DuPont R.L., Humphreys K.
Substance Abuse: 2011, 32, p. 1–6.
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On the basis of three innovative US programmes for offenders or doctors with substance use problems, this analysis concludes that many seriously dependent individuals stop using if non-use is enforced through intensive monitoring and swift, certain but not necessarily severe consequences.
Summary Typical US substance use treatment amounts to a few weeks of outpatient counselling. Given that these disorders are characterised by lifelong risk of relapse, it is not surprising that many treatments yield suboptimal outcomes for many patients. Interventions that work:
• last months or years rather than weeks;
• carefully monitor use of alcohol or other drugs of abuse;
• impose swift, certain, and meaningful consequences for use and non-use of substances.
This article profiles three innovative care management programmes with these characteristics: physician health programmes, and two therapeutic jurisprudence programmes – South Dakota's 24/7 Sobriety Project and HOPE probation. These actively and intensively manage the environments in which people with substance use disorders make decisions to use or not to use.
Physician health programmes offer drug- and alcohol-using physicians the opportunity, motivation, and support to achieve long-term recovery, using all three strategies in the new paradigm: monitoring, treatment, and 12-step programmes. In return, physicians sign contracts, typically for five years, to adhere to the programme, including completing treatment and submitting to frequent random drug testing to ensure abstinence. Each working day physicians phone or log-in to find out if they must report for testing. All are expected to be active in 12-step or similar community support programmes. Substance use or any other evidence of non-compliance typically results in immediate removal from medical practice to arrange extended treatment followed by more intensive monitoring.A chart review study of a single episode of physician health programme care involving 904 physicians showed that only 0.5% of tests on this high risk, substance abusing population were positive for alcohol or other drugs of abuse.
The Hawaii Opportunity Probation with Enforcement (HOPE) programme manages convicted offenders, most of whom are identified as likely to violate community supervision requirements. Their most common drug problem is smoked crystal methamphetamine. A judge tells offenders about the rules, including that they are subject to intensive random testing similar to that used by physician health programmes. Violations of probation, including any drug or alcohol use, missed drug tests, or missed appointments, are met with certain, swift but brief imprisonment.
When asked at the start of the programme, only a few HOPE probationers choose treatment to help them meet the abstinence requirement. The remainder are simply monitored unless they violate probation; most are then referred to treatment. About 85% complete the programme (which can last up to six years) without treatment.
In a 12-month period, 61% of HOPE offenders had no positive drug tests and fewer than 5% had four or more. A study compared probationers randomly assigned to HOPE or to standard probation. After a year, HOPE probationers were 55% less likely to be arrested for a new crime, 72% less likely to use drugs, 61% less likely to miss supervisory appointments, 53% less likely to have their probation revoked, and were sentenced to 48% fewer days of prison.South Dakota's 24/7 Sobriety programme serves drink-driving offenders, nearly half of whom have three or more drink-driving convictions. Participants must undergo twice-daily alcohol breath tests at a local police station or wear continuous transdermal alcohol monitoring bracelets and are also subject to regular drug urinalyses or must wear drug detection patches. Positive tests result in immediate brief imprisonment and missed appointments in immediate issuance of arrest warrants. Results are impressive: over 90% of all types of tests are negative, for alcohol breath tests, virtually all. Post-programme recidivism among twice-daily tested offenders is considerably lower than among comparison offenders.
A distinctive feature of these three interventions is the strong leverage used to sanction substance use and to reward abstinence: in physician health programmes, removal from practice and ultimately the loss of medical license versus continuing to practice in a prestigious and well paid profession; in HOPE and 24/7 Sobriety, immediate brief imprisonment versus freedom.
Mandatory abstinence in this new paradigm contrasts sharply with programmes which mandate treatment but do not impose meaningful consequences for substance use. The two offender programmes contrast with common approaches where consequences for non-compliance, including substance use, are delayed, uncertain, and, when applied often after many violations, draconian. This new way of managing substance use patients challenges the view that relapse is an essential feature of their disorder, shifts the focus away from finding new biological treatments, and shows that the key to long-term success lies in sustained changes in the environment in which decisions to use and not use are made. If this passively or actively rewards substance use, use is likely to continue, but the drinking and drug use of many – not all – seriously dependent individuals stops if the environment not only prohibits use, but enforces this with intensive monitoring and swift, certain but not necessarily severe consequences.
commentary For Findings entries on the three programmes mentioned in the featured article see:
Setting the standard for recovery: physicians' health programs
Managing drug involved probationers with swift and certain sanctions: evaluating Hawaii's HOPE
Is 24/7 Sobriety a good goal for repeat driving under the influence (DUI) offenders?
Analysis of South Dakota 24-7 Sobriety program data
South Dakota 24/7 Sobriety Program evaluation findings report
The 24/7 Sobriety project
Last revised 14 March 2011
DOCUMENT 2012 Will intensive testing and sanctions displace treatment?
HOT TOPIC 2016 Don’t treat, just test and sanction
STUDY 2009 The 24/7 Sobriety Project