We incarcerate too many patients

3/13/2014 01:14:00 PM
Washington Post has a fairly spectacular graph today:
Basically, we don't have a crime problem. We just mistook our drug problem for a crime problem.
The law treats drug use the same as it does, say, a bank robbery--a rational decision to seek an illicit reward, which can be deterred by imposing a cost on that choice in the form of some risk of going to prison. Yet the AMA and others know differently::
"addiction is now known to be a chronic and progressive brain disease that attacks and damages key parts of the limbic system and cerebral cortex, which in turn results in compulsive cravings, obsessive seekings, and irrational over-use despite harmful and often devastating consequences."
I think more people need to consider the AMA's position: they are resolutely opposed to legalizing drugs (they even think e-cigarettes should be regulated), yet they also oppose sending drug users to prison.

What this boils down to is that you don't have to take any particular stance on drugs and drug use to recognize that the current system of sending them all to prison is totally insane. The AMA and many others strongly support treatment outside of prison. There are reams of research showing that treatment is more effective--even more cost-effective--than prison or treatment-in-prison. So why don't we just change the drug laws and put these patients in treatment rather than prison?

I suspect the reason is that while it's fairly unambiguous that treatment offers more social benefits per dollar spent--recidivism is much lower among recovering addicts who get treatment rather than prison, and their contributions to society in terms of holding steady employment etc, are much higher--the public is worried that it will still cost more total dollars to treat drug offenders. Something can be both more cost-effective and more costly, and the public naively tends to care more about the latter.

But is treatment more costly? I've not seen a convincing comparison. Any cost comparison compares the cost of X amount of treatment to Y amount of prison time. Obviously, that comparison depends entirely on the magnitudes of X and Y. You can argue that, objectively speaking, Y needs to be equal to the current sentencing guidelines for drug offenders. A user found to have 5 grams of meth will get a minimum of 5 years in prison according to the guidelines, so lets say Y=5. The problem is how to we pick X? Most comparisons are based on existing rehab programs, which have lengths designed and determined by medical professionals. But, those programs are substantially more effective than 5 years of prison, so I would argue that that's not a legit comparison at all.

Here's how we should think about cost comparisons for drug policies. A five year prison term for a meth user is associated with a certain amount of deterrent. The question, then, is how much treatment X would we need to achieve the same level of deterrent--that is, after how many weeks of treatment is a patient no more likely to relapse than if he had been sent to prison? Realistically, several weeks of treatment can achieve the same deterrent effect of several years worth of prison. We aren't comparing X=5 to Y=5, but something more like X=0.5 to Y=5.

When we frame the question this way, it becomes clear how even very expensive treatments can actually be way cheaper than prison. Assuming 6 months of treatment yields the same probability of recidivism as 5 years in prison, then even if treatment costs up to ten times as much per month as prison does, it would still cost less to send drug offenders to treatment than to prison.