David Farabee
Integrated Substance Abuse Programs
UCLA Department of Psychiatry & Biobehavioral Sciences
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
45
40
35
30
25
20
15
10
5
0
41.7
33.8
31.1
18.4
13.6
13.5
15.9
4.6
Illicit Drug Use
(Past Mo)
(SAMHSA, 2009)
Illicit Drug
Alcohol Abuse/Dep AOD Dep/Abuse
Dependence (Past
(Past Yr)
(Past Yr)
Yr)
Probationers
General Population



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%
 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 )

Most alcohol and drug use occurs among
persons who are not violent.

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.




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).




Professional judgment
Evidence-based tools
Evidence-based and dynamic
Systematic and comprehensive
Andrews et al. (2006) Crime & Delinquency, 52, 7-27.



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.

Validate COMPAS Needs Scales
 Concurrent validity (with relevant LSI-R scales)

Validate Treatment Effectiveness Assessment
(TEA)
 Compare with ASI
 Examine concordance with UA results
COMPAS
Criminal Involvement
History of Non Compliance
History of Violence
Current Violence
Criminal Associates/Peers
Substance Abuse
Financial Problems/Poverty
Vocational/Education Problems
Criminal Thinking
Family Criminality
Social Environment Problems
Leisure and Recreation
Residential Instability
Social Adjustment Problems
Socialization Failure
Criminal Opportunity
Criminal Personality
Social Isolation
LSI-R
Criminal History
Companions
Alcohol/Drug Problems
Financial
Education/Employment
Attitudes/Orientation
Family/Marital
Leisure/Recreation
Accommodation




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?
100
90
80
70
60
50
COMPAS
40
LSI-R
30
20
10
0
Substance
Abuse
Financial
Housing
Educ/Voc
COMPAS
LSI-R
Single Item
TABE
COMPAS
LSI-R
Single Item
TABE
1.0
.41***
.23*
-.31**
1.0
.40***
-.16
1.0
-.34**
1.0

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)
UA -
UA+
Sig.
ASI
.17 (SD=.10)
.23 (SD=.10) P <.001
TEA
4.6 (SD=2.9) 3.4 (SD=2.2) P <.001
40
35
38
31
% RTC
30
25
27
21
20
15
10
5
0
Treated
Untreated
No Desire for
Treatment
Desire for Treatment



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
88
100
78
80
64
58
60
40
20
0
% Rearrested
Treatment (n=139)
Gottfredson et al. (2006)
% Reconvicted
Control (n=96)

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
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






Regular, random drug testing
Swift and certain consequences for positive
tests
No a priori assumption of the need for
treatment

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]
30
27
25
20
%
27
26
22
19
Arrests
15
11
10
5
0
Sanctions Treatment Standard
Harrell et al., 2000
All clean UAs
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.




Outcome
HOPE
Control
9%
23%
13%
46%
New arrest rate (probationers rearrested)
21%
47%
Revocation rate (probationers revoked)
7%*
15%
138 days*
267 days
No-shows for probation appointments
(average of appointments per probationer)
Positive urine tests (average of tests per
probationer)
Incarceration (days sentenced)
80
74%
70
63%
Percent
60
50
40
30
20
30%
19%
17%
Transportation
Work schedule
18%
10
0
Housing
Family
responsibilities
Unwilling to
comply
Motivation
Notes: Data are from the 2007 Proposition 36 Treatment Provider Survey. The results reflect
responses from randomly selected Proposition 36 Treatment Providers (n = 87).
100
80%
Percent
80
60
40
20
19%
1%
0
No
Maybe
Yes
Notes: Data are from the 2007 Prop 36 Treatment Provider Survey. The results reflect
responses from randomly selected Prop 36 Treatment Providers (n = 87).


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 selfreferrals in greater need of care.
60%
51%
50%
Percentage
40%
30%
28%
20%
12%
10%
5%
2%
1%
1%
4
5
6
0%
0
1
2
3
Number of positive drug tests




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.



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)
6
Substance Abuse
Mental Health
17
8
Hybrid

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.
12
Frequency
10
8
6
Quality
4
Dissemination
2
0
<1.0 1.0-1.4 1.5-1.9 2.0-2.4 2.5-2.9 3.0-3.4 3.5-4.0
Score
Program Type
Quality
Dissemination
Substance Abuse (n=17)
Mean=2.8 (SD=0.52)
Range=1.7-3.8
Mean=2.6 (SD=0.87)
Range=0.8-4.0
Mental Health (n=8)
Mean=3.0 (SD=0.37)
Range=2.2-3.5
Mean=2.7 (SD=0.92)
Range=1.3-4.0
Hybrid (n=6)
Mean=3.00 (SD=0.49)
Range=2.1-3.5
Mean=3.17 (SD=0.82)
Range=1.5-3.9
One third of the EBPs had not been replicated.
Substance Abuse (N=64)
58
Mental Health (N=27)
56
Hybrid (N=32)
38
Total (N=123)
52
0
20
40
60
%
80
100



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.
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.




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 postrelease mortality rates).



There is tremendous variation in the
quality/dissemination readiness of the CJfocused NREPP studies.
Lack of evaluator independence undermines
confidence in findings.
Inhibits innovation in a field that desperately
needs it.
1. Rates of opiate use among offenders have
stabilized over the past 5 years.
a. True
b. False
2. Good risk/needs assessment cannot be
accomplished without an in-depth client.
interview
a. True
b. False
3. Many offenders with serious drug problems
can quit when subjected to frequent, random
drug tests coupled with mild sanctions.
a. True
b. False