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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!
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