criminal justice and substance abuse treatment

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

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David Farabee Integrated Substance Abuse Programs UCLA Department of Psychiatry & Biobehavioral Sciences. Criminal Justice and Substance Abuse Treatment. Disclosure Information Criminal Justice & Substance Abuse Treatment David Farabee, PhD . - PowerPoint PPT Presentation

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Page 1: Criminal Justice and Substance Abuse Treatment

Criminal Justice and Substance Abuse Treatment

David FarabeeIntegrated Substance Abuse ProgramsUCLA Department of Psychiatry & Biobehavioral Sciences

Page 2: Criminal Justice and Substance Abuse Treatment

Disclosure InformationCriminal Justice & Substance Abuse TreatmentDavid Farabee, PhD

Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose.

David Farabee, PhD I have no financial relationships to disclose

-andI will not discuss off label use and/or investigational use in my

presentation

Page 3: Criminal Justice and Substance Abuse Treatment

Prevalence of Drug Use Among Offenders

Page 4: Criminal Justice and Substance Abuse Treatment

Past-Month Drug Use among Probationers and Non-Probationers

Illicit Drug Use (Past Mo)

Illicit Drug Dependence

(Past Yr)

Alcohol Abuse/Dep

(Past Yr)

AOD Dep/Abuse (Past Yr)

05

1015202530354045

31.1

18.4

33.8

41.7

13.5

4.6

13.6 15.9

Probationers General Population(SAMHSA, 2009)

Page 5: Criminal Justice and Substance Abuse Treatment

ADAM (UA) Results Use of any drug among arrestees in

2010 ranged from 52% in Washington, D.C. to 83% in Chicago.

Marijuana was most common; Cocaine is on the decline.

Opiates showed the greatest increases over the past 5 years: Portland: 10% to 22% Sacramento: 6% to 11% Indianapolis: 5% to 11%

Page 6: Criminal Justice and Substance Abuse Treatment

Routes of Influence

Economic-CompulsiveIntentional 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.

SystemicCrimes associated with drug manufacturing and distribution.

(Goldstein (1985). JDI, 15, 493-506 )

Page 7: Criminal Justice and Substance Abuse Treatment

Violence: The Big Picture

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.

Page 8: Criminal Justice and Substance Abuse Treatment

Public Health and Safety Consequences

IDU accounts for 7% of new HIV cases among males; 14% of cases among females (CDC, 2009);

Prevalence of HCV among IDUs is 35% (Amon et al., 2008);

Over the course of an addiction career, periods of elevated narcotics use are associated with commensurate increases in both property crime and drug dealing (Anglin & Speckart, 1988);

The risk of death among parolees 2 weeks following release is ~ 13 times > than that of the general population, with drug overdose being the leading cause (Binswanger et al., 2007).

Page 9: Criminal Justice and Substance Abuse Treatment

Assessing Drug Use and Treatment Needs Among Offenders

Page 10: Criminal Justice and Substance Abuse Treatment

Stages of Risk Assessment Professional judgment Evidence-based tools Evidence-based and dynamic Systematic and comprehensive

Andrews et al. (2006) Crime & Delinquency, 52, 7-27.

Page 11: Criminal Justice and Substance Abuse Treatment

Value of Actuarial Approaches Clinical Versus Statistical Prediction: A

Theoretical Analysis and a Review of the Evidence (Meehl, 1954/1996);

20 published studies comparing the predictive efficacy of informal clinical judgments with that of standardized assessments;

In every one of these comparisons, the actuarial approaches performed as well as or better than the subjective approaches.

Page 12: Criminal Justice and Substance Abuse Treatment

Two Studies Validate COMPAS Needs Scales

Concurrent validity (with relevant LSI-R scales)

Validate Treatment Effectiveness Assessment (TEA) Compare with ASI Examine concordance with UA results

Page 13: Criminal Justice and Substance Abuse Treatment

Overlapping Constructs of the COMPAS and LSI-R Assessments

COMPAS LSI-RCriminal Involvement Criminal HistoryHistory of Non Compliance History of Violence Current Violence Criminal Associates/Peers CompanionsSubstance Abuse Alcohol/Drug ProblemsFinancial Problems/Poverty FinancialVocational/Education Problems Education/EmploymentCriminal Thinking Attitudes/OrientationFamily Criminality Family/MaritalSocial Environment Problems Leisure and Recreation Leisure/RecreationResidential Instability AccommodationSocial Adjustment Problems Socialization Failure Criminal Opportunity Criminal Personality Social Isolation

Page 14: Criminal Justice and Substance Abuse Treatment

Four Yes/No Questions:

Do you need substance abuse treatment?

Do you need help earning a high school diploma/GED?

Do you need help learning skills that will help you find employment?

Do you need help finding a safe place to live?

Page 15: Criminal Justice and Substance Abuse Treatment

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

Substance Abuse

Financial Housing Educ/Voc0

102030405060708090

100

COMPASLSI-R

Page 16: Criminal Justice and Substance Abuse Treatment

Correlations with TABE Reading Score

COMPAS LSI-R Single Item TABE

COMPAS 1.0 .41*** .23* -.31**

LSI-R 1.0 .40*** -.16

Single Item 1.0 -.34**

TABE 1.0

Page 17: Criminal Justice and Substance Abuse Treatment

TEA vs ASI

Treatment Effectiveness Assessment (Ling et al., 2013) Please rate your drug use on a 0-10

scale (0=problematic - 10=doing well) Addiction Severity Index

13 questions combined using a weighting scheme, computer scored.

R=-.34 (p <.001; N=300)

Page 18: Criminal Justice and Substance Abuse Treatment

Comparisons of TEA/ASI Scores by UA Result (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

Page 19: Criminal Justice and Substance Abuse Treatment

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

Treated Untreated05

10152025303540 38

2127

31No Desire for TreatmentDesire for Treatment%

RTC

Page 20: Criminal Justice and Substance Abuse Treatment

Interventions for AOD-Involved Offenders

Page 21: Criminal Justice and Substance Abuse Treatment

Drug CourtsTesting and SanctionsPharmacotherapies

Page 22: Criminal Justice and Substance Abuse Treatment

Drug Courts

Page 23: Criminal Justice and Substance Abuse Treatment

Overview of Drug Courts

First established in Florida in 1989 Nearly 1,700 drug courts currently

exist in the U.S. Emphasis on treatment, regular

court hearings, frequent testing, and graduated sanctions

Page 24: Criminal Justice and Substance Abuse Treatment

Baltimore City Drug Court—A Randomized Comparison (3 Yrs)

% Rearrested % Reconvicted0

102030405060708090

100 78

58

88

64

Treatment (n=139) Control (n=96)

Gottfredson et al. (2006)

Page 25: Criminal Justice and Substance Abuse Treatment

GAO Review (2005)

117 drug court evaluations between May 1997 and January 2004 27 were selected

Must have comparison group Must have recidivism, drug use, or

completion outcome 8 of the studies provided cost-benefit

data

Page 26: Criminal Justice and Substance Abuse Treatment

GAO Findings Typical program lasts about 1 year Completion rates range from 27% to 66% Drug court participants were less

criminally active than non-participants (both during and after treatment)

Drug test results showed lower use among drug court participants while in treatment, self reported levels did not differ

Cost savings ranged from $1,000-$15,000 per participant

Page 27: Criminal Justice and Substance Abuse Treatment

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

Page 28: Criminal Justice and Substance Abuse Treatment

Testing & Sanctions

Page 29: Criminal Justice and Substance Abuse Treatment

Testing & Sanctions

Regular, random drug testing Swift and certain consequences for

positive tests No a priori assumption of the need

for treatment

Page 30: Criminal Justice and Substance Abuse Treatment

Superior Court Drug Intervention Program—Design Random assignment to—

Sanctions docket [graduated sanctions, random testing, judicial monitoring]

Treatment docket [weekly drug testing and intensive day treatment]

Standard docket [weekly drug testing, monitoring, and encouragement to enter treatment]

Page 31: Criminal Justice and Substance Abuse Treatment

Superior Court Drug Intervention Program—Results

Sanctions Treatment Standard0

5

10

15

20

25

30

19

26 2727

22

11ArrestsAll clean UAs

%

Harrell et al., 2000

Page 32: Criminal Justice and Substance Abuse Treatment

The HOPE Program Warning hearings H.O.P.E. hotline > 1 weekly random drug testing (6x per

mo) Every violation (e.g., dirty UA or missed

appointment) leads to an immediate arrest and sanction

Short terms, typically 2 days (served on weekend if employed). Terms increase for repeat violations.

Page 33: Criminal Justice and Substance Abuse Treatment

RCT Outcomes

Outcome HOPE Control

No-shows for probation appointments (average of appointments per probationer)

9% 23%

Positive urine tests (average of tests per probationer)

13% 46%

New arrest rate (probationers rearrested)

21% 47%

Revocation rate (probationers revoked)

7%* 15%

Incarceration (days sentenced) 138 days* 267 days

Page 34: Criminal Justice and Substance Abuse Treatment

Treatment Provider Perceptions of Why Prop 36 Cients Did Not Complete Treatment

63%

74%

18%

30%

17%19%

0

10

20

30

40

50

60

70

80

Transportation Work schedule Housing Familyresponsibilities

Unwilling tocomply

Motivation

Perc

ent

Notes: Data are from the 2007 Proposition 36 Treatment Provider Survey. The results reflect responses from randomly selected Proposition 36 Treatment Providers (n = 87).

Page 35: Criminal Justice and Substance Abuse Treatment

Providers’ Perceptions – Would Jail Sanctions for Non-compliance Improve Treatment Outcomes?

19%

1%

80%

0

20

40

60

80

100

No Maybe Yes

Perc

ent

Notes: Data are from the 2007 Prop 36 Treatment Provider Survey. The results reflect responses from randomly selected Prop 36 Treatment Providers (n = 87).

Page 36: Criminal Justice and Substance Abuse Treatment

Behavioral Triage Model

Page 37: Criminal Justice and Substance Abuse Treatment

Behavioral Triage Model (BTM)

Treatment decisions based on probationers’ revealed behavior

Allocates treatment resources more efficiently Under diversion programs many

probationers mandated to treatment do not have a diagnosable substance abuse disorder, wasting scarce treatment resources and displacing self-referrals in greater need of care.

Page 38: Criminal Justice and Substance Abuse Treatment

Distribution of Positive Drug Tests

0 1 2 3 4 5 60%

10%

20%

30%

40%

50%

60%

51%

28%

12%

5%2% 1% 1%

Number of positive drug tests

Perc

enta

ge

Page 39: Criminal Justice and Substance Abuse Treatment

Pharmacotherapies for Opiate-Dependent Offenders Referral to community-based counseling (usually OP)—

inexpensive but insufficient. Methadone & buprenorphine can be effective, but partial

agonists are unpopular among CJ administrators. Oral opioid antagonists are more acceptable, but adherence

(as with psychosocial treatments) is low. Long-acting opioid antagonists

Overcome the problem of non-compliance (at least for monthly segments);

Eliminate concerns about potential diversion; Can still be coupled with psychosocial treatment; and A single dose provides protection during the period of

highest risk for relapse and overdose—the first 2-3 weeks following release.

Page 40: Criminal Justice and Substance Abuse Treatment

What is the Evidence for Evidence-Based Offender Programs?

Page 41: Criminal Justice and Substance Abuse Treatment

National Registry of Evidence-based Programs and Practices (NREPP)

Managed and funded by SAMHSA Began in 1997 Purpose: “[T]o assist the public in

identifying approaches to preventing and treating mental and/or substance abuse disorders that have been scientifically tested and that can be readily disseminated to the field.” (NREPP, 2009)

Page 42: Criminal Justice and Substance Abuse Treatment

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

17

8

6

Substance AbuseMental HealthHybrid

Page 43: Criminal Justice and Substance Abuse Treatment

NREPP Review Criteria Quality of research is reported results

using the following six criteria: Reliability of measures Validity of measures Intervention fidelity Missing data and attrition Potential confounding variables Appropriateness of analysis

Reviewers use a scale of 0.0 to 4.0, with 4.0 being the most favorable.

Page 44: Criminal Justice and Substance Abuse Treatment

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

<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

02468

1012

QualityDissemination

Score

Freq

uenc

y

Page 45: Criminal Justice and Substance Abuse Treatment

Ratings by Program Type (N=31)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.

Page 46: Criminal Justice and Substance Abuse Treatment

Developers as Evaluators

Total (N=123)

Hybrid (N=32)

Mental Health (N=27)

Substance Abuse (N=64)

0 10 20 30 40 50 60 70 80 90 100

52

38

56

58

%

Page 47: Criminal Justice and Substance Abuse Treatment

Summary: Prevalence

Illicit drug use and dependence is approximately 2-5 times more common among offenders than the general population.

50%-80% of arrestees test positive for at least one illicit drug.

Cocaine use is declining; opiate use is increasing.

Page 48: Criminal Justice and Substance Abuse Treatment

Summary: Assessment Studies of the added value of more complex

assessments over that of single-item questions suggest that some offender needs (esp. drug problems) can be assessed using single items with binary responses

70%-90% of those identified as needing AOD, financial, or housing assistance on the COMPAS or LSI-R were also identified with the single-item measures.

Likewise, compared to the ASI drug-use composite measure, the TEA score was as predictive of UA results as the ASI composite score.

Page 49: Criminal Justice and Substance Abuse Treatment

Summary: Interventions Drug court approach can be effective but

not a panacea. BTM may be a useful alternative that helps

practitioners focus on those with most severe problems.

Depot medications for opiate dependence address many of the problems associated with offender treatment (e.g., CJS resistance, poor adherence, risk of diversion, high post-release mortality rates).

Page 50: Criminal Justice and Substance Abuse Treatment

Summary: Evidence-Based Programs There is tremendous variation in the

quality/dissemination readiness of the CJ-focused NREPP studies.

Lack of evaluator independence undermines confidence in findings.

Inhibits innovation in a field that desperately needs it.

Page 51: Criminal Justice and Substance Abuse Treatment

Questions

1. Rates of opiate use among offenders have stabilized over the past 5 years.

a. Trueb. False

Page 52: Criminal Justice and Substance Abuse Treatment

Questions

2. Good risk/needs assessment cannot be accomplished without an in-depth client. interviewa. Trueb. False

Page 53: Criminal Justice and Substance Abuse Treatment

Questions

3. Many offenders with serious drug problems can quit when subjected to frequent, random drug tests coupled with mild sanctions.a. Trueb. False