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

44

Two Key Resources Available from NIDA(http://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

Applegate, B. K., & Santana, S. (2000). Intervening with youthful substance abusers: A preliminary analysis of a juvenile drug court. The Justice System Journal, 21(3), 281-300.

Bhati et al. (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders.  Washington, DC: Urban Institute.

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

Chandler, R.K., Fletcher, B.W., Volkow, N.D. (2009).  Treating drug abuse and addiction in the criminal justice system: Improving public health and safety.  Journal American Medical Association, 301(2), 183-190

Dennis, M. L., Scott, C. K. (2007). Managing Addiction as a Chronic Condition. Addiction Science & Clinical Practice , 4(1), 45-55.

Dennis, M. L., Scott, C. K., Funk, R. R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment. Journal of Substance Abuse Treatment, 28(2 Suppl), S51-S62.

Dennis, M. L., Titus, J. C., White, M., Unsicker, J., & Hodgkins, D. (2003). Global Appraisal of Individual Needs (GAIN): Administration guide for the GAIN and related measures. (Version 5 ed.). Bloomington, IL: Chestnut Health Systems. Retrieved from www.gaincc.org.

Dennis, M.L., White, M., Ives, M.I (2009). Individual characteristics and needs associated with substance misuse of adolescents and young adults in addiction treatment. In Carl Leukefeld, Tom Gullotta and Michele Staton Tindall (Ed.), Handbook on Adolescent Substance Abuse Prevention and Treatment: Evidence-Based Practice. New London, CT: Child and Family Agency Press.

Ettner, S.L., Huang, D., Evans, E., Ash, D.R., Hardy, M., Jourabchi, M., & Hser, Y.I. (2006).  Benefit Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment Pay for Itself?.  Health Services Research, 41(1), 192-213.

French, M.T., Popovici, I., & Tapsell, L. (2008). The economic costs of substance abuse treatment: Updated estimates of cost bands for program assessment and reimbursement. Journal of Substance Abuse Treatment, 35, 462-469

Henggeler, S. W., Halliday-Boykins, C. A., Cunningham, P. B., Randall, J., Shapiro, S. B., Chapman, J. E. (2006). Juvenile drug court: enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology, 74(1), 42-54.

Institute of Medicine (2006). Improving the Quality of Health Care for Mental and Substance-Use Conditions . National Academy Press.  Retrieved from http://www.nap.edu/catalog.php?record_id=11470

Ives, M.L., Chan, Y.F., Modisett, K.C., & Dennis, M.L. (2010). Characteristics, needs, services, and outcomes of youths in juvenile treatment drug courts as compared to adolescent outpatient treatment. Drug Court Review, 7(1), 10-56.

References

70

Marlowe, D. (2008). Recent studies of drug courts and DWI courts: Crime reduction and cost savings. Miller, M. L., Scocas, E. A., & O’Connell, J. P. (1998). Evaluation of the juvenile drug court diversion program.

Dover DE: Delaware Statistical Analysis Center, USA. National Association of Drug Court Professionals (1997). Defining Drug Courts: The Key Components. Washington,

DC: U.S. Department of Justice Office of Justice Programs. Retrieved from https://www.ncjrs.gov/pdffiles1/bja/205621.pdf .

National Institute on Drug Abuse (2000). Principles of Drug Addiction Treatment: A Research-Based Guide. Rockville, MD: Author. NIH Publication No.00-4180 . On line at http://www.drugabuse.gov/PODAT/PODATIndex.html

National Institute on Drug Abuse (2006). Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide. Rockville, MD: Author. NIH Publication No. 06-5316. On line at http://www.drugabuse.gov/PODAT_CJ/

Office of Applies Studies. (1995). National Household Survey on Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Office of Juvenile Justice and Delinquency Prevention (OJJDP). (May 2001). Juvenile Drug Court Program. Department of Justice, OJJDP, Washington, DC. NCJ 184744

Rodriguez, N., & Webb, V. J. (2004). Multiple measures of juvenile drug court effectiveness: Results of a quasi-experimental design. Crime & Delinquency, 50(2), 292-314.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2012). National Survey on Drug Use and Health, 2009. [Computer file] ICPSR29621-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2012-02-10. doi:10.3886/ICPSR29621.v2. Retrieved from http://www.icpsr.umich.edu/icpsrweb/SAMHDA/studies/29621/detail .

Scott, C.K. & Dennis, M.L. (2009). Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users. Addiction, 104, 959-971.

Sloan, J. J., Smykla, J. O., & Rush, J. P. (2004). Do juvenile drug courts educe recidivism? Outcomes of drug court and an adolescent substance abuse program. American Journal of Criminal Justice, 29(1), 95-116.

Teplin, L.A., Elkington, K.S., McClelland, G.M., Abram, K.M., Mericle, A.A., and Washburn, J.J. (2001). Major mental disorders, substance use disorders, comorbidity, and HIV-AIDS risk behaviors in juvenile detainees. Psychiatric Services, 56(7), 823–828.

References

71