Hooked in the Heartland: As prison population grows, officials focus on treatment for drug addiction

Sitting behind his desk on a recent snowy morning, Grand Forks Police Chief Mark Nelson described the recent spike in drug overdoses in personal terms.

Fentanyl, a potent synthetic opioid, took the life of one of his son's friends a couple of years ago. That death helped prompt a federal investigation into the drug's distribution.

Nelson cited the experience of watching his son act as a pallbearer at Evan Poitra's funeral in arguing drug abuse isn't a "victimless crime." There are parents, friends and classmates who suffer.

"There's a trail of victims left behind," Nelson said.

But Nelson said he couldn't simply arrest his way out of persistent problems with drug abuse in the community. He advocated for a wider approach that includes education and treatment, with law enforcement representing just one part of the response.

Attitudes about drug addiction appear to be shifting, which could hold implications for how those on the front line choose to address drug policy questions more than four decades after the start of the so-called "war on drugs."

"I think there's certainly been a greater understanding among law enforcement that treatment is necessary and that addiction can't be treated with handcuffs," said Kevin Sabet, a former White House drug policy adviser and the director of the Drug Policy Institute at the University of Florida. "We've seen how (the criminal justice system and public health) can often work together."

In a 2014 Pew Research Center survey, only 26 percent of respondents said the government should focus more on prosecuting illegal drug users in dealing with drug policy, while 67 percent said officials should focus on treatment for users.

In that same survey, 63 percent of respondents said it was a good thing that states were moving away from mandatory drug sentences, up from 46 percent who said the same thing 13 years earlier.

North Dakota Attorney General Wayne Stenehjem acknowledged his views on drug policy have shifted over the years. First elected to the North Dakota Legislature in 1976 before winning the attorney general's post in 2000, he felt "punishment is the best course" early in his career.

"And now we just know that isn't the case, that if we don't address the addiction issues, these are folks, who for the most part will get out, and they'll go back to their old way of life and their old environment, and they're going to come back in again," Stenehjem said.

Current approaches to drug offenses are having costly consequences. From 2005 to 2015, appropriations for the North Dakota Department of Corrections and Rehabilitation more than doubled to $178 million, Stenehjem said. In that same time, the state's prison population increased from 1,329 to 1,751, a 32 percent jump.

Stenehjem said legislation will be introduced in the upcoming session "designed to increase the treatment aspects of our criminal justice problems" as well as remove barriers to entering the addiction treatment profession.

"There are those who are selling these drugs in large quantities and that's why we have prisons," Stenehjem said. "We're not designing anything to give them a break. But we know that 80 percent of the people in prison have addiction issues or mental health issues, and we're not addressing them adequately."

Meanwhile, spending for substance addiction treatment services increased from $36 million in the 2011-13 biennium to $40.1 million in the following biennium, according to information provided by North Dakota Department of Human Services Chief Financial Officer Debra McDermott. The current budget for the 2015-17 biennium is $48.7 million.

Multiprong approach

A Substance Abuse and Mental Health Services Administration survey showed 22.5 million people ages 12 or older needed treatment for illicit drug or alcohol use in 2014, but only 18.5 percent of them actually received any substance use treatment in the same year.

Dr. Melinda Campopiano, chief medical officer for SAMHSA's Center for Substance Abuse Treatment, cited availability and affordability issues, fear of stigma over seeking treatment and a lack of understanding about what treatment entails as some reasons few people access care.

She said there's a "widespread misbelief that addiction is somehow a moral failing."

But Campopiano is hopeful attitudes are shifting.

"I think we're at the point of turning a corner, or I hope we are," she said.

Sabet said policymakers should focus more on promising programs such as drug courts. In North Dakota, that system is a court-supervised treatment program that focuses on nonviolent participants, according to the state Department of Corrections.

"It's public health and public safety working together," Sabet said. "We need to take those to scale in communities large and small. I don't think we've done that."

The rash of opioid-related deaths in the Red River Valley over the past few years also has caught the eye of North Dakota's congressional delegation. Sen. Heidi Heitkamp, D-N.D., along with fellow Democratic Sen. Amy Klobuchar of Minnesota, sponsored legislation this year that would establish a one-cent fee on each milligram of active opioid ingredient in prescription pain pills. The money would be used to boost substance abuse treatment programs.

Heitkamp, who convened a roundtable discussion on opioids in Grand Forks earlier this year, acknowledged there has been an "alarming" increase in overdose deaths driven by opioids such as fentanyl. But she argued the meth problem that reared its head while she was North Dakota's attorney general in the 1990s hasn't gone away.

North Dakota Bureau of Criminal Investigation data shows amphetamine/methamphetamine violations skyrocketed by 564 percent between 2010 and 2015.

"To just look at this in terms of opioids and not look at it in terms of addiction ... I think would lead you to some false conclusions," Heitkamp said in an interview. She added that it has to be dealt with as a larger mental health problem, and alcohol could not be ignored, either.

Today, there is a focus on drug treatment that wasn't as prevalent in the 1990s, Heitkamp said.

But like Stenehjem, she said policymakers can't shy away from enforcement. Heitkamp called for a "multipronged" approach.

Nelson echoed that sentiment.

"It's going to take a community to solve this problem," he said.

Legalize it?

As policymakers grapple with how to address drug addiction issues, a growing number of states have legalized marijuana for recreational use. North Dakota voters approved a measure legalizing medical marijuana in November.
The New York City-based Drug Policy Alliance argues the criminalization of marijuana doesn't curb youth access to the drug, but it disproportionately affects people of color and helps boost "massive levels of violence and corruption." It argues instead that legalization will help boost tax revenue and put law enforcement resources to better use.

The growth in legal marijuana comes more than four decades after former President Richard Nixon said drug abuse was "public enemy No. 1," according to National Public Radio, marking the start of the "war on drugs."

Stenehjem is opposed to legalization, arguing "North Dakota would be less healthy and less safe," and that it may contribute to property crimes committed by those looking for money to feed their habit.

Heitkamp was similarly resistant to the idea of legalization because it may "normalize" drug use.

"I'm not saying that we shouldn't re-examine how we approach it, but I think legalization will lead to even greater levels of addiction than what we have right now," she said.