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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to a health podocy. I'm your host, Rob Lott. A few years ago, health affairs had some tote bags made to give away pledge drive style to various subscribers and contributors. Our logo, was imprinted on these bags, and so are these words in big red letters. All policy is health policy.
Rob Lott:Another common version of this refrain is, quote, health in all policies, and it's a pretty intuitive concept. It's the idea that even if we're not talking about typical topics in health services research and public health policy like insurance or drug prices, even if we look further afield, there's always, always a health angle. And our criminal justice system is a great example of this, I think. For years, we've studied these systems in terms of the law and enforcement and their effects on things like crime rates and public safety. And while we know those factors are, of course, shaped by policy choices, it's just as clear that those very same choices inevitably affect people's health in fundamental ways.
Rob Lott:Fortunately, we have researchers looking at that intersection in thoughtful ways and asking if it's possible to craft a criminal justice policy that also prevents harm and maybe even drives positive health outcomes? That's the subject of today's health policy. I'm here with Elizabeth von Nostrandt, an associate professor in the Department of Health Services Administration and Policy at Temple University. Together with co authors, she has a new study in the pages of Health Affairs September issue, a theme issue dedicated entirely to the opioid crisis. The article's title is also one of its main findings.
Rob Lott:Quote, Indiana adults who participated in treatment court programs had better health outcomes than those who did not. I cannot wait to hear all about their findings from Indiana and the implications for states across the nation. Elizabeth von Nonstrand, welcome to A Health Odyssey.
Elizabeth Van Nostrand:Thank you so much for having me.
Rob Lott:Well, let's start with some background. Maybe you can tell us a little bit about the typical relationship between, substance use and criminal justice. What are the proportion of arrests, for example, that are connected to substance related crimes? And what do we know about the typical experience of those individuals?
Elizabeth Van Nostrand:So I was very surprised when I started doing research for my article to find that in The United States, there are more people arrested for substance use or substance related crimes such as, like, selling drugs or committing crimes to get money to buy drugs than any other offense. It's in fact, it's about four in ten people in federal penitentiaries, and about one in ten people in state prisons fit into this category of offenses. Although the goals for incarcerated people include rehabilitation and deterrence of criminal behavior, research shows that incarcerating these people does not achieve these goals. On the contrary, incarcerating people for substance use and substance related crimes does not improve state crime statistics, nor does it reduce substance use.
Rob Lott:So the disconnect there between sort of the intention and whether or not we're achieving that goal of rehabilitation, how did that come about? Was it just simply that substance use was not as big of an issue when we were creating these policies or it wasn't a priority? What's changed there?
Elizabeth Van Nostrand:Well, I think you have to look historically back to the Reagan administration, actually, and the war on drugs. For a long time, our society did not look at substance use as a disease. It viewed substance use as a crime. And so, what do we do to people who commit crimes? We punish them, either to impose sanctions on them themselves or to protect society in some way.
Rob Lott:Okay. So after all that, here we are today. What is the sort of typical experience of someone with a substance use disorder who is incarcerated?
Elizabeth Van Nostrand:Incarceration is especially detrimental for individuals with a substance use disorder. And people who are incarcerated are almost four times more likely to have a substance use disorder diagnosis than people who are Overdose is the third leading cause of death for people who are incarcerated, and it is the leading cause of death after they're released from prison, especially if they didn't receive adequate treatment like medication for substance use disorder, while they were incarcerated. And the two week period post release after they get out of the criminal justice system is especially a dangerous time frame for these folks.
Rob Lott:Okay. So it's against this backdrop that we have an intervention known as treatment courts or treatment court programs that have emerged as an alternative. And I'd love it if you could say a little bit about how the programs work. And I assume not all treatment courts are created equal. So what do we know about the variation from intervention to intervention or program to program?
Elizabeth Van Nostrand:So I'm a former litigator. So I can tell you from personal experience that courts can be very adversarial. You have your opponent coming after you. Sometimes you have the judge coming after you. You can even have your client coming after you.
Elizabeth Van Nostrand:But treatment court is different. I had the opportunity to observe four different courts in Indiana during the course of our study. And to be honest, I was really moved by what I saw. Treatment courts, as opposed to the traditional judicial system, adopt a team approach. They have teams composed of judges and prosecuting attorney, the defense attorney, behavioral health folks, mental health professionals, all pulling for the treatment court participant to succeed.
Elizabeth Van Nostrand:Currently, are about 4,200 treatment courts across The United States. And that is an umbrella term that includes courts such as veteran treatment courts and mental health courts, adult drug courts, juvenile drug courts, tribal healing to wellness courts. Each year about 150,000 people participate in one of those types of treatment court programs. Typically, treatment court programs adopt a public perspective
Rob Lott:and recognize that substance use is a disease, and they attempt to address the underlying causes or issues associated
Elizabeth Van Nostrand:with Treatment substance use. There are best practices that are established for treatment courts. There's a group in Alexandria called All Rise, Alexandria, Virginia called All Rise, which put together these best practices. But in reality, treatment courts have a lot of autonomy, they have a lot of leeway in what they can do in terms of deciding who's eligible to participate, and what services are offered, what sorts of sanctions they want to impose for noncompliance, and incentives for completing different phases of the treatment court program. Typically, treatment courts use a phased approach, where participants come to court every week or every other week or some sort of timeframe where they present what's going on in their lives, where they are in their substance recovery to the court.
Elizabeth Van Nostrand:When people apply to treatment court, they plead guilty. They plead guilty, but the courts hold that plea in abeyance. They don't move forward with that plea unless the person fails in their participation of the treatment court program. If they do, they go back to the traditional judicial system, and they can ultimately be incarcerated.
Rob Lott:Got it. Okay. So very helpful context about treatment courts. Now, tell us a little bit about your study in that context.
Elizabeth Van Nostrand:So what we wanted to find out was whether treatment court participation was associated with health outcomes. So our study took place in the state of Indiana. We selected Indiana even though we're researchers from Pennsylvania, because number one, it has a history of high rates of overdose fatalities. In 2022, Indiana had the fourteenth worst overdose death rate in the country. Second, we picked Indiana because it has a wide variety of treatment courts.
Elizabeth Van Nostrand:In 2018, it had eight different types of treatment courts in 52 of its 92 counties. And third of all, we selected Indiana because it has a governmentally run data warehouse called the management performance hub. The management performance hub has data sets from a variety of Indiana agencies all in one place. Data acquisition is a real issue, a negative issue in The United States. And having all the data sets that we were interested in being housed in one central repository was really critical for our study.
Elizabeth Van Nostrand:Under Indiana law, though, unlike typical criminal records, treatment court records are considered to be privileged, kind of like medical records. So before we started our study, we had to get the permission of the Indiana Supreme Court to have treatment court records released to the management performance hub. It was the first time that they received such a request. We also had to get permission from individual treatment courts to allow their participant records to be released to the management performance hub. We approached 77 of them in Indiana.
Elizabeth Van Nostrand:And, after two informational webinars that that we hosted, we were delighted that 30 of the eligible Indiana treatment courts or about 39% agreed to participate in our project. So from those courts, the Management Performance Hub received treatment court records of five thirty people who applied to treatment court and were accepted. Of those five thirty people, three fifty actually participated and completed programs, and 180 were accepted, but for some reason decided not to go. So those were our two comparison groups, people who were eligible to participate in treatment court programs who went through the programs, versus people who are eligible for the programs but did not go through the programs. So the first thing we did was we interviewed judges to see what sorts of therapies and programs they provided to their treatment court participants.
Elizabeth Van Nostrand:We also got information from the prescription drug monitoring program, which is a central repository of prescriptions for controlled substances such as those that are used to treat substance use disorder. So we were able to create individual profiles of these five thirty people, we knew for person number one, which treatment court program they applied to, whether they were accepted and completed their program or were accepted and decided not to go, what sorts of interventions the courts offered, what kinds of prescriptions they were provided to treat their substance use disorder. And, we followed them for a year, and we looked at whether they had EMS calls, whether they presented in an emergency department, whether they were alive, and whether they were rearrested.
Rob Lott:Well, in just a minute, I wanna ask you about your findings. But first, let's take a quick break. And we're back. I'm here talking with Elizabeth Van Nostrand about, the research of her and her colleagues published in the September issue of Health Affairs all about treatment court programs in Indiana. Alright.
Rob Lott:Well, you just described the complex but relatively precise and targeted approach to your study. What did you find?
Elizabeth Van Nostrand:We were very surprised, to be honest, with what we found. Because when you looked at the socio demographic characteristics, or, the profiles of the two groups, people who participated in treatment court program versus those who did not, the people who participated in the programs had many more characteristics pointing to poor health outcomes than the non participants. For example, they were more than twice as likely to be unemployed, they were more than twice as likely to be disabled, they were more than twice as likely to have a substance use disorder diagnosis than the non participants. And each of those characteristics is associated with a higher likelihood of poor health outcomes and overdose. So, we expected them to have poor health outcomes.
Elizabeth Van Nostrand:But the reverse was true. Compared to the nonparticipants, the participant group with a higher risk profile were thirty four percent less likely to present at an emergency department, seventy four percent less likely to use EMS for a substance related issue, and eighty three percent less likely to die than the non participant groups. And we followed these two groups for a year after they either completed their treatment court programs, or they decided not to participate in treatment court. And those results were pretty much the same across races and ethnicities as well as genders.
Rob Lott:What do we know about the crime related outcomes of programs like these, outcomes like recidivism and the like?
Elizabeth Van Nostrand:So we actually did study rearrest in in our in our in our study. We did not include those results in the paper for a couple of reasons. Number one, we had word constraints. We didn't we had a certain amount of or a certain number of words that we were allowed to use.
Rob Lott:Alright. Note to the health affairs editors there.
Elizabeth Van Nostrand:We also didn't include it. We also didn't include it because it's been pretty well studied. There have been plenty of other studies that support the notion that treatment court participation lessens the chances of being rearrested. And in our study, we found that, people who were involved in the programs were about ninety three percent less likely to be rearrested.
Rob Lott:Oh, wow. And, so these findings are pretty compelling. And in your discussion, you say that they can they quote, can be used to expand the number of treatment courts in underserved areas. What are some of the obstacles, to expansion, and what should policymakers be doing to overcome them?
Elizabeth Van Nostrand:Well, let me say at the outset, that the act of arrest in and of itself can be a very traumatizing experience. And I do not suggest that arresting people for substance use disorder is the way to go. But we as a society continue to arrest people for substance use and substance use related, offenses. So treatment courts offer services that might not otherwise be made available to these folks who use substances. And I think that there are some barriers currently with respect to expanding treatment court programs.
Elizabeth Van Nostrand:Number one, ours is one of the first studies to show the results of treatment or an association between treatment court participation and health outcomes. So, more research needs to be done in that area. Also, the courts vary tremendously with respect to eligibility requirements, like a lot of courts will not accept you into their treatment court, if you have a history of violence, or if you have serious mental or physical health issues. So that's one barrier. And one way to work around that is to beef up treatment court teams to allow them to accept more individuals into their programs.
Elizabeth Van Nostrand:Another common barrier for participants is not having housing or transportation because they have to come and go to these programs. And if they can't get there, they can't participate. Not everyone knows what a treatment court is or what a treatment court does. And as I said, except for rearrest, few research studies have shown the benefits that treatment courts do provide. Not everybody embraces the notion that substance use is a disease.
Elizabeth Van Nostrand:So, they subscribe to the idea that people who use substances need to be punished. It also costs money to set up a treatment court and to run a treatment court. But if you look at it, in the long term, or over the long term, it's economically beneficial. Treatment Court participation costs per participant somewhere between $2,504,000 per participant, whereas to incarcerate an individual costs upwards of $43,000 So it actually is a cost effective way to treat people with a substance use disorder. You know, we need to as a society accept the fact that substance use impacts much more than just an individual, it really impacts entire families, entire communities.
Elizabeth Van Nostrand:There's a lot of stigma still associated with substance use, which needs to be mitigated by providing people with treatment so they can return to be productive, healthy, members of society.
Rob Lott:Wow. Well, a great roadmap for future potential efforts. You said a moment ago that not everyone knows what treatment courts are. And hopefully, with your research, our conversation here today even, we might be able, to help expand people's understanding and and appreciation of those programs and their impact. So Elizabeth von Nastran, thank you so much for taking the time to talk with us today.
Rob Lott:It was a lot of fun.
Elizabeth Van Nostrand:Thank you for having me.
Rob Lott:And to our listeners, thanks for tuning in. If you enjoyed this episode, please recommend it to a friend. Leave a review, and, of course, sign in next week. Thanks, everyone. Thanks for listening.
Rob Lott:If you enjoyed today's episode, I hope you'll tell a friend about a health policy.