Criminal Justice and Substance Abuse Treatment

1. David Farabee Integrated Substance Abuse Programs UCLA Department of Psychiatry & Biobehavioral Sciences Criminal Justice and Substance Abuse Treatment

2. Disclosure InformationCriminal Justice & Substance Abuse TreatmentDavid Farabee, PhD Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose. David Farabee, PhD I have no financial relationships to disclose -and I will not discuss off label use and/or investigational use in my presentation

3. Prevalence of Drug Use Among Offenders

4. Past-Month Drug Use among Probationers and Non-Probationers (SAMHSA, 2009)

5. ADAM (UA) Results • Use of any drug among arrestees in 2010 ranged from 52% in Washington, D.C. to 83% in Chicago. • Marijuana was most common; Cocaine is on the decline. • Opiates showed the greatest increases over the past 5 years: • Portland: 10% to 22% • Sacramento: 6% to 11% • Indianapolis: 5% to 11%

6. Routes of Influence  Economic-Compulsive Intentional crime that results from drug users engaging in an economically oriented crime to support their own addiction. •  Pharmacological • Crimes that occur as a result of the excitability, paranoia, or poor impulse control associated with use of certain drugs.  Systemic Crimes associated with drug manufacturing and distribution. (Goldstein (1985). JDI, 15, 493-506 )

7. Violence: The Big Picture • Most alcohol and drug use occurs among persons who are notviolent. • Individual histories of aggression and violence are key to predicting whether drug use will increase these behaviors. • Alcohol is more closely related to murder, rape, and assault than any other substance (Parker & Rebhun, 1995). For a review, see Boles & Miotto (2003). Aggression & Violent Behavior, 8, 155-174.

8. Public Health and Safety Consequences • IDU accounts for 7% of new HIV cases among males; 14% of cases among females (CDC, 2009); • Prevalence of HCV among IDUs is 35% (Amon et al., 2008); • Over the course of an addiction career, periods of elevated narcotics use are associated with commensurate increases in both property crime and drug dealing (Anglin & Speckart, 1988); • The risk of death among parolees 2 weeks following release is ~ 13 times > than that of the general population, with drug overdose being the leading cause (Binswanger et al., 2007).

9. Assessing Drug Use and Treatment Needs Among Offenders

10. Stages of Risk Assessment • Professional judgment • Evidence-based tools • Evidence-based and dynamic • Systematic and comprehensive Andrews et al. (2006) Crime & Delinquency, 52, 7-27.

11. Value of Actuarial Approaches • Clinical Versus Statistical Prediction: A Theoretical Analysis and a Review of the Evidence (Meehl, 1954/1996); • 20 published studies comparing the predictive efficacy of informal clinical judgments with that of standardized assessments; • In every one of these comparisons, the actuarial approaches performed as well as or better than the subjective approaches.

12. Two Studies • Validate COMPAS Needs Scales • Concurrent validity (with relevant LSI-R scales) • Validate Treatment Effectiveness Assessment (TEA) • Compare with ASI • Examine concordance with UA results

13. Overlapping Constructs of the COMPAS and LSI-R Assessments

14. Four Yes/No Questions: • Do you need substance abuse treatment? • Do you need help earning a high school diploma/GED? • Do you need help learning skills that will help you find employment? • Do you need help finding a safe place to live?

15. % of “High-Need” Inmates Identified Using Single Item (N=75)

16. Correlations with TABE Reading Score

17. TEA vs ASI • Treatment Effectiveness Assessment (Ling et al., 2013) • Please rate your drug use on a 0-10 scale (0=problematic - 10=doing well) • Addiction Severity Index • 13 questions combined using a weighting scheme, computer scored. • R=-.34 (p <.001; N=300)

18. Comparisons of TEA/ASI Scores by UA Result (N=300)

19. 6-Mo. RTC by Motivation for and Receipt of Treatment (N=800)

20. Interventions for AOD-Involved Offenders

21. Drug CourtsTesting and SanctionsPharmacotherapies

22. Drug Courts

23. Overview of Drug Courts • First established in Florida in 1989 • Nearly 1,700 drug courts currently exist in the U.S. • Emphasis on treatment, regular court hearings, frequent testing, and graduated sanctions

24. Baltimore City Drug Court—A Randomized Comparison (3 Yrs) Gottfredson et al. (2006)

25. GAO Review (2005) • 117 drug court evaluations between May 1997 and January 2004 • 27 were selected • Must have comparison group • Must have recidivism, drug use, or completion outcome • 8 of the studies provided cost-benefit data

26. GAO Findings • Typical program lasts about 1 year • Completion rates range from 27% to 66% • Drug court participants were less criminally active than non-participants (both during and after treatment) • Drug test results showed lower use among drug court participants while in treatment, self reported levels did not differ • Cost savings ranged from $1,000-$15,000 per participant

27. “[W]e were unable to find conclusive evidence that the specific drug court components, such as the behavior of the judge, treatment provided, level of supervision, and sanctions for noncompliance affect the participants’ [outcomes]”(GAO, 2005; p.6)

28. Testing & Sanctions

29. Testing & Sanctions • Regular, random drug testing • Swift and certain consequences for positive tests • No a priori assumption of the need for treatment

30. Superior Court Drug Intervention Program—Design • Random assignment to— • Sanctions docket [graduated sanctions, random testing, judicial monitoring] • Treatment docket [weekly drug testing and intensive day treatment] • Standard docket [weekly drug testing, monitoring, and encouragement to enter treatment]

31. Superior Court Drug Intervention Program—Results Harrell et al., 2000

32. The HOPE Program • Warning hearings • H.O.P.E. hotline • > 1 weekly random drug testing (6x per mo) • Every violation (e.g., dirty UA or missed appointment) leads to an immediate arrest and sanction • Short terms, typically 2 days (served on weekend if employed). Terms increase for repeat violations.

33. RCT Outcomes

34. Treatment Provider Perceptions of Why Prop 36 Cients Did Not Complete Treatment Notes: Data are from the 2007 Proposition 36 Treatment Provider Survey. The results reflect responses from randomly selected Proposition 36 Treatment Providers (n = 87).

35. Providers’ Perceptions – Would Jail Sanctions for Non-compliance Improve Treatment Outcomes? Notes: Data are from the 2007 Prop 36 Treatment Provider Survey. The results reflect responses from randomly selected Prop 36 Treatment Providers (n = 87).

36. Behavioral Triage Model

37. Behavioral Triage Model (BTM) • Treatment decisions based on probationers’ revealed behavior • Allocates treatment resources more efficiently • Under diversion programs many probationers mandated to treatment do not have a diagnosable substance abuse disorder, wasting scarce treatment resources and displacing self-referrals in greater need of care.

38. Distribution of Positive Drug Tests Percentage Number of positive drug tests

39. Pharmacotherapies for Opiate-Dependent Offenders • Referral to community-based counseling (usually OP)—inexpensive but insufficient. • Methadone & buprenorphine can be effective, but partial agonists are unpopular among CJ administrators. • Oral opioid antagonists are more acceptable, but adherence (as with psychosocial treatments) is low. • Long-acting opioid antagonists • Overcome the problem of non-compliance (at least for monthly segments); • Eliminate concerns about potential diversion; • Can still be coupled with psychosocial treatment; and • A single dose provides protection during the period of highest risk for relapse and overdose—the first 2-3 weeks following release.

40. What is the Evidence for Evidence-Based Offender Programs?

41. National Registry of Evidence-based Programs and Practices (NREPP) • Managed and funded by SAMHSA • Began in 1997 • Purpose: “[T]o assist the public in identifying approaches to preventing and treating mental and/or substance abuse disorders that have been scientifically tested and that can be readily disseminated to the field.” (NREPP, 2009)

42. Types of Interventions Included in This Study (N=31)

43. NREPP Review Criteria • Quality of research is reported results using the following six criteria: • Reliability of measures • Validity of measures • Intervention fidelity • Missing data and attrition • Potential confounding variables • Appropriateness of analysis • Reviewers use a scale of 0.0 to 4.0, with 4.0 being the most favorable.

44. Distribution of NREPP Quality and Dissemination Readiness Scores (N=31)

45. Ratings by Program Type (N=31) One third of the EBPs had not been replicated.

46. Developers as Evaluators

47. Summary: Prevalence • Illicit drug use and dependence is approximately 2-5 times more common among offenders than the general population. • 50%-80% of arrestees test positive for at least one illicit drug. • Cocaine use is declining; opiate use is increasing.

48. Summary: Assessment • Studies of the added value of more complex assessments over that of single-item questions suggest that some offender needs (esp. drug problems) can be assessed using single items with binary responses • 70%-90% of those identified as needing AOD, financial, or housing assistance on the COMPAS or LSI-R were also identified with the single-item measures. • Likewise, compared to the ASI drug-use composite measure, the TEA score was as predictive of UA results as the ASI composite score.

49. Summary: Interventions • Drug court approach can be effective but not a panacea. • BTM may be a useful alternative that helps practitioners focus on those with most severe problems. • Depot medications for opiate dependence address many of the problems associated with offender treatment (e.g., CJS resistance, poor adherence, risk of diversion, high post-release mortality rates).

50. Summary: Evidence-Based Programs • There is tremendous variation in the quality/dissemination readiness of the CJ-focused NREPP studies. • Lack of evaluator independence undermines confidence in findings. • Inhibits innovation in a field that desperately needs it.