Post on 24-Dec-2015
Judges’ Roles in Implementing the Science of Addiction Treatment
Michael L. Dennis, Ph.D.Chestnut Health Systems Normal, IL
Presentation slides for the Maryland Judicial Institutes “Sentencing Workshop” , Annapolis, MD, April 19, 2012. This presentation was supported by funds from Maryland Judicial Institute and Bureau of Justice Assistance Edward Byrne Grant. It also uses data from NIDA grants no. R01 DA15523, R37-DA11323, and CSAT contract no. 270-07-0191. It is available electronically at http://www.gaincc.org/presentations . The opinions are those of the authors do not reflect official positions of the government. Please address comments or questions to the author at mdennis@chestnut.org or 309-451-7801.
2
Part 1. Chronic Nature of Addiction and the Correlates of Recovery
3
Understand that Addiction is a Chronic Disease / Condition
Identify the major predictors of positive treatment outcomes
Understand that Recovery is broader than just abstinence and takes time
Science Learning Objectives
4
1-2 M in 3-4 5-6
6-7 7-8 8-9
9-10 10-20 20-30
1-2 M in 3-4 5-6
6-7 7-8 8-9
9-10 10-20 20-30
Brain Activity on PET Scan After Using Cocaine
Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377.
Rapid rise in brain activity after taking
cocaine
Actually ends up lower than they
started
5
Normal
10 days of abstinence
100 days of abstinence
Source: Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.
Prolonged Substance Use Injures The Brain:Healing Takes Time
Normal levels of brain activity in PET
scans show up in yellow to red
After 100 days of abstinence, we can
see brain activity “starting” to recover
Reduced brain activity after regular
use can be seen even after 10 days
of abstinence
6
Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.
pain
Adolescent Brain Development Occurs from
the Inside to Out and from Back to Front
6
7
Alcohol and Other Drug Abuse, Dependence and Problem Use Peaks at Age 20
Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000
0
10
20
30
40
50
60
70
80
90
100
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
65+Other drug or heavy alcohol use in the past yearAlcohol or Drug Use (AOD) Abuse or Dependence in the past year
Age
Severity Category
Over 90% of use and
problems start between the ages of
12-20
It takes decades before most recover or die
Per
cent
age
People with drug dependence die an
average of 22.5 years sooner than those
without a diagnosis
8
Committing property crime, drug related crimes, gang related crimes, prostitution, and gambling to trade or get the money for alcohol or other drugs
Committing more impulsive and/or violent acts while under the influence of alcohol and other drugs
Crime levels peak between ages of 15-20 (periods or increased stimulation and low impulse control in the brain)
Adolescent crime is still the main predictor of adult crime
Parent substance use is intertwined with child maltreatment and neglect – which in turn is associated with more use, mental health problems and perpetration of violence on others
Overlap with Crime and Civil Issues
9
Yet Recovery is likely and better than averagecompared with other Mental Health Diagnoses
Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication
15% 13%8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%A
ny A
OD
Alc
ohol
Dru
g
Any
Ext
erna
lizi
ng
Con
duct
Opp
osit
iona
lD
efia
nt
Inte
rmit
tent
Exp
losi
ve
Att
enti
on D
efic
it
Any
Int
erna
lizi
ng
Anx
iety
:
Moo
d :
Pos
ttra
umat
icS
tres
s
Lifetime Diagnosis
10% 10% 7%
Past Year Recovery (no past year symptoms)
66%
77%
83%
Recovery Rate (% Recovery / % Dependent)
25%
10% 10% 8% 8%
46%
31%
7%
20%
15% 8% 9%4%
18%12% 11%
3%4%
58%
89% 89%
45%50%
39%
56% 48%40%
SUD Remission Rates are BETTER than many other DSM Diagnoses
Median of 8 to 9 years in recovery
9
10
People Entering Publicly Funded Treatment Generally Use For Decades
Per
cent
sti
ll u
sing
Years from first use to 1+ years of abstinence302520151050
Source: Dennis et al., 2005
100%90%80%70%60%50%40%30%20%10%0%
It takes 27 years before half reach 1 or more years of abstinence or die
11
Per
cent
sti
ll u
sing
Years from first use to 1+ years of abstinence
under 15*
21+
15-20
Age of First Use
302520151050
Source: Dennis et al., 2005
100%90%80%70%60%50%40%30%20%10%0%
60% longer
The Younger They Start, The Longer They Use
* p<.05
12
Per
cent
sti
ll u
sing
Years from first use to 1+ years of abstinence
Years to first
Treatment Admission*
302520151050
Source: Dennis et al., 2005
100%90%80%70%60%50%40%30%20%10%0%
20 or more years
0 to 9 years
10 to 19 years
57% quicker
The Sooner They Get To Treatment, The Quicker They Get To Abstinence
* p<.05
13
After Initial Treatment…
Relapse is common, particularly for those who: – Are Younger– Have already been to treatment multiple times – Have more mental health issues or pain
It takes an average of 3 to 4 treatment admissions over 9 years before half reach a year of abstinence
Yet over 2/3rds do eventually abstain Treatment predicts who starts abstinence Self help engagement predicts who stays
abstinent
Source: Dennis et al., 2005, Scott et al 2005
14* p<.05
The Likelihood of Sustaining Abstinence Another Year Grows Over Time
36%
66%
86%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 to 12 months 1 to 3 years 4 to 7 years
Duration of Abstinence*
% S
usta
inin
g A
bsti
nenc
eA
noth
er Y
ear
.
After 1 to 3 years of abstinence, 2/3rds will make it another year
After 4 years of abstinence, about 86% will make it
another year
Source: Dennis, Foss & Scott (2007)
Only a third of people with
1 to 12 months of abstinence will
sustain it another year
But even after 7 years of abstinence, about
14% relapse each year14
15Source: Dennis, Foss & Scott (2007)
What does recovery look like on average? Duration of Abstinence
1-12 Months 1-3 Years 4-7 Years
• More social and spiritual support• Better mental health • Housing and living situations continue to improve • Dramatic rise in employment and income • Dramatic drop in people living below the poverty line
• Virtual elimination of illegal activity and illegal income
• Better housing and living situations • Increasing employment and income
• More clean and sober friends• Less illegal activity and incarceration
• Less homelessness, violence and victimization
• Less use by others at home, work, and by social peers
15
16
Sustained Abstinence Also ReducesThe Risk of Death*
Source: Scott, Dennis, Laudet, Funk & Simeone (in press)
-
Users/Early Abstainers
more likely to die in
the next 12 months
The Risk of Death goes down with
years of sustained abstinence
It takes 4 or more years of abstinence for
risk to get down to
community levels
(Matched on Gender, Race & Age)
Dea
ths
in th
e ne
xt 1
2 m
onth
s
* p<.05
17
Other factors related to death rates
Death is more likely for those who – Are older– Are engaged in illegal activity– Have chronic health conditions– Spend a lot of time in and out of hospitals– Spend a lot of time in and out of substance abuse
treatment
Death is less common for those who – Have a greater percent of time abstinent– Have longer periods of continuous abstinence– Get back to treatment sooner after relapse
Source: Scott, Dennis, Laudet, Funk & Simeone (2011)
18
The Cyclical Course of Relapse, Incarceration, Treatment and Recovery (Pathway Adults)
In the Community
Using (53% stable)
In Treatment (21% stable)
In Recovery (58% stable)
Incarcerated(37% stable)
6%
28%
13%
30%
8%
25%
31%
4%
44%7%
29%
7%
Treatment is the most likely path to
recovery
P not the same in both directions
Over half change status annually
Source: Scott, Dennis, & Foss (2005)
19
Source: Scott, Dennis, & Foss (2005)
Predictors of Change Also Vary by Direction
In the Community
Using (53% stable)
In Recovery (58% stable)
28%
29%
Probability of Sustaining Abstinence - times in treatment (0.83) + Female (1.72)- homelessness (0.61) + ASI legal composite (1.19)- number of arrests (0.89) + # of sober friend (1.22)
+ per 77 self help sessions (1.82)
Probability of Transitioning from Using to Abstinence - mental distress (0.88) + older at first use (1.12) - ASI legal composite (0.84) + homelessness (1.27)
+ # of sober friend (1.23)+ per 8 weeks in treatment (1.14)
20
Summary of Key Points
Addiction is a brain disorder with the highest risk being during the period of adolescent to young adult brain development
Addiction is chronic in the sense that it often lasts for years, the risk of relapse is high, and multiple interventions are likely to be needed
Yet over two thirds of the people with addiction do achieve recovery
Treatment increases the likelihood of transitioning from use to recovery
Self help, peers and recovery environment help predict who stays there
Recovery is broader than just abstinence
21
Part 2. The Need and Value of Standardized Screening
22
To show the large gap between need for and receipt of substance abuse treatment
To demonstrate the feasibility, validity and usefulness of low cost screening to identify substance use and co-occurring mental health, monitor placement, and predict the risk of recidivism
Science Learning Objectives
12 to 17 18 to 25 26 or older0%
5%
10%
15%
20%
25%
7.4%
20.1%
7.0%
0.4% 1.1% 0.6%
Abuse or Dependence in past year Treatment in past year
While Substance Use Disorders are Common,
Treatment Participation Rates Are Low
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]
Over 88% of adolescent and young adult treatment and
over 50% of adult treatment is publicly funded
Few Get Treatment: 1 in 20 adolescents,
1 in 18 young adults, 1 in 11 adults
Much of the private funding is limited to 30
days or less and authorized day by day or
week by week
23
Potential AOD Screening & Intervention Sites:Adolescents (age 12-17)
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]
SUD Tx Detention Prob/Pa-role
Hosptial MH Tx Emer. Dept.
Work School 0%
20%
40%
60%
80%
100%1% 0% 1%
4%
12%
29%
30%
93%
1% 1% 3% 5%
13%
35% 41
%
97%
1% 4%
9% 8% 12%
41%
42%
95%
10%
8%
15%
11%
23%
49%
46%
95%
No use in past year Less than weekly use Weekly Use Abuse or dependence
% A
ny
Con
tact
24
Potential AOD Screening & Intervention Sites:Adults (age 18+)
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file] 25
Adolescent Rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in WA State
77% 86
%
73%
75%
61%67
%
83%
62%
75%
60%
57%
40% 46
%
12%
12%
47%
37%
35%
12%
11%
0%10%20%30%40%50%60%70%80%90%
100%
Substance AbuseTreatment(n=8,213)
StudentAssistancePrograms(n=8,777)
Juvenile Justice(n=2,024)
Mental HealthTreatment(10,937)
Children'sAdministration
(n=239)
Either High on Mental Health High on Substance High on Both
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/
Problems could be easily identified
Virtually all Sub. Use
co-occurring in school
26
Adult rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in WA State
81%
78%
65%
64% 69
%
18%
68% 73
%
43%
44%
69%
17%
69%
51%
53%
51%
17%
4%
56%
46%
31%
31%
17%
3%
0%10%20%30%40%50%60%70%80%90%
100%
SubstanceAbuse
Treatment(n=75,208)
Eastern StateHospital(n=422)
Corrections:Community(n=2,723)
Corrections:Prison
(n=7,881)
Mental HealthTreatment(55,847)
ChildrensAdministration
(n=1,238)
Either High on Mental Health High on Substance High on Both
Lower than expected rates of SA in mental health & children’s
admin
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/ 27
35%
12%
11%
56%
34%
15%
9%
47%
0%10%20%30%40%50%60%70%80%90%
100%
Substance AbuseTreatment(n=8,213)
Juvenile Justice(n=2,024)
Mental HealthTreatment (10,937)
Children'sAdministration
(n=239)
GAIN Short Screener Clinical Indicators
Adolescent Client Validation of High Co-Occurring from GAIN Short Screener vs. Clinical Records by Setting in WA State
Two-page measure closely approximated all found in the clinical record after the next 2 years
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/ 28
Adult Client Validation of High Co-Occurring from GAIN Short Screener vs. Clinical Records by Setting in WA State
17%
3%
59%
39%
22%
56%
0%10%20%30%40%50%
60%70%80%90%
100%
Substance AbuseTreatment (n=75,208)
Mental Health Treatment(55,847)
Childrens Administration(n=1,238)
GAIN Short Screener Clinical Indicators
Higher rate in clinical record in mental health and children’s administration
(But that was past on “any use” vs. “abuse/dependence” and 2 years vs. past year)
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/ 29
30
0 5,000 10,000 15,000 20,000 25,000
Any BehavioralHealth (n=22,879)
Mental Health(21,568)
Substance AbuseNeed (10,464)
Co-occurring(9,155)
Substance Abuse Treatment Student Assistance Program
Juvenile Justice Mental Health Treatment
Children's Administration
Where in the System are the Adolescents with Mental Health, Substance Abuse and Co-occurring?
Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/
School Assistance Programs (SAP) largest part of BH/MH system; 2nd largest of SA & Co-
occurring systems
Where in the System are the Adults with Mental Health, Substance Abuse and Co-occurring?
Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/
More Mental Health than Substance
Abuse
Total Disorder Screener for Adolescents
0%1%2%3%4%5%6%7%8%9%
10%11%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Total Disorder Sceener (TDScr) Score
% w
ith
in L
ev
el
of
Care
Residential (n=1,965)
OP/IOP (n=2,499)
Low
Mod. High ->
32
Total Disorder Screener Severity by Level of Care: Adolescents
Source: SAPISP 2009 Data and Dennis et al 2006
Residential Median= 10.5
Outpatient Median=6.0
Few missed
(1/2-3%) About 30% of OP are in the high severity range more typical of residential
About 41% of Resid are below 10 (more likely typical OP
Total Disorder Screener for Adults
0%1%2%3%4%5%6%7%8%9%
10%11%12%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Total Disorder Sceener (TDScr) Score
% w
ith
in L
ev
el
of
Care
Residential (n=1,965)
OP/IOP (n=2,499)
Low
Mod. High ->
33
Total Disorder Screener Severity by Level of Care: Adults
Source: SAPISP 2009 Data and Dennis et al 2006
Residential Median= 8.5(41% below)
Outpatient Median=4.5(29% at 10+)
10% of adult OP missed)
Youth have to be more severe on
average to access services
Any Illegal Activity in the Next Twelve Months by Intake Severity on Crime/Violence and Substance Disorder Screeners
High Mod Low0%
20%
40%
60%
LowMod
High
41%
30%
17%
55%
35%
29%
61%
42%
30%
Crime/Violence Screener (past year at Intake)
An
y Ill
egal
Act
ivit
y(m
on
ths1
-6)
Substance Disorder Screener (past year at Intake)
Source: CSAT 2010 Summary Analytic Dataset (n=20,982)34
Predictive Power of Simple Screener
Crime/ViolenceScreener
SubstanceDisorder Screener
12 MonthRecidivism
Rate
Odds Ratio
\aLow (0) Low (0) 17% 1.0 Low (0) Mod (1-2) 29% 2.0*Low (0) High (3-5) 30% 2.1*Mod (1-2) Low (0) 30% 2.1*Mod (1-2) Mod (1-2) 35% 2.6*Mod (1-2) High (3-5) 42% 3.5*High (3-5) Low (0) 41% 3.4*High (3-5) Mod (1-2) 55% 6.0*High (3-5) High (3-5) 61% 7.6*
* p<.05 \a Odds of row (%/(1-%) over low/low odds across all groups
Source: CSAT 2010 Summary Analytic Dataset (n=20,932) 35
36
Summary of Key Points
There is a large gap between those getting treatment and those in need, ranging from 1-20 adolescents to 1 in 11 adults
The people in need are coming into contact with a range of systems that could serve as screening sites where problems could be identified and addressed before people end up in the courts
Simple Screening tools are feasible, valid and useful to identify substance use disorders, co-occurring behavioral health, monitor placement and predict the risk of recidivism
37
Part 3. What works in Treatment?
38
Define what we mean by treatment Hand out NIDA handbook on the Principals
of Addiction Treatment in the Justice System Identify the key predictors of effectiveness Highlight some of the serious limitations
and problems of the current public treatment
Science Learning Objectives
39
What is Treatment?
Motivational Interviewing and other protocols to help them understand how their problems are related to their substance use and that they are solvable
Residential, IOP and other types of structured environments to reduce short term risk of relapse
Detoxification and medication to reduce pain/risk of withdrawal and relapse, including tobacco cessation
Evaluation of antecedents and consequences of use Community Reinforcement Approaches (CRA) Relapse Prevention Planning Cognitive Behavioral Therapy (CBT) Proactive urine monitoring Motivational Incentives / Contingency Management Access to communities of recovery for long term support,
including 12-step, recovery coaches, recovery schools, recovery housing, workplace programs
Continuing care, phases for multiple admission
40
Other Specific Services that are Screened for and Needed by People in Treatment:
Trauma, suicide ideation, and para-suicidal behavior Child maltreatment and domestic violence
interventions (not just reporting protocols) Psychiatric services related to depression, anxiety,
ADHD/Impulse control, conduct disorder/ ASPD/ BPD, Gambling
Anger Management HIV Intervention to reduce high risk pattern of
behavior (sexual, violence, & needle use) Tobacco cessation Family, school and work problems Case management and work across multiple systems
of care and time
41
Number of Problems by Level of Care (Triage)
39%50% 55%
67%78%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Outpatient(OR=1)
IntensiveOutpatient(OR=1.6)
Long TermResidential(OR=1.9)
Med. TermResidential(OR=3.2)
Short TermResidential(OR=5.5)
0 to 1
2 to 4
5 or more
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824)
Clients entering Short Term Residential
(usually dual diagnosis) have 5.5 times higher
odds of having 5+ major problems*
42
15%
45%
70%
0%10%20%30%40%50%60%70%80%90%
100%
Low (OR 1.0)
Mod.(OR=4.6)
High(OR=13.2)
NoneOneTwoThreeFourFive+
No. of Problems* by Severity of Victimization
Severity of Victimization
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824)
Those with high lifetime levels of
victimization have 13 times higher odds of
having 5+ major problems*
43
Components of Comprehensive Drug Addiction Treatment Recommended by NIDA
www.drugabuse.gov
45
Major Predictors of Bigger Effects
1. A strong intervention protocol based on prior evidence
2. Quality assurance to ensure protocol adherence and project implementation
3. Proactive case supervision of individual
4. Triage to focus on the highest severity subgroup
46
Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice Studies in Lipsey Meta Analysis
Source: Adapted from Lipsey, 1997, 2005
Average Practice
The more features, the
lower the recidivism
47
Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing Juvenile Recidivism (29% vs. 40%)
Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving MET/CBT combinations and Other manualized CBT Multisystemic Therapy (MST) Functional Family Therapy (FFT) Multidimensional Family Therapy (MDFT) Adolescent Community Reinforcement Approach (ACRA) Assertive Continuing Care
Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004
NOTE: There is generally little or no differences in mean effect size between these brand names
48
15%
19%
5%3%
0%
5%
10%
15%
20%
25%
Mon 12 Mon 24
Off Site
On-SiteWithImmediateFeedback
Impact of Simple On-site Urine Protocol with Feedback On False Negative Urines
Source: Scott & Dennis (in press)
On-site Urine
Feedback Protocol
associated with Lower
False Negatives (19 v 3%)
49
Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate)
The effect of a well implemented weak program is
as big as a strong program implemented poorly
The best is to have a strong
program implemented
well
Thus one should optimally pick the strongest intervention that one can
implement wellSource: Adapted from Lipsey, 1997, 2005
Less than half stay the 90 or more days Recommended by Research
Source: Office of Applied Studies 2007Discharge – Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm
Detox (n=341,866)
Residential (n=317,967)
IOP (n=182,465)
OP (n=786,707)
Total (n=1,629,00
5)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% 1%16%
28%
46%
29% 91+ days
31 to 90 days
0 to 30 days
50
Less than Half are Positively Discharged
Source: Office of Applied Studies 2007 Discharge – Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm
Detox (n=341,848)
Residential (n=317,945)
IOP (n=182,441)
OP (n=786,662)
Total (n=1,628,89
6)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
12%
16%
22% 14%
15%
65%52%
34% 36%45%
Completed
Transferred
AMA
ASR
Other
Transfer rates from higher levels of care are dismal
51
52
Programs often LACK Evidenced Based Assessment to Identify and Practices to Treat:
Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment
Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidal thoughts)
Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime)
HIV risk behaviors (needle use, sexual risk, victimization)
Child maltreatment (physical, sexual, emotional) Recovery environment and peer risk
53
Summary of Key Points
Over half the people present to substance abuse treatment with 5 or more overlapping problems that require a range of interventions
The best predictors of outcome are the use of evidenced based assessment and practice that have worked for others, have strong quality assurance, strong case supervision, and good triage of services to well defined problems.
Conversely, the lack of evidenced based assessment, treatment practices and resources leads to high drop out
54
Part 4. What makes Drug Treatment Courts Effective?
55
Describe rational and key components associated with Drug Treatment Court Success
Evaluate the state of the evidence on the effectiveness of drug treatment courts
Highlight the most recent findings on the effectiveness of juvenile treatment drug courts (JTDC) in general versus the more comprehensive/ trauma focused Reclaiming Futures JTDC
Science Learning Objectives
Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 in 2009 dollars
The Cost of Treatment Episode vs. Consequences
$407$1,132$1,249$1,384$1,517$2,486$4,277
$10,228$14,818
$0 $10,
000
$20,
000
$30,
000
$40,
000
$50,
000
$60,
000
$70,
000
Screening & Brief Inter.(1-2 days)Outpatient (18 weeks)
In-prison Therap. Com. (28 weeks) Intensive Outpatient (12 weeks)
Adolescent Outpatient (12 weeks)Treatment Drug Court (46 weeks)
Methadone Maintenance (87 weeks)Residential (13 weeks)
Therapeutic Community (33 weeks)
$22,000 / year to incarcerate
an adult
$30,000/ child-year in foster care
$70,000/year to keep a child in
detention
• $750 per night in Medical Detox• $1,115 per night in hospital • $13,000 per week in intensive care for premature baby• $27,000 per robbery• $67,000 per assault
SBIRT models popular due to ease of implementation
and low cost
56
Return on Investment (ROI)57
Source: Bhati et al., (2008); Ettner et al., (2006)
This also means that for every dollar treatment is cut, it costs society more money than was
saved within the same year
• Substance abuse treatment has been shown to have a ROI within the year of between $1.28 to $7.26 per dollar invested
• Best estimates are that Treatment Drug Courts have an average ROI of $2.14 to $2.71 per dollar invested
57
Key Components Adult & Juvenile Treatment Drug Courts
1. Formal screening process for early identification and referral for substance use and other disorders/needs
2. Multidimensional standardized assessment to guide clinical decision-making related to diagnosis, treatment planning, placement and outcome monitoring
3. Interdisciplinary-treatment drug court team
4. Comprehensive non-adversarial team-developed treatment plan, including youth and family
5. Continuum of substance-abuse treatment and other rehabilitative services to address the youths needs
6. Use of evidence-based treatment practices
58
6. Monitoring progress through urine screens and weekly interdisciplinary-treatment drug court team staffings
7. Feedback to the judge followed by graduated performance-based rewards and sanctions
8. Reducing judicial involvement from weekly to monthly with evidence of favorable behavior change over a year or longer
9. Advanced agreement between parties on how on assessment information will be used to avoid self-incrimination
10. Use of information technology to connect parties and proactively monitor implementation at the client and program level
Source: National Association of Drug Court Professionals, 1997; Henggeler et al., 2006; Ives et al., 2010.
Key Components Treatment Drug Court(cont.)
59
Level of Evidenced is Available on Drug Treatment Courts
Meta Analyses of Experiments/ Quasi Experiments (Summary v Predictive, Specificity, Replicated, Consistency)
Dismantling/ Matching study (What worked for whom)
Experimental Studies (Multi-site, Independent, Replicated, Fidelity, Consistency)
Quasi-Experiments (Quality of Matching, Multi-site, Independent, Replicated, Consistency)
Pre-Post (multiple waves), Expert ConsensusCorrelation and Observational studiesCase Studies, Focus GroupsPre-data Theories, Logic ModelsAnecdotes, Analogies
Beyond a Reasonable
Doubt
Clear andConvincing
EvidencePreponderance
of the Evidence
ProbableCause
ReasonableSuspicion
Law ScienceST
RO
NG
ER
Source: Marlowe 2008, Ives et al 2010 60
Meta Analyses of Experiments/ Quasi Experiments (Summary v Predictive, Specificity, Replicated, Consistency)
Dismantling/ Matching study (What worked for whom)
Experimental Studies (Multi-site, Independent, Replicated, Fidelity, Consistency)
Quasi-Experiments (Quality of Matching, Multi-site, Independent, Replicated, Consistency)
Pre-Post (multiple waves), Expert ConsensusCorrelation and Observational studiesCase Studies, Focus GroupsPre-data Theories, Logic ModelsAnecdotes, Analogies
Beyond a Reasonable
Doubt
Clear andConvincing
EvidencePreponderance
of the Evidence
ProbableCause
ReasonableSuspicion
Law ScienceST
RO
NG
ER
Source: Marlowe 2008, Ives et al 2010
Adult Drug Treatment Courts: 5 meta analyses of 76 studies found crime reduced 7-26% with
$1.74 to $6.32 return on investment
Juvenile Drug Treatment Courts – one 2006 experiment, one 2010 large multisite quasi-
experiment, & several small studies with similar or better effects than regular adolescent
outpatient treatment
DWI Treatment Courts: one quasi experiment and five observational studies positive findings
Family Drug Treatment Courts: one multisite quasi experiment with positive findings for
parent and child
61
Level of Evidenced is Available on Drug Treatment Courts
Change in Days of Abstinence*
Juvenile Treatment Drug Court (JTDC) \a
Reclaiming Futures JTDC
(RF-JTDC) \a, b
Juvenile Treatment Drug Court (JTDC) \a
Reclaiming Futures JTDC
(RF-JTDC) \a, b
In-take*
56.4 55.27
12 Months
70.8386 78.5221
Raw Change
14.4386 23.2521
% Change
0.256003546099291 0.420700199022978
5
25
45
65
85
Of
the P
ast
90
Da
ys
* Days of abstinence from alcohol and other drugs while living in the community; If coming from detention at intake, based on the 90 days before detention.\a p<.05 that post minus pre change is statistically significant\b p<.05 that change for Reclaiming Futures JTDC is better than the average for other JTDC
Source: CSAT 2010 SA Data Set subset to 1+ Follow ups 62
Change in Days of Victimization*
Juvenile Treatment Drug Court (JTDC)
Reclaiming Futures JTDC
(RF-JTDC) \a, b
Juvenile Treatment Drug Court (JTDC)
Reclaiming Futures JTDC
(RF-JTDC) \a, b
Intake 0.694736842105263 2.9280303030303
12 Months
0.954385964912281 0.0757575757575757
Raw Change
0.259649122807018 -2.85227272727272
% Change
0.373737373737375 -0.974126778783959
0.5
1.5
2.5
3.5
Of
the p
ast
90
da
ys
*Number of days victimized (physically, sexually, or emotionally ) in past 90\a p<.05 that post minus pre change is statistically significant
CSAT 2010 SA Data Set subset to 1+ Follow ups63
Change in Average Number of Crimes Reported
Juvenile Treatment Drug Court (JTDC) /a
Reclaiming Futures JTDC
(RF-JTDC) /a, b
Juvenile Treatment Drug Court (JTDC) /a
Reclaiming Futures JTDC
(RF-JTDC) /a, b
Year Prior
36.6437546193643 35.7852459016393
Year After
20.2978566149298 14.1508196721311
Raw Change
-16.3458980044345 -21.6344262295082
% Change
-0.446075959579659 -0.604562737642586
313233343
Average N
um
ber o
f C
rim
es
\a p<.05 that post minus pre change is statistically significant\b p<.05 that change for Reclaiming Futures JTDC is better than the average for other JTDC
CSAT 2010 SA Data Set subset to 1+ Follow ups64
Change in Average Number of Crimes Reported by Type*
Property JTDC /a
PropertyRF-JTDC /a
ViolentJTDC /a
ViolentRF-JTDC /a, b
Drug/Other JTDC /a
Drug/Other RF-JTDC /a, b
Property JTDC /a
PropertyRF-JTDC /a
ViolentJTDC /a
ViolentRF-JTDC /a, b
Drug/Other JTDC /a
Drug/Other RF-JTDC /a, b
Year Prior
16.2653362897265
18.1524590163934
5.65262379896526
6.16065573770491
14.7257945306725
11.4909688013136
Year Af-ter
8.37767923133778
9.37377049180328
4.03399852180339
1.96885245901639
7.88617886178861
2.8128078817734
Raw Change
-7.8876570583
8872
-8.7786885245
9012
-1.6186252771
6187
-4.1918032786
8852
-6.8396156688
8389
-8.6781609195
402
% Change
-0.4849366110
78291
-0.4836087781
08912
-0.2863493723
84939
-0.6804151144
22565
-0.4644649668
74119
-0.7552157759
35981
2.5
7.5
12.5
17.5
Ave
rage
Num
ber
of C
rim
es
*Sum of all crimes reported by type\a p<.05 that post minus pre change is statistically significant\b p<.05 that change for Reclaiming Futures JTDC is better than the average for other JTDC
CSAT 2010 SA Data Set subset to 1+ Follow ups65
Change in Cost of Crime to Society*
Juvenile Treatment Drug Court (JTDC)\a
Reclaiming Futures JTDC
(RF-JTDC)\a, b
Juvenile Treatment Drug Court (JTDC)\a
Reclaiming Futures JTDC
(RF-JTDC)\a, b
Year Prior
389109.54 403991.44
Year Af-ter
321660.8 93789.22
Raw Change
-67448.74 -310202.22
% Change
-0.173341265289975 -0.767843546388013
$50,000$150,000$250,000$350,000$450,000
Average A
nn
ual
Cost
of
Crim
e
*Based on the frequency of crime times the average cost to society of that crime estimated by McCollister et al (2010) in 2010 dollars; distribution capped at 99th percentile to minimize the impact of outliers..\a p<.05 that post minus pre change is statistically significant\b p<.05 that change for Reclaiming Futures JTDC is better than the average for other JTDC
CSAT 2010 SA Data Set subset to 1+ Follow ups 66
Return on Investment
\a Based on change in youth reported cost of service utilization and other short term costs; DOES NOT include other real costs for implementing JTDC and/or RF-JTDC model and is therefor likely an underestimate\b Based on the frequency of crime times the average cost to society of that crime estimated by McCollister et al (2010) in 2010 dollars; distribution capped at 99th percentile to minimize the impact of outliers..
CSAT 2010 SA Data Set subset to 1+ Follow ups
Other JTDC RF-JTDCIncreased Cost of Service Utilization\a + $1,673 + $4,022
Reduced Cost of Crime to Society\b - $67,449 - $310,202
Return on Investment 40 to 1 77 to 1
67
68
Summary of Key Points
Comprehensive, integrated, and collaborative drug courts are generally more effective
While they are often small and cost more in services, drug treatment courts can produce high returns on investment relative to reduced costs to society
More comprehensive models (like Reclaiming Futures) that focused on evidenced based assessment and treatment and providing more trauma/mental health services cost more but work even better and have even higher rates of return.
Other Resources you can use now Cost-Effective evidence-based practices A-CRA & MET/CBT
tracks here, more at http://www.nrepp.samhsa.gov/ or http://www.chestnut.org/li/apss/CSAT/protocols/index.html
Most withdrawal symptoms appeared more appropriate for ambulatory/outpatient detoxification, see http://www.aafp.org/afp/2005/0201/p495.html
Trauma informed therapy and sucide prevention at http://www.nctsn.org/nccts and http://www.sprc.org/
Externalizing disorders medication & practices http://systemsofcare.samhsa.gov/ResourceGuide/ebp.html
Tobacco cessation protocols for youth http://www.cdc.gov/tobacco/quit_smoking/cessation/youth_tobacco_cessation/index.htm
HIV prevention with more focus on sexual risk and interpersonal victimization at http://www.who.int/gender/violence/en/ or http://www.effectiveinterventions.org/en/home.aspx
For individual level strengths see http://www.chestnut.org/li/apss/CSAT/protocols/index.html
For improving customer services http://www.niatx.net 69
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Capriccioso, R. (2004). Foster care: No cure for mental illness. Connect for Kids. Accessed on 6/3/09 from http://www.connectforkids.org/node/571
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