Keith HumphreysProfessor of Psychiatry, Stanford University

Visiting Professor of Psychiatry, King’s College LondonResearch Career Scientist, VA Health Care System

knh@stanford.edu

Presented at 2012 NDASG, Llandrindod Wells, Wales

Public Safety Threats Stemming from Alcohol/Drug UseStreet ViolenceDriving while ImpairedSpousal Battering and Child AbuseHome Invasion, Property TheftMass Transit AccidentsSubstandard or Reckless Medical

Practice

Criminologist James Q. Wilson’s analogy for howwe respond to criminal offenders

New paradigm

Traditional Paradigm New Paradigm

Make rules complex and covert Make rules simple and transparent

Assume long-term orientation in offender

Assume short-term orientation in offender

Punish unpredictably Punish with certainty

Punish harshly Punish proportionately

Punish slowly Punish swiftly

Use Imprisonment indiscriminantly Employ behavioral triage to reserve prison for appropriate offenders

Mandate treatment, hope for abstinence

Mandate abstinence, offer treatment

Exemplars of the New ParadigmPhysician Health Plans

HOPE Probation

24/7 Sobriety

Physician Health PlansRate of physician addiction equal to general

population

Historically, doctors could get away with it until an undeniable catastrophe occurred

PHPs designed to change this through intensive monitoring

Content of PHPCan temporarily or permanently remove license

Not treatment, though they arrange treatment

All conditions specified in a contract

Comprehensive, random drug and alcohol testing

Immediate, graduated reaction to positive test

Outcome Data on 802 Physicians over five years80.7% (n=647) completed all five years of

monitoring

Only 19.5% of completers had even a single positive test

Only 5.1% had more than one positive test

Over 60,000 tests done total, 99.5% negative

Source: McLellan et al. (2008) BMJ, 337, a2038.

The World of ProbationLow social capital offenders

More serious co-occurring problems

Overwhelmed staff

Unclear rules, inconsistent rewards and punishments

HOPE Probation for Drug-involved offenders in HawaiiAll probationers given full orientation to rules

and onus of responsibility placed on them

Dirty or missed random urinalysis results in prompt arrest and certain, modest punishment (brief jail stay)

Treatment offered by not required

Inexpensive because it reduces return to prison

Randomized evaluation of HOPEIncluded all probation officers, average

caseload 87 clients, average years of experience 4.3 years

493 Felony Probationers, average 17 prior arrests

Primary drug: Crystal meth

Major 1-year trial findings of HOPE versus usual probation

Source: Hawken, A., & Kleiman, M. A. R. (2009). Managing Drug Involved Probationers with Swift and Certain Sanctions: Evaluating Hawaii's HOPE. Report to National Institute of Justice, Washington, D.C.

Drink drivers in the U.S. Northern PlainsOver 10,000 Americans a year die in alcohol-

involved car accidents

The peak states are in the Northern Plains (e.g., Montana, North Dakota, South Dakota)

Typical penalties, e.g., license removal, widely ignored

A county prosecutor (Larry Long) decided to innovate

24/7 Sobriety for repeat drink drivers in South DakotaAll offenders get careful orientation to program

rules

Twice-daily breath testing or alcohol-sensing bracelet

Alcohol use or no show results in prompt arrest and certain, modest punishment (1 night in jail)

Nearly self-sustaining financially because offenders pay for own testing

Alcohol-Impaired Motor Vehicle Fatalities/Vehicle Miles Traveled

Source: U.S. National Highway Safety and Transportation Agency

Other key data points on 24/7

Over 99% of tests collected are negative

66% of offenders have perfect compliance

Recidivism rates less than half of non-24/7 offenders

In summary, all three programsGive offenders simple, transparent rules, which

encourages responsibility and a sense of fairness

Use swift, certain and modest consequences

Mandate abstinence for all, treatment or prison only as appropriate

Have evidence of effectiveness and of cost-effectiveness

Political ProcessCame to attention of Scottish VRU and

London Deputy Mayor

Attracted Cross-Party interest in Parliament

Passed as Amendment in House of Lords in March

Law of the England and Wales as of May 1

What does the success of these programmes tell us about drink problems?

The Role of Treatment in Problem Resolution

The Role of Self-Control in Drinking

Can’t versus Won’t versus It’s Hard

Thank you for your attention!