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.
Part 1.
Chronic Nature of Addiction
and the Correlates of Recovery
2
Science Learning Objectives

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
3
Brain Activity on PET Scan After
Using Cocaine
Rapid rise in brain
activity after taking
cocaine
Actually ends up
lower than they
started
1-2 Min
3-4
5-6
6-7
7-8
8-9
9-10
10-20
20-30
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.
4
Prolonged Substance Use Injures The Brain:
Healing Takes Time
Normal levels of
brain activity in PET
scans show up in
yellow to red
Reduced brain
activity after regular
use can be seen
even after 10 days
of abstinence
Normal
10 days of abstinence
After 100 days of
abstinence, we can
see brain activity
“starting” to recover
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.
5
Adolescent Brain
Development Occurs from
the Inside to Out and
Photo courtesy of
the NIDA
Web site.to
FromFront
A
from
Back
Slide Teaching Packet: The Brain and the
Actions of Cocaine, Opiates, and Marijuana.
pain
6
6
Alcohol and Other Drug Abuse, Dependence and
Problem Use Peaks at Age 20
100
90
80
70
Percentage
60
Over 90% of
use and
problems
start between
the ages of
12-20
People with drug
dependence die an
average of 22.5 years
sooner than those
without a diagnosis
It takes decades before
most recover or die
Severity Category
Other drug or
heavy alcohol use
in the past year
Alcohol or Drug Use
(AOD) Abuse or
Dependence in the
past year
50
40
30
20
10
0
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
Age
Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000
7
Overlap with Crime and Civil Issues





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
8
Yet Recovery is likely and better than average
compared with other Mental Health Diagnoses
SUD Remission Rates
are BETTER than many
other DSM Diagnoses
100%
90%
70%
58%
Median of
8 to 9 years
in recovery
31%
20%
Drug
Lifetime Diagnosis
8%
9%
4%
4%
7%
12%
11%
3%
Posttraumatic
Stress
Alcohol
0%
15%
18%
Mood :
7%
8%
Anxiety :
10%
8%
Any Internalizing
10%
10%
Attention Deficit
10%
8%
Intermittent
Explosive
13%
Oppositional
Defiant
15%
Any AOD
10%
46% 40% 39%
45%
25%
30%
20%
56% 48%
50%
Conduct
40%
66%
Any
Externalizing
50%
89%
77%
80%
60%
89%
83%
Past Year Recovery (no past year symptoms)
Recovery Rate (% Recovery / % Dependent)
Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication
9
9
Percent still using
People Entering Publicly Funded Treatment
Generally Use For Decades
It takes 27 years
before half reach
1 or more years of
abstinence or die
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0
5
10
15
20
25
Years from first use to 1+ years of abstinence
30
10
Percent still using
The Younger They Start,
The Longer They Use
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Age of
First Use
under 15*
60% longer
15-20
21+
0
5
10
15
20
25
Years from first use to 1+ years of abstinence
30
*
11
Percent still using
The Sooner They Get To Treatment,
The Quicker They Get To Abstinence
Years to
first
Treatment
Admission*
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
20 or
more
years
57% quicker
10 to 19
years
0
5
10
15
20
25
Years from first use to 1+ years of abstinence
0 to 9
30 years
*
12
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
13
.
The Likelihood of Sustaining Abstinence
After 4 years of
Another Year Grows Over Time
abstinence, about
100%
% Sustaining Abstinence
Another Year
90%
80%
70%
60%
50%
40%
Only a third of
people with
1 to 12 months of
abstinence will
sustain it
another year
After 1 to 3 years of
abstinence, 2/3rds will
make it another year
86% will make it
another year
86%
66%
36%
30%
20%
10%
0%
1 to 12 months
1 to 3 years
Duration of Abstinence*
Source: Dennis, Foss & Scott (2007) * p<.05
4 to 7 years
But even after 7 years
of abstinence, about
14% relapse each year1414
What does recovery look like on average?
1-12 Months
Duration of Abstinence
1-3 Years
4-7 Years
• 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
• Virtual elimination of illegal activity and illegal
income
• Better housing and living situations
• Increasing employment and income
• 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
Source: Dennis, Foss & Scott (2007)
15
15
Deaths in the next 12 months
Sustained Abstinence Also Reduces
The Risk of Death*
The Risk of Death
goes down with
years of sustained
abstinence
Users/Early
Abstainers
more likely
to die in
the next 12
months
It takes 4 or
more years of
abstinence for
risk to get
down to
community
levels
(Matched on Gender,
Race & Age)
Source: Scott, Dennis, Laudet, Funk & Simeone (in press) *
16
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)
17
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery (Pathway Adults)
Over half change
status annually
P not the same in
both directions
Incarcerated
(37% stable)
6%
7%
25%
30%
In the
Community
Using
(53% stable)
13%
8%
28%
In Recovery
(58% stable)
29%
4%
44%
31%
In Treatment
(21% stable)
Source: Scott, Dennis, & Foss (2005)
7%
Treatment is the
most likely path to
recovery
18
Predictors of Change Also Vary by Direction
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)
In the
Community
Using
(53% stable)
28%
In Recovery
(58% stable)
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)
Source: Scott, Dennis, & Foss
19
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
20
Part 2.
The Need and Value of
Standardized Screening
21
Science Learning Objectives

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
22
While Substance Use Disorders are Common,
Treatment Participation Rates Are Low
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
25%
Much of the private
funding is limited to 30
days or less and
authorized day by day or
week by week
20.1%
20%
15%
10%
7.4%
7.0%
5%
1.1%
0.4%
0.6%
0%
12 to 17
18 to 25
Abuse or Dependence in past year
26 or older
Treatment in past year
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]
23
93%
97%
95%
95%
Potential AOD Screening & Intervention Sites:
Adolescents (age 12-17)
80%
60%
40%
20%
1%
1%
1%
10%
0%
1%
4%
8%
1%
3%
9%
15%
4%
5%
8%
11%
12%
13%
12%
23%
29%
35%
41%
49%
30%
41%
42%
46%
% Any Contact
100%
0%
SUD Tx
No use in past year
Detention Prob/Parole Hosptial
Less than weekly use
MH Tx Emer. Dept.
Weekly Use
Work
School
Abuse or dependence
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]
24
Potential AOD Screening & Intervention Sites:
Adults (age 18+)
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]
25
Juvenile Justice
(n=2,024)
High on Mental Health
12%
11%
Student
Assistance
Programs
(n=8,777)
61%
60%
75%
75%
46%
35%
73%
62%
40%
37%
Substance Abuse
Treatment
(n=8,213)
Either
Problems could be easily identified
12%
12%
Virtually all
Sub. Use
co-occurring
in school
77%
67%
57%
47%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
86%
83%
Adolescent Rates of High (2+) Scores on Mental Health (MH) or
Substance Abuse (SA) Screener by Setting in WA State
Mental Health
Treatment
(10,937)
Children's
Administration
(n=239)
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/
26
4%
3%
17%
17%
18%
17%
Lower than expected
rates of SA in mental
health & children’s
admin
69%
69%
44%
51%
31%
64%
43%
53%
31%
65%
51%
46%
78%
73%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
81%
68%
69%
56%
Adult rates of High (2+) Scores on Mental Health (MH) or
Substance Abuse (SA) Screener by Setting in WA State
Substance
Abuse
Treatment
(n=75,208)
Either
Eastern State
Hospital
(n=422)
Corrections:
Community
(n=2,723)
High on Mental Health
Corrections:
Prison
(n=7,881)
Mental Health
Childrens
Treatment Administration
(55,847)
(n=1,238)
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/
27
Adolescent Client Validation of High Co-Occurring from GAIN
Short Screener vs. Clinical Records by Setting in WA State
Substance Abuse
Treatment
(n=8,213)
Juvenile Justice
(n=2,024)
GAIN Short Screener
Mental Health
Treatment (10,937)
9%
11%
15%
12%
34%
35%
56%
Two-page measure closely approximated all found
in the clinical record after the next 2 years
47%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Children's
Administration
(n=239)
Clinical Indicators
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
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)
3%
17%
22%
39%
59%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
56%
Adult Client Validation of High Co-Occurring from GAIN
Short Screener vs. Clinical Records by Setting in WA State
Substance Abuse
Treatment (n=75,208)
Mental Health Treatment Childrens Administration
(55,847)
(n=1,238)
GAIN Short Screener
Clinical Indicators
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
Where in the System are the Adolescents with Mental
Health, Substance Abuse and Co-occurring?
0
5,000
10,000
15,000
20,000
25,000
Any Behavioral
Health (n=22,879)
Mental Health
(21,568)
Substance Abuse
Need (10,464)
Co-occurring
(9,155)
Substance Abuse Treatment
Juvenile Justice
Children's Administration
School Assistance
Programs (SAP) largest
part of BH/MH system;
2nd largest of SA & Cooccurring systems
Student Assistance Program
Mental Health Treatment
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/
30
Where in the System are the Adults with Mental
Health, Substance Abuse and Co-occurring?
More Mental
Health than
Substance
Abuse
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/
% within Level of Care
Total Disorder Screener Severity
Disorder Screener for Adolescents
by Level ofTotal
Care:
Adolescents
11%
Lo Mod. High ->
10%
w
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
0 1 2 3 4 5
Outpatient
Median=6.0
Residential (n=1,965)
OP/IOP (n=2,499)
Residential
Median= 10.5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20
Few
Total Disorder Sceener (TDScr) Score
missed
(1/2-3%) About 41% of Resid are below 10 About 30% of OP are in the high severity
likelyand
typical
Source: SAPISP(more
2009 Data
DennisOP
et al 2006
range more typical of residential
32
Total Disorder Screener Severity
Total Disorder Screener for Adults
by Level of Care:
Adults
% within Level of Care
12%
Outpatient
Lo
Mod.
High
->
Residential (n=1,965)
11%
Median=4.5
10% w
(29% at 10+)
OP/IOP (n=2,499)
9%
8%
Youth have to be
7%
more severe on
6%
average to access
5%
services
4%
3%
Residential
2%
Median= 8.5
1%
(41% below)
0%
10% of 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
adult OP
Total Disorder Sceener (TDScr) Score
missed)
Source: SAPISP 2009 Data and Dennis et al 2006
33
Any Illegal Activity in the Next Twelve
Months by Intake Severity on Crime/Violence
and Substance Disorder Screeners
Any Illegal Activity
(months1-6)
61%
60%
55%
42%
40%
30%
35%
41%
29%
30%
20%
17%
High
Mod
0%
High
Mod
Low
Low
Crime/Violence Screener
(past year at Intake)
Source: CSAT 2010 Summary Analytic Dataset (n=20,982)
Substance
Disorder Screener
(past year at Intake)
34
Predictive Power of Simple Screener
Crime/
Violence
Screener
Low (0)
Low (0)
Low (0)
Mod (1-2)
Mod (1-2)
Mod (1-2)
High (3-5)
High (3-5)
High (3-5)
Substance
Disorder
Screener
Low (0)
Mod (1-2)
High (3-5)
Low (0)
Mod (1-2)
High (3-5)
Low (0)
Mod (1-2)
High (3-5)
12 Month
Recidivism
Rate
17%
29%
30%
30%
35%
42%
41%
55%
61%
Odds
Ratio
\a
1.0
2.0*
2.1*
2.1*
2.6*
3.5*
3.4*
6.0*
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
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
36
Part 3.
What works in Treatment?
37
Science Learning Objectives

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
38
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
39
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
40
Number of Problems by Level of Care (Triage)
100%
90%
0 to 1
80%
2 to 4
70%
60%
5 or more
50%
40%
67%
30%
20%
50%
78%
55%
39%
10%
0%
Outpatient
(OR=1)
Intensive
Outpatient
(OR=1.6)
Long Term
Residential
(OR=1.9)
Source: Dennis et al 2009; CSAT 2007 Adolescent
Treatment Outcome Data Set (n=12,824)
Med. Term
Residential
(OR=3.2)
*
Short Term
Residential
(OR=5.5)
Clients entering
Short Term
Residential
(usually dual
diagnosis) have
5.5 times higher
odds of having 5+
major problems*
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
41
No. of Problems* by Severity of Victimization
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
None
One
Two
Three
Four
Five+
70%
45%
15%
Low
(OR 1.0)
Mod.
(OR=4.6)
High
(OR=13.2)
Those with high
lifetime levels of
victimization
have 13 times
higher odds of
having 5+ major
problems*
Severity of Victimization
Source: Dennis et al 2009; CSAT 2007 Adolescent
Treatment Outcome Data Set (n=12,824)
*
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
42
Components of Comprehensive Drug
Addiction Treatment Recommended by NIDA
www.drugabuse.gov
43
Two Key Resources Available from NIDA
(http://www.drugabuse.gov )
44
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
45
Impact of the numbers of these Favorable
features on Recidivism in 509 Juvenile
Justice Studies in Lipsey Meta Analysis
Average
Practice
Source: Adapted from Lipsey, 1997, 2005
The more
features, the
lower the
recidivism
46
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
NOTE: There is generally little or no differences in mean
effect size between these brand names
Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004
47
Impact of Simple On-site Urine Protocol
with Feedback On False Negative Urines
25%
Off Site
19%
20%
15%
15%
On-Site
With
Immediate
Feedback
10%
5%
On-site
Urine
Feedback
Protocol
associated
with Lower
False
Negatives
(19 v 3%)
5%
3%
0%
Mon 12
Source: Scott & Dennis (in press)
Mon 24
48
Implementation is Essential
(Reduction in Recidivism from .50 Control Group Rate)
The best is to
have a strong
program
implemented
well
Thus one should optimally pick the
strongest intervention that one can
implement well
Source: Adapted from Lipsey, 1997, 2005
The effect of a well
implemented weak program is
as big as a strong program
implemented poorly
49
Less than half stay the 90 or more days
Recommended by Research
100%
90%
80%
1%
16%
28%
29%
91+ days
46%
70%
31 to 90
days
60%
50%
0 to 30
days
40%
30%
20%
10%
0%
Detox
Residential
IOP
OP
Total
(n=341,866) (n=317,967) (n=182,465) (n=786,707) (n=1,629,005)
Source: Office of Applied Studies 2007Discharge – Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm
50
Less than Half are Positively Discharged
Transfer rates from higher levels of care are dismal
100%
90%
34%
80%
70%
45%
52%
Completed
65%
60%
22%
50%
Transferred
14%
15%
40%
30%
36%
AMA
16%
12%
ASR
20%
10%
Other
0%
Detox
(n=341,848)
Residential
(n=317,945)
IOP
(n=182,441)
OP
Total
(n=786,662) (n=1,628,896)
Source: Office of Applied Studies 2007 Discharge – Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm
51
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
52
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
53
Part 4.
What makes Drug Treatment
Courts Effective?
54
Science Learning Objectives

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
55
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)
$70,000
$60,000
$50,000
$40,000
$30,000
$20,000
$0
SBIRT models popular due
to ease of implementation
and low cost
$10,000
The Cost of Treatment Episode vs.
Consequences
$407
• $750 per night in Medical Detox
$1,132
• $1,115 per night in hospital
$1,249
• $13,000 per week in intensive
$1,384
care for premature baby
$1,517
• $27,000 per robbery
$2,486
• $67,000 per assault
$4,277
$10,228
$14,818
$22,000 / year
to incarcerate
an adult
$30,000/
child-year in
foster care
$70,000/year to
keep a child in
detention
Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 in 2009 dollars
56
Return on Investment (ROI)
57
• 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
This also means that for every dollar treatment
is cut, it costs society more money than was
saved within the same year
Source: Bhati et al., (2008); Ettner et al., (2006)
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
Key Components Treatment Drug Court
(cont.)
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 selfincrimination
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.
59
Level of Evidenced is Available on
Drug Treatment Courts
Science
Law
Beyond a
Reasonable
Doubt
STRONGER
Meta Analyses of Experiments/ Quasi
Experiments (Summary v Predictive,
Specificity, Replicated, Consistency)
Dismantling/ Matching study (What worked for
Clear and
whom)
Convincing
Experimental Studies (Multi-site, Independent,
Evidence
Replicated, Fidelity, Consistency)
Preponderance
Quasi-Experiments (Quality of Matching, Multiof the Evidence
site, Independent, Replicated, Consistency)
Pre-Post (multiple waves), Expert Consensus
Probable
Correlation and Observational studies
Cause
Case Studies, Focus Groups
Reasonable
Pre-data Theories, Logic Models
Suspicion
Anecdotes, Analogies
60
Source: Marlowe 2008, Ives et al 2010
Level of Evidenced is Available on
Drug Treatment Courts
Science
Law
AdultAnalyses
Drug Treatment
Courts: 5Quasi
meta analyses
Meta
of Experiments/
of
76 studies found
crimevreduced
7-26% with
Experiments
(Summary
Predictive,
$1.74 toReplicated,
$6.32 return
on investment
Specificity,
Consistency)
Dismantling/
Matching
study
worked for
DWI Treatment
Courts:
one (What
quasi experiment
Clear and
and
five observational studies positive findings
whom)
Convincing
Experimental Studies (Multi-site, Independent,
Evidence
Family
DrugFidelity,
Treatment
Courts: one multisite
Replicated,
Consistency)
quasi experiment with positive findings for
Preponderance
Quasi-Experiments
(Quality
of Matching, Multiparent
and
child
of the Evidence
site, Independent, Replicated, Consistency)
Pre-Post
(multiple
waves), Expert
Juvenile
Drug Treatment
CourtsConsensus
– one 2006
Probable
Correlation
andone
Observational
studies quasiexperiment,
2010 large multisite
Cause
Case
Studies,&Focus
Groups
experiment,
several
small studies with similar
Reasonable
or better
effects
thanModels
regular adolescent
Pre-data
Theories,
Logic
Suspicion
outpatient treatment
Anecdotes, Analogies
61
Source: Marlowe 2008, Ives et al 2010
Beyond a
Reasonable
Doubt
STRONGER
Of the Past 90 Days
Change in Days of Abstinence*
90
80
70
60
50
40
30
20
10
0
Intake*
12 Months
Raw Change
% Change
Juvenile Treatment Drug Court
(JTDC) \a
56
71
14
26%
Reclaiming Futures JTDC
(RF-JTDC) \a, b
55
79
23
42%
* 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*
Of the past 90 days
4
3
2
1
0
Intake
12 Months
Raw Change
% Change
Juvenile Treatment Drug Court
(JTDC)
0.69
0.95
0.26
37%
Reclaiming Futures JTDC
(RF-JTDC) \a, b
2.93
0.08
-2.85
-97%
*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 ups
63
Average Number of Crimes
Change in Average Number of Crimes Reported
50
45
40
35
30
25
20
15
10
5
0
Year Prior
Year After
Raw Change
% Change
Juvenile Treatment Drug Court
(JTDC) /a
37
20
-16
-45%
Reclaiming Futures JTDC
(RF-JTDC) /a, b
36
14
-22
-60%
\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
64
Average Number of Crimes
Change in Average Number of Crimes Reported
by Type*
20
15
10
5
0
Property JTDC
/a
Year Prior
16
Year After
8
Raw Change
-8
% Change
-48%
Property
RF-JTDC /a
18
9
-9
-48%
Violent
JTDC /a
6
4
-2
-29%
Violent
RF-JTDC /a, b
6
2
-4
-68%
Drug/Other
JTDC /a
15
8
-7
-46%
Drug/Other
RF-JTDC /a, b
11
3
-9
-76%
*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 ups
65
Average Annual Cost of Crime
Change in Cost of Crime to Society*
$500,000
$400,000
$300,000
$200,000
$100,000
$0
Year Prior
Year After
Raw Change
% Change
Juvenile Treatment Drug
Court (JTDC)\a
$389,110
$321,661
-$67,449
-17%
Reclaiming Futures JTDC
(RF-JTDC)\a, b
$403,991
$93,789
-$310,202
-77%
*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
Increased Cost of
Service Utilization\a
Reduced Cost of
Crime to Society\b
Return on
Investment
Other JTDC
RF-JTDC
+ $1,673
+ $4,022
- $67,449
- $310,202
40 to 1
77 to 1
\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..
67
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.
68
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_tobacc
o_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
References





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.
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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
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youths in juvenile treatment drug courts as compared to adolescent outpatient treatment. Drug Court Review, 7(1),
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





References












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.
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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
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71