Drug and Alcohol Findings home page in a new window Druglink page for October/November 2012

Will intensive testing and sanctions displace treatment?

Influential US researchers have argued that US programmes (evaluations of which are collected together in this Findings bulletin) show many seriously dependent individuals stop using if non-use is enforced through intensive monitoring and swift, certain, but not necessarily severe sanctions (Source study 1). Rather than mandating treatment, these programmes directly mandate abstinence. Since among the researchers were top White House drugs advisers, not surprisingly their perspective found its way in to the 2012 US anti-drug policy.

First of these three exemplar programmes was one for US doctors whose performance is threatened by their drinking or drug use (Source study 2). To keep practising they have to sign contracts to adhere to the programme, including completing treatment and frequent random drug testing. 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.

Second was the HOPE (Hawaii Opportunity Probation with Enforcement) programme for offenders on probation (Source study 3). Offenders are sentenced to brief jail stays for each probation violation, including illicit drug use revealed by testing; continued violations result in longer sentences. Treatment is imposed only if tests continue to be positive for drugs or a referral is requested. Compared to other offenders, those on the HOPE programme become much less likely to test positive, missed far fewer appointments, and were dramatically less likely to be arrested.

Last was South Dakota's 24/7 Sobriety programme for drink-driving offenders, which requires twice-daily alcohol breath tests at a local police station or wearing alcohol monitoring bracelets, plus regular drug urinalyses or drug detection patches (Source study 4). Positive tests result in immediate brief imprisonment, and missed appointments in immediate issuance of arrest warrants. Records show that over 90% of all types of tests are negative and post-programme recidivism among twice-daily tested offenders is considerably lower than among comparison offenders.

Signs of a similar approach can be found in Britain. British courts now have drug abstinence requirements at their disposal and, inspired by the US example, government is funding a trial of alcohol-detecting tags for serious drink-related offenders; signs of drinking will trigger a short prison sentence.

The UK too has what is now a considerable history of implementing testing-based programmes for offenders, though generally as a way of monitoring progress and to 'grip' offenders while treatment exerts its effects. The US programmes challenge this subsidiary role, elevating testing and sanctions to the primary role and relegating treatment (if available at all) to those unable to comply without it.

A distinctive feature of the US programmes is the strong leverage available to sanction substance use and reward abstinence: in physician health programmes, deprivation of a prestigious and well paid profession; in programmes for offenders, immediate brief imprisonment versus freedom. Results are said to challenge the view that relapse is an essential feature of substance dependence, and to demonstrate 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 rewards substance use it is likely to continue, but the drinking and drug use of many seriously dependent individuals stops if the environment not only prohibits use, but enforces this through intensive monitoring and meaningful consequences.

The problems facing wider application include engineering or finding sufficient leverage and having both the legal authority and the resources to swiftly and certainly sanction transgressors. Without leverage, programmes risk simply siphoning non-compliant offenders in to conventional penal sanctions; without sure sanctions, the programme exists only on paper and can safely be ignored by offenders.

For evaluations of the cited programmes see this Findings bulletin. For all Findings analyses on testing and sanctions programmes run this search.

Source studies Click blue titles to download the Findings analysis

1 "A new paradigm for long-term recovery." DuPont R.L., Humphreys K. Substance Abuse: 2011, 32, p. 1–6.

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.

2 "Setting the standard for recovery: physicians' health programs." DuPont R.L., McLellan A.T., White W.L. et al. Journal of Substance Abuse Treatment: 2009, 36, p. 159–171.

US physician health programmes demonstrate that long-term intensive monitoring of substance use allied with swift and certain sanctions and abstinence-based mutual aid and treatment can enable seriously dependent individuals to stop using psychoactive substances.

3 Managing drug involved probationers with swift and certain sanctions: evaluating Hawaii's HOPE. Hawken A., Kleiman M. Report submitted to the US Department of Justice, 2009.

Intensive testing allied with swift and certain but not severe sanctions for non-compliance dramatically curbed drug use, prison time and re-arrest rates among a high risk group of drug using US offenders; most did not need treatment to help them comply with the court orders.

4 South Dakota 24/7 Sobriety program evaluation findings report. Loudenburg R., Drube G., Leonardson G. Mountain Plains Evaluation, LLC, 2010.

Drink-driving offenders on South Dakota's 24/7 Sobriety project test alcohol-free at over 99% of the twice-daily breath tests intended to enforce abstinence via the threat of immediate brief imprisonment, and subsequent recidivism was lower than among other drink-driving offenders in the state.

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