Can GLP-1s reduce crime? We are planning a study to find out.
A support plus GLP-1 study that confronts the cycle of addiction and incarceration amongst women.
Nick Horton is the Co-Executive Director of OpenDoors, an agency that provides support and advocacy to formerly incarcerated individuals in Rhode Island.
I’ve spent the last twenty years helping people to not go back to prison. I am still not sure if it’s possible. What I mean is that while I know what helps, and I know that with enough support many people can transform their lives, I’m still not sure if a social service program, even one able and willing to go to great lengths to provide assistance, can make a long-term, measurably significant impact. Often, despite every effort, people cannot escape their addictions. Over the next four years, we are going to put our best efforts to the test, and now, by adding access to semaglutide to our supportive services, I think we will succeed.
OpenDoors, the agency I help run, recently received a Department of Justice Second Chance Act Award to offer 300 women coming out of prison in Rhode Island wrap-around help including transitional housing, case management, peer recovery coaching, and cognitive behavioral therapy. In collaboration with CASPR and Brown University, we are writing grants to raise funds to add access to semaglutide treatment for addiction to the array of available services. The program is set up as a randomized controlled trial, and researchers at Brown University will evaluate the impact of this package of supportive services and GLP-1 medication on recidivism, overdose deaths, family reunification, and other outcomes.
This would be one of the first sizable RCT’s looking at semaglutide and addiction, but the goal is not to provide the proof needed by the FDA to approve a GLP-1 for addiction treatment. The hope is that we can provide the proof needed to show that semaglutide could help the United States break our cycle of addiction and incarceration. I believe that the energy needed to catalyze an investment in addiction treatment will not come from evidence that GLP-1’s help individuals (although that will also be necessary), it will come from evidence that GLP-1’s can reduce the social costs of addiction.
Social Programs Have Struggled to Break the Cycle of Relapse and Re-Arrest
OpenDoors currently houses around 320 people a day, including in our two women’s transitional houses. These houses are run by women that themselves overcame these same obstacles, women who are proof of what is possible when we invest in and believe in people’s ability to overcome addiction. However, for many in our programs, that success will not be attainable, even with our help.
The women living in these houses have been through so much trauma and struggle. Some have been in and out of prison over thirty times as they try to self-medicate over and over with cocaine, alcohol, or opiates. They try and try to change but then end up back in prison for shoplifting, check fraud, or drug possession, re-traumatized, their children again taken from them. Once they are released, they start the struggle over from the beginning. The majority of women in prison have been the victim of some sort of sexual abuse, meaning that incarceration of victims is one of the primary ways we as a society respond to sexual violence.
The current cycle not only exacerbates the challenge of rehabilitation and addiction recovery, but it also costs society a tremendous amount of money. Rhode Island spends over seventeen million dollars a year on the women’s prison with an average census of only around 120 women. The social costs of this cycle measured in increased emergency medical care, the costs of crime, and the impact on children in the foster care system, are well beyond that figure.
Even putting the moral imperative of providing transformative care aside, the financial savings of ending this cycle of addiction and incarceration are clearly tremendous. They would even be enough to financially justify widespread access to GLP-1’s as part of Medicaid, should they prove effective. But even if medical trials can overcome the scientific obstacles, the political obstacles to widespread availability of this addiction treatment will be even greater. The goal of this study is to provide the evidence necessary to justify semaglutide access not just to improve the lives of these women, but also financially. If we can demonstrate cost savings, then our approach is much more likely to be replicated and scaled nationally by other organizations.
Has anything been proven to reduce crime?
Which brings us back to the initial challenge—do we have proof that we can, on a societal level, really reduce crime? Unfortunately, not really. There are a limited number of randomized controlled trials measuring the impact of various interventions on recidivism and even fewer that measure those impacts beyond three or six months. Meta-analysis of these studies found no measurable impact1. A recent paper by the economist Megan Stevenson begins with the sentence: “This Article is built around a central empirical claim: most reforms and interventions in the criminal legal space are shown to have little lasting impact when evaluated with gold-standard methods of causal inference.”
This was my own experience a decade ago when OpenDoors ran a pilot of a similar program called ‘9 Yards.’ After five years of excruciating work providing every possible level of assistance we could muster to 110 men, we compiled strong evidence that while they were in the program they went back to prison less than those in the control group. Once they left the program, however, the long-term impact of our help was not definitive.
Intensive support prevents overdose and re-arrest, but only as long as it lasts
In 2014, when we launched the pilot, I formed particularly close bonds with the first group of fourteen men. I worked with them for a year in prison before moving in with them in our halfway house upon their release. I spent years trying everything I could think of to help people I cared about stop using drugs–free housing, job placement, educational opportunities, a caring person to talk with, regular drug testing, access to medical care. Four are now dead, three from addiction related deaths. Of those with cocaine or opiate addictions, all constantly struggle with relapse and reincarceration. The lesson for me was not that intervention is hopeless–there were dramatic reductions in recidivism for the treatment group for the first year after release in comparison to the control group. What I saw was that without extensive help, almost everyone goes back to prison. Then, once help runs out and life gets underway, even those that received extra help still relapse.
Those struggling with addiction are eager to see if these medicines can help them now. Many folks with more resources are already using GLP-1s for addiction at home or in clinics like Caron Treatment Centers, and doctors are prescribing them across the country for SUDs. At a recent house meeting at one of our recovery houses, we asked the women what they thought of trying semaglutide. Almost all of them expressed interest.
OpenDoors is collaborating with the Brown University School of Public Health on this project and we are still in the planning stages of the GLP-1 component. CASPR is providing some of the funding, but we will need to raise a lot more money to be able to provide several years of GLP-1 medication to the over two hundred women struggling with substance use disorder that we think will want it.
This crisis and this state of medical research personally reminds me most of the AIDS epidemic and ACT UP’s criticism of the medical field for not pursuing treatment more aggressively. In the 1980’s ACT UP activists chanted "Hey, hey, FDA, how many people have you killed today?" and organized die-in’s and protests across the country to try to spur investment in AIDS research and treatment. This bravery and pressure from advocates, combined with an intense focus on developing and testing new medical treatments, lead to a breakthrough. When the first antiretroviral came to market, deaths dropped from roughly 50,000 a year at the peak to 20,000 within 3 years, an incredible 60% decline.
The mortality rate from addiction in the US is far higher than it ever was for AIDS2. We as a society continue to primarily blame the ones dying from addiction like we blamed those dying of AIDS back then.
But with addiction, there is still a general assumption that the cure is not medical. I for one, no longer believe that. Instead, I hope that rapid GLP-1 trials will prove it to be an effective treatment. I do not see any other solution on the horizon, and help cannot come soon enough.
Note from Nicholas Reville, CASPR:
This study at OpenDoors has the potential to transform post-incarceration treatment, reduce addictions and overdoses, and reduce crime. CASPR is working with OpenDoors and researchers at Brown University to develop this study and is providing seed funding for the GLP-1 component. If you are interested in donating to support this project, please write to me or Nick Horton, nhorton@opendoorsri.org. Fully funding this trial soon will accelerate the timeline substantially, and will bring us all answers sooner.
International Journal of Offender Therapy and Comparative Criminology, 2018 Oct;62(14):4655-4676
In 1995, the rate of AIDS mortality was 16.2/100,000..In 2023, there were 105,007 drug overdose deaths, resulting in an age-adjusted rate of 31.3 deaths per 100,000 population. This marks a slight decrease from 2022, which had a rate of 32.6 per 100,000 (CDC). In 2020, the age-adjusted rate of alcohol-induced deaths was 13.1 per 100,000 population, up from 10.4 in 2019 (CDC). Combining these figures, the age-adjusted mortality rate from drug overdoses and alcohol-induced causes is approximately 44.4 deaths per 100,000 population
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