Keith HumphreysProfessor of Psychiatry, Stanford University

Honorary Professor of Psychiatry, King’s College Londonknh@stanford.edu

18 March 2014 Policy Exchange

Public Safety Threats Stemming from Both Legal and Illegal Substance UseStreet ViolenceDriving while ImpairedSpousal Battering and Child AbuseHome Invasion, Property TheftMass Transit AccidentsSubstandard or Reckless Medical

PracticeArrests and Incarcerations

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

New paradigm

Traditional Paradigm New Paradigm

Punish unpredictably Punish with certainty and transparency

Punish harshly Punish proportionately

Punish slowly Punish swiftly

Mandate treatment, hope for behavioural change

Mandate behavioural change, 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 by putting them under a regime of swift and certain consequences for substance use

Content of PHP

Not treatment, though they arrange treatment

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

1-year randomized trial findings of HOPE versus usual probation (n=493)

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

Ratio of Alcohol-Involved Motor Fatalities/Mile in South Dakota Versus the US as a Whole

2003-2004: Pre-24/7 Sobriety2005-2006: 24/7 Piloted in an Increasing Number of Counties2007-2010: 24/7 Operating Statewide

Source: Professor Keith Humphreys, Stanford University based on U.S. National Highway Traffic Safety Administration data

Key Outcomes of RAND Study

Over 99% of tests are taken and negative

Repeat drink driving arrests down 12%

Domestic violence arrests down 9%Source: Kilmer, B. et al. (2013). Efficacy of Frequent Monitoring With Swift, Certain, and Modest Sanctions for Violations: Insights From South Dakota’s 24/7 Sobriety Project. American Journal of Public Health, Volume 103.

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

which encourages responsibility, learning and a sense of fairness

Use swift, certain and modest punishment

Mandate change, offer treatment

Have evidence of effectiveness and of cost-effectiveness

UK DevelopmentsGLA Mayor’s Office

Home Office

Scottish Trial in Strathclyde

England and Wales Law passed in 2012

Current Status

Thank you for your attention!