrS

CriminallyActive

8.l

210.0

7.111.48.15

6.95.2

10.0

5.69.7

9.0

6. Assessing Implementation

Th e purpose of our implementation (or process) evaluation is two-fold: first, to determine



Figure 1highlights impo rtant changes that hav e occurred during the pre-testlpost-test

period at the twelve HID TA sites. In terms of the developm ent of a continuum of care consistent

with the HID TA Mod el, three sites had actually developed such a continuum prior to the

initiation of the HIDTA project. By the time of our post-test review, ten sites had such a system

in place. Only two sites had drug-testing policies in place prior to the initiation of the HlDT A

project, as compared to ten sites at th e time of our post-test review. And finally, only one site

had developed a system of graduated sanctions for either treatment providers or comm unity

correction agents prior to the start of the HID TA project, as compared to nine sites following

implementation of the HID TA system. Although Figure 1highlights the fact that there wa s

considerably less progress in other related areas, it does appear that the HIDTA M odel has

fundamen tally changed the way these jurisdictions respond to hard-core drug users. W e expand

on this finding below, focusing on three imp lementation areas: (1) continuum of care, (2) drug

testing, and (3) graduated sanctions.



Figure 1. Progress on Implementing Seamless System Components

11

I 10

nE3

1 1

J

07

10

2

I0I9

0I13

Continuum of Grad uated Graduated Integrated Drug Testing Integrated Formalized Integrated

Treatment Criminal of Graduated SharingCare Sanctions -- Sanctions -- Application Fblicies Service Mix Information Assessment

Justice Sanctions

Re-HIDTA

0 IDTA



0based treatment, etc . It also allows the use of less intensive services as offender’s progress in their

recovery (see Appendix A - TreatmentRrim inal Ju stice Flow C hart Sample Seamless System).

Table 4 highlights the site-specific variations in the development of a comprehensive

continuum of care system. Although our review has identified ten jurisdictions with a clearly

defined con tinuum of care system in place, only one jurisdiction has developed a system that

incorporates all four modalities of treatment (Montgomery County). This finding can be directly

I

linked to the resource constraints faced by program developers at the other eleven sites.

Table 4. Continuum of Care Models in the HZDTA Sites

Models

Resihentiauoutpatient

Intensive Care Facility/Outpatient

Intensive Outpatiendoutpatient

Sites

Montgomery County, M DFairfax County, VAWashington, DCBaltimore City, MDArlington County, VABaltimore County, MDWashington DCMontgomery County, MD

Alexandria City, VAFairfax County, VAPrince William County, VA



concepts: com pletion of the first phase or mo vem ent into another more app ropriate treatment

experience. T he seam less system provides that protocol for the transition based on the

offender’s progress. The continuum is built on the notion that some clients need less intensive

services as the secon d phase, som e need m ore intensive services, and som e can suffice with

aftercare services of self-help groups or vocational education. That is, the system mu st function

to mo ve the offen der into the appropriate level of care. In addition to de termining the

appropriate level of initial treatment, i t is also critically important to assess the progress of the

offender. This needs to be approached from a systemic perspective to determine whether more

treatment is warranted and the type of treatment that is most ap propriate at th e time.

0

/

I

Table 5 illustrates key performance measu res regarding the treatment com pon ent of the

program . Since each jurisdiction has a different planned treatment continuum (as discussed in

Ap pend ix A), the patterns of length of stay vary differently. It should be noted that the

comp letion rates for the first phase of treatment are higher than those reported in DA TO S whe re

forty (40) percent of the clients completed treatm ent similar types of treatment (Simpson, et al.,

0



Table 5. Treatment Duration & Completion of First Phase of Treatment

*Note that successful completion refers to the completion of the expected duration of treatment. Often criminal justice clients, due to the ir status,

may not complete due to a change in legal s ta tus , movement across the legal spectrum, etc. Many offenders transition into other levels of serviceregardless of whether they complete the duration of a particular time frame in a given program. This varies depending on he jurisdictions and

the continuum of care available in that jurisdiction.

The HlDTA protocol has two m ain features that affect the offender’s duration in

treatment. First, the protocol is designed to step treatment up or down based on progress. Even



Area 2: Implementing a System for Drug Testing Offenders

The HIDTA protocol targets the criminally active substance abuser under the co ntrol of

the criminal justic e sys tem. Th e protocol involves drug testing the offender while the offende r is

actively involved in treatment. Drug testing provides an objective measure of whether the

offender is continuing to abu se drugs while involved in treatment. Early in the HIDTA program,iI

ONDCP ma de funds ava ilable to enhance drug testing around the region. During the first two

cohorts of the H lD TA p rogram, direct funding for drug testing was available. In 1997, funds

were removed fro m the HIDTA budget for drug testing. Jurisdictions were asked to continue

drug-testing offenders using av ailable funds in their jurisdiction. Ma ny jurisdictions

implemen ted drug testing on various schedules based on the available funds from either the

criminal justice o r treatment systems. As level funding occurred, many of the program s

attempted to maintain the following schedu le through existing funds. Table 6 shows the 1998

Drug Testing Protocols.



are under legal control that serve s to suppress their use of illicit drugs. Of the thirty-five (35)0

Howard

percent that test p ositive for an illicit substance during this pre-treatment period, the drug of

1 5 % 63

choice in the HIDTA jurisdictions based on drug test results are: cocaine/crack (11percent);

marijuana (6 percent); and heroin ( 5 percent). It should be noted that these drugs of choice are

slightly different than the self-reported drug of choice where addicts tend to emphasize their use

of coc aine krac k, heroin, and then marijuana. Table 7 show s the drug test results by jurisdiction.

Table 7. Drug Test ing Results for HIDTA Jurisdictions



constant and con sistent pattern of testing o ffenders results in reduced positive test rates (W ish &

Gropper, 1990).

e

Overall the testing illustrates that treatment contributes to a significant reduction in the

test positive rate. Th e estimate of offenders testing positive at intake is thirty-five (35) percent.

These results illustrate that treatment contributes to a forty-nine (49) percent decline in the test

positive rate-from thirty-five (35) to eighteen (18) percent. It should also be noted that many

offenders are more likely to continue to test positive for marijuana than other illicit drugs such as

cocaine and heroin. Th e change in drug of choice also contributes to reduce non-drug use

criminal behavior because the literature is less clear about the marijuana-crime nexus (as

compared to the cocainek rackhero in nexus).

Area 3: Implementing a System of Sanctions and Rewards

The cornerstone of the HIDTA protocol is enhanced supervision and case mana gem ent of

the offender to include the use of sanctions and rew ards to address offender compliance patterns.

Th e consequence protocol was designed to be specific to each jurisdiction with the jurisdiction

a



goals of reducing drug use and criminal behavior through a purposeful response to negative

behavior. An ad vantage of the approach is that communication with th e offender is more

targeted and focused on outcomes. To facilitate the process, many jurisdictions d eveloped a

behavioral or sanctions contract, which provides a framew ork for commun icating the negative

behavior and expected consequences to the offender. This contract can incorporate both

administrative and judicially ordered sanctions. So me jurisdictions incorporated the sanctions

into the standard practice of treatment and supervision. At th e end of th e 1997 training session it

was realized that more attention was needed to the developm ent and implementation of the

sanction protocol in large part due to philosophical differences between the treatment criminal

justice personnel on the type of sanctions to be used. Sim ilarly, a lack of consensus was also

i

reported in the developm ent of a reward structure.

Table 8. Graduated Sanctions Protocols

Graduated Sanct ions (1997)

Administrative SanctionsFirst Positive Test:

Sites That Implement These Sanct ions

Alexandria City, VA

Arlington County, V A



Figure 2

implementation.

llustrates that the sanction protocol needs further work in terms of the

Th e exhib it shows that there is som e progressive nature’ of the action-as the

nega tive behavior continues , the type of responses is altered. Ye t, it also shows that there is little

variation across the first three positive drug tests. An exam ination of Table 8 illustrates that

eight (8) of the twelve (12 ) jurisdictions are implementing adm inistrative sanctions an d three (3)

jurisdictions are implementing judicial order sanctions and that the concepts of certain and

progressives are not well implemented. So m e jurisdictions like Alexandria City and Prince

William, which developed strict policies and procedures, have translated into clearer practices.

More attention in the other jurisdictions is needed on the development of their policies. Further,

development is also needed on th e training of staff (treatment and criminal justice), supervisors,

and other interested parties. How ever, we should point out one important, unanticipated

consequence of the development of graduated sanctions: increased tolerance by criminal justice

decision-makers for multiple drug test failures. It may be that the reason HlD TA offenders are

staying in treatment longer and com pleting treatment program levels more frequently is that

iI



First



@this evaluation does not represent a test of a specific treatment modality (such as methedone fo r

heroin addicts), but rather a general, system-wide orientation toward im pioving both treatment

quantity and quality. Similarly, the HIDT A Model does not specify a particular supervision

level, drug testing protocol, an d or graduated sanction system. Given the variations we have

already documented in the development and im plementation of the HIDTA Model across twelve

jurisdictions, we anticipated much interjurisdictional variation in our primary outcome measure

- the offending rates of hard-core drug users. However, we did not anticipate either the reduction

in drug use during the post-test period documented in the previous section or the significant,

overall reductions in arrest levels and offending rates we describe below. W hy did these changes

occur in drug use and offending? Perhaps the simplest answer is the most accurate: it is not a

matter of specific program development - it is a matter of general systems development (Taxm an

& Bouffard, 2000).eThe evaluation strategy involved a pre-post design that compares the actual reoffending

rate of the offender with prior offending patterns. Table 9 shows the rearrest rates based on tw o



Table 9. Comparison of Actual Rearrest Rate at 6 and 12 Month

Follow-up Periods

Site

Alexandria CityArlington CountyFa irfM alls ChurchLoudoun Countv

6 Month Arrest

for New Crime (%)12Mon th Arrest for

New Crime (9%)

8% 16%

3 16

17 32

5 10

Prince William County

District of ColumbiaBaltimore CityBaltimore CountyCharles CountyHoward CountyMontgomery CountyPrince George's CountyOverall

Th e evaluation is designed to exam ine the hypothesis about the impact of the HJDTA

treatment protocol on rearrest rates. The base rate or the likelihood that offenders w ill be

rearrested is derived from the average rate of offending for the offender. That is, given the high

11 24

10 225 13

3 30

9 20

11 **0 6

6 11

11 16



Table 9 illustrates that the average rearrest rate was sixteen (16) percent, compared to the

expected fifty-two (52) percent rearrest rate. This is a seventy (70)percent reduction from the

base rate, demonstrating that the HIDTA intervention likely affected the frequency of the

offender offending in the different jurisdictions. It also appears to demonstrate the sustained

effects of the HlDTA initiative, supporting th e strength and utility of the HlDTA approach, and

underscoring th e apparent importance of treatment duration. The average offender is reported to

have participated in 208 days of treatment or over six months in treatment; this is consistent with

m -

B = '

!i2 = -

Y

0 4 -

Y

Ce, 20.

2

researchers that suggest longer duration in treatment as a tool to reduce criminal behavior a nd

c

//

//

/+/4

substance abuse.



Table 10. Comparison of Base Rate with Participation in the W B HIDTA

Protocol

Charles CountyHoward CountyMontgomery CountyPrince George’s CountyOverall

.71 .20 -72

.3 3 * *

.60 .06 -90

.49 .ll -77

.53 .16 -70

Although these initial findings are prom ising, we must emphasize that they are

preliminary, non-experimen tal and in need of further review. With such sma ll sample sizes and



System” Model examined in this evaluation attempts to address this problem by focusing on the

development of a coo rdinated, multi-system treatment and control strategy. It is this general,

systemwide model that is the focus of both our process and impact evaluation. Rather than

offering an assessment of a particular treatment modality (e.g., methadone maintenance

programs) we are attemp ting to gauge the implemen tation and impact of a treatmentjcontrol

system for all forms of drug addiction.

Our evaluation un derscored both the d ifficulties inherent in a mu lti-jurisdictional

systemwide change effort (see e.g., Taxm an & Bouffard, 2000 for a more complete review) and

the potential positive effects of this type of systemwide collaborative effort on the cessation of

both the offenders’ addiction and criminal careers. Perhaps most imp ortant is our finding that

HIDT A offenders remained in treatment longer (an average stay of 208 days in treatment) and

had a higher than expected program com pletion rate (sixty-four [64] ercent successfully

completed treatment). The impact of these two basic changes in treatment provision on offen der

behavior are worth considering, despite the preliminary nature of the research: (1)HIDTA



decision-making to make changes in the offender’s life. The question is how much the model

motivated offenders to change. Th is further research is needed to understand th e issues related to

treatment and control and how they are perceived by the offender.

This stu dy has also offered an interesting approach to an often vexing problem fo r

research scientists interested in conducting a controlled, randomized field experiment: Ho w d o

you identify jurisdictions who have fully implemen ted the “treatment” being examined (in this

case, the HlDTA Seamless System)? Far oo often in the area of criminal justice, researchers

have wasted time , money and othe r resources trying to conduc t experiments on “failed”

programs (in terms of implementation lev el, targeting strategies and samp le size). To address

this problem, we have conducted a fairly comprehensive implementation evaluation across

twelve (12) separate jurisdictions in order to identify subgroup of sites that appear to be ready f or

a controlled field experiment. Since the twelve (12) jurisdictions are not only interested in

implementation, but also impact, we have employed a less rigorous and less costly evaluation

design to measure th e prelimin ary effectiveness of this strategy across all sites. As a result of



specific treatment mod alities, and more important to think creatively and decisively about how to

improve the quantity and quality of both crim inal justice supervision and treatment service

delivery systems. The HlDTA “Seam less System” Model evaluated in this report offers an

excellent exam ple of this type of intersystem cooperation and collaboration.

While w e must resist the urge to focus too much attention to the positive (albeit

preliminary) findings we report on the recidivism reduction effects of the HIDTA Model, it does

appear that this approach has the potential for significant system-wide cost savings. In addition,

an equally important implementation finding was that improvements in intra- and intro-system

coordination and treatment resource availability resulted in noticeable increases in both treatment

program co mpletion rates and length of stay in treatment. It should be obvious to even the casual

observer that you are not going to change a “lifetime” of addiction and criminality with any

single, short-term strategy.

The fact that this is a coerced treatment strategy with com pliance monitoring

(via drug testing) and graduated sanctions fo r continued drug use should not be forgotten,



drug use (i.e., marijuana vs. heroin) - epresents an even more fundamental change: a growing

goal consensus between treatment and control staff in such areas as the need fo r proper

assessment, th e importance of treatment protocols, and the recognition that the cessation of an

offender’s addiction career is not going to happen overnight. Stated simply, both treatment and

control appear to now agree: long-term problems require long-term solutions.

a



0 References

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a

2-7.



Appendix haracteristics of the Sam ple Per Justification (1997) 0

?rinceWilliam

eounty

:% I

84313

Fairfax

County

(%)

532621

PG

County

( % o )

32

617

Montgomery

County

(%)

14

2858

Howard

County

27

1855

Charles

County

(% I

11

881

10

28

34150

1

16

20

319180

22

26

2

4

4

36280

Baltimore

County

531928

Loudoun

County

[% I

8848

4rlington

County

412039

WashingtonD.C. (%)

32

2939

0

1340

13

0

0

33

BaltimoreCity (%)

175726

PlexandriaCity (%)

452827

Previous

Treatment

YesNo

Unknown

Dru g of

Choice*

Alcohol

Crac k/Cocaine

HeroinMarijuana

PCPOther

Unknown

8

512

370

22

18

34

28141

1

5

3

23

1582

1

49

0

500

50

000

6

5010

20

3

10

7

0

00

0

0

0

100

0

0

0

0

0

0

100

21

57

140

0

0

7

0

0

0

0

0

0

100

0

73

714

0

0

7

Mode ofConsumption*

Injection

Smoking

OralInhalation

Other

Unknown

Freauency ofUse*

No past monthuse

1-3 times in past

month1-2 times in past

week

3-6 times in past

week

DailyUnknownNo t collected

-3

2

798

0

0

11

17

47183

105

533

530

49

7730

70

13

0

0

0

0

0

100

0

0

0

0

0

1000

0

0

0

0

0

100

0

0

0

0

0

100

0

14

2914290

14

0

0

0

0

21

3636

0

0

0

0

0

100

0

0

0

7

17

680

2446

9150

7

0

0

0

0

1000

0

7

63100

0

20

0

0

0

10

47330

27

130

130

47

0

0

10

10

28

450

32

22

6

3

8290

4

2

4

17

712

0

0

0

7

0

930

0

33

9

3

3

20

330

and do not necessarily reflect the official position or policies of the U.S. Department of Justice.been published by the Department. Opinions or points of view expressed are those of the author(s)This document is a research report submitted to the U.S. Department of Justice. This report has not



PROPERTY OFNational CriminalJustice Reference Service (NCJRS)Box 6000

and do not necessarily reflect the official position or policies of the U.S. Department of Justice.been published by the Department. Opinions or points of view expressed are those of the author(s)This document is a research report submitted to the U.S. Department of Justice. This report has not





TREATMENTKRIMINAL JUSTICE FLOW CHART

SAMPLE SEAMLESS SYSTEM

Identify

Screen & SelectEligible Offenders-

Emergency

Criminal JusticeRisk Assessment

1 /. 3.

Assign Risk LevelDevelop

LEGEND

= Criminal Justice Function

= Treatment Function

= Shared Criminal Justice andTreatment Function

0

= Information Sharing

c

Adminster TreatmentDischargereatment

Documents

Evaluating the Implementation & Impact of a Seamless System of Care for Substance Abusing Offenders: The HIDTA Model