Judges’ Roles in Implementing the Science of Addiction Treatment Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation slides for the Maryland Judicial Institutes “Sentencing Workshop”, Annapolis, MD, April 19, This presentation was supported by funds from Maryland Judicial Institute and Bureau of Justice Assistance Edward Byrne Grant. It also uses data from NIDA grants no. R01 DA15523, R37-DA11323, and CSAT contract no It is available electronically at The opinions are those of the authors do not reflect official positions of the government. Please address comments or questions to the author at or

2 Part 1. Chronic Nature of Addiction and the Correlates of Recovery

3 Understand that Addiction is a Chronic Disease / Condition Identify the major predictors of positive treatment outcomes Understand that Recovery is broader than just abstinence and takes time Science Learning Objectives

4 Brain Activity on PET Scan After Using Cocaine Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4): Rapid rise in brain activity after taking cocaine Actually ends up lower than they started

5 Normal 10 days of abstinence 100 days of abstinence Source: Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11: , 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14: , Prolonged Substance Use Injures The Brain: Healing Takes Time Normal levels of brain activity in PET scans show up in yellow to red After 100 days of abstinence, we can see brain activity “starting” to recover Reduced brain activity after regular use can be seen even after 10 days of abstinence

6 Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana. pain Adolescent Brain Development Occurs from the Inside to Out and from Back to Front 6

7 Alcohol and Other Drug Abuse, Dependence and Problem Use Peaks at Age 20 Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., Other drug or heavy alcohol use in the past year Alcohol or Drug Use (AOD) Abuse or Dependence in the past year Age Severity Category Over 90% of use and problems start between the ages of It takes decades before most recover or die Percentage People with drug dependence die an average of 22.5 years sooner than those without a diagnosis

8 Committing property crime, drug related crimes, gang related crimes, prostitution, and gambling to trade or get the money for alcohol or other drugs Committing more impulsive and/or violent acts while under the influence of alcohol and other drugs Crime levels peak between ages of (periods or increased stimulation and low impulse control in the brain) Adolescent crime is still the main predictor of adult crime Parent substance use is intertwined with child maltreatment and neglect – which in turn is associated with more use, mental health problems and perpetration of violence on others Overlap with Crime and Civil Issues

9 Yet Recovery is likely and better than average compared with other Mental Health Diagnoses Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication 15% 13% 8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD Alcohol Drug Any Externalizing Conduct Oppositional Defiant Intermittent Explosive Attention Deficit Any Internalizing Anxiety : Mood : Posttraumatic Stress Lifetime Diagnosis 10% 7% Past Year Recovery (no past year symptoms) 66% 77% 83% Recovery Rate (% Recovery / % Dependent) 25% 10% 8% 46% 31% 7% 20% 15% 8%9% 4% 18% 12% 11% 3% 4% 58% 89% 45% 50% 39% 56% 48% 40% SUD Remission Rates are BETTER than many other DSM Diagnoses Median of 8 to 9 years in recovery 9

10 People Entering Publicly Funded Treatment Generally Use For Decades P e r c e n t s t i l l u s i n g Years from first use to 1+ years of abstinence Source: Dennis et al., % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% It takes 27 years before half reach 1 or more years of abstinence or die

11 Percent still using Years from first use to 1+ years of abstinence under 15* Age of First Use Source: Dennis et al., % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 60% longer The Younger They Start, The Longer They Use * p<.05

12 Percent still using Years from first use to 1+ years of abstinence Years to first Treatment Admission* Source: Dennis et al., % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 20 or more years 0 to 9 years 10 to 19 years 57% quicker The Sooner They Get To Treatment, The Quicker They Get To Abstinence * p<.05

13 After Initial Treatment… Relapse is common, particularly for those who: – Are Younger – Have already been to treatment multiple times – Have more mental health issues or pain It takes an average of 3 to 4 treatment admissions over 9 years before half reach a year of abstinence Yet over 2/3rds do eventually abstain Treatment predicts who starts abstinence Self help engagement predicts who stays abstinent Source: Dennis et al., 2005, Scott et al 2005

14 * p<.05 The Likelihood of Sustaining Abstinence Another Year Grows Over Time 36% 66% 86% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 to 12 months1 to 3 years4 to 7 years Duration of Abstinence* % Sustaining Abstinence Another Year. After 1 to 3 years of abstinence, 2/3rds will make it another year After 4 years of abstinence, about 86% will make it another year Source: Dennis, Foss & Scott (2007) Only a third of people with 1 to 12 months of abstinence will sustain it another year But even after 7 years of abstinence, about 14% relapse each year 14

15 Source: Dennis, Foss & Scott (2007) What does recovery look like on average? Duration of Abstinence 1-12 Months 1-3 Years 4-7 Years More social and spiritual support Better mental health Housing and living situations continue to improve Dramatic rise in employment and income Dramatic drop in people living below the poverty line Virtual elimination of illegal activity and illegal income Better housing and living situations Increasing employment and income More clean and sober friends Less illegal activity and incarceration Less homelessness, violence and victimization Less use by others at home, work, and by social peers 15

16 Sustained Abstinence Also Reduces The Risk of Death* Source: Scott, Dennis, Laudet, Funk & Simeone (in press) - Users/Early Abstainers more likely to die in the next 12 months The Risk of Death goes down with years of sustained abstinence It takes 4 or more years of abstinence for risk to get down to community levels (Matched on Gender, Race & Age) Deaths in the next 12 months * p<.05

17 Other factors related to death rates Death is more likely for those who – Are older – Are engaged in illegal activity – Have chronic health conditions – Spend a lot of time in and out of hospitals – Spend a lot of time in and out of substance abuse treatment Death is less common for those who – Have a greater percent of time abstinent – Have longer periods of continuous abstinence – Get back to treatment sooner after relapse Source: Scott, Dennis, Laudet, Funk & Simeone (2011)

18 The Cyclical Course of Relapse, Incarceration, Treatment and Recovery (Pathway Adults) In the Community Using (53% stable) In Treatment (21% stable) In Recovery (58% stable) Incarcerated (37% stable) 6% 28% 13% 30% 8% 25% 31% 4% 44% 7% 29% 7% Treatment is the most likely path to recovery P not the same in both directions Over half change status annually Source: Scott, Dennis, & Foss (2005)

19 Source: Scott, Dennis, & Foss (2005) Predictors of Change Also Vary by Direction In the Community Using (53% stable) In Recovery (58% stable) 28% 29% Probability of Sustaining Abstinence - times in treatment (0.83) + Female (1.72) - homelessness (0.61)+ ASI legal composite (1.19) - number of arrests (0.89)+ # of sober friend (1.22) + per 77 self help sessions (1.82) Probability of Transitioning from Using to Abstinence - mental distress (0.88)+ older at first use (1.12) -ASI legal composite (0.84) + homelessness (1.27) + # of sober friend (1.23) + per 8 weeks in treatment (1.14)

20 Summary of Key Points Addiction is a brain disorder with the highest risk being during the period of adolescent to young adult brain development Addiction is chronic in the sense that it often lasts for years, the risk of relapse is high, and multiple interventions are likely to be needed Yet over two thirds of the people with addiction do achieve recovery Treatment increases the likelihood of transitioning from use to recovery Self help, peers and recovery environment help predict who stays there Recovery is broader than just abstinence

21 Part 2. The Need and Value of Standardized Screening

22 To show the large gap between need for and receipt of substance abuse treatment To demonstrate the feasibility, validity and usefulness of low cost screening to identify substance use and co-occurring mental health, monitor placement, and predict the risk of recidivism Science Learning Objectives

While Substance Use Disorders are Common, Treatment Participation Rates Are Low Source: SAMHSA National Survey On Drug Use And Health, 2010 [Computer file] Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Few Get Treatment: 1 in 20 adolescents, 1 in 18 young adults, 1 in 11 adults Much of the private funding is limited to 30 days or less and authorized day by day or week by week 23

Potential AOD Screening & Intervention Sites: Adolescents (age 12-17) Source: SAMHSA National Survey On Drug Use And Health, 2010 [Computer file] 24

Potential AOD Screening & Intervention Sites: Adults (age 18+) Source: SAMHSA National Survey On Drug Use And Health, 2010 [Computer file] 25

Adolescent Rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in WA State Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from Problems could be easily identified Virtually all Sub. Use co-occurring in school 26

Adult rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in WA State Lower than expected rates of SA in mental health & children’s admin Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from 27

Adolescent Client Validation of High Co-Occurring from GAIN Short Screener vs. Clinical Records by Setting in WA State Two-page measure closely approximated all found in the clinical record after the next 2 years Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from 28

Adult Client Validation of High Co-Occurring from GAIN Short Screener vs. Clinical Records by Setting in WA State Higher rate in clinical record in mental health and children’s administration (But that was past on “any use” vs. “abuse/dependence” and 2 years vs. past year) Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from 29

30 Where in the System are the Adolescents with Mental Health, Substance Abuse and Co-occurring? Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from School Assistance Programs (SAP) largest part of BH/MH system; 2 nd largest of SA & Co- occurring systems

Where in the System are the Adults with Mental Health, Substance Abuse and Co-occurring? Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from More Mental Health than Substance Abuse

32 Total Disorder Screener Severity by Level of Care: Adolescents Source: SAPISP 2009 Data and Dennis et al 2006 Residential Median= 10.5 Outpatient Median=6.0 Few missed (1/2-3%) About 30% of OP are in the high severity range more typical of residential About 41% of Resid are below 10 (more likely typical OP

33 Total Disorder Screener Severity by Level of Care: Adults Source: SAPISP 2009 Data and Dennis et al 2006 Residential Median= 8.5 (41% below) Outpatient Median=4.5 (29% at 10+) 10% of adult OP missed) Youth have to be more severe on average to access services

Any Illegal Activity in the Next Twelve Months by Intake Severity on Crime/Violence and Substance Disorder Screeners Source: CSAT 2010 Summary Analytic Dataset (n=20,982) 34

Predictive Power of Simple Screener Crime/ Violence Screener Substance Disorder Screener 12 Month Recidivism Rate Odds Ratio \a Low (0) 17% 1.0 Low (0)Mod (1-2)29%2.0* Low (0)High (3-5)30%2.1* Mod (1-2)Low (0)30%2.1* Mod (1-2) 35%2.6* Mod (1-2)High (3-5)42%3.5* High (3-5)Low (0)41%3.4* High (3-5)Mod (1-2)55%6.0* High (3-5) 61%7.6* * p<.05 \a Odds of row (%/(1-%) over low/low odds across all groups Source: CSAT 2010 Summary Analytic Dataset (n=20,932) 35

36 Summary of Key Points There is a large gap between those getting treatment and those in need, ranging from 1-20 adolescents to 1 in 11 adults The people in need are coming into contact with a range of systems that could serve as screening sites where problems could be identified and addressed before people end up in the courts Simple Screening tools are feasible, valid and useful to identify substance use disorders, co-occurring behavioral health, monitor placement and predict the risk of recidivism

37 Part 3. What works in Treatment?

38 Define what we mean by treatment Hand out NIDA handbook on the Principals of Addiction Treatment in the Justice System Identify the key predictors of effectiveness Highlight some of the serious limitations and problems of the current public treatment Science Learning Objectives

39 What is Treatment? Motivational Interviewing and other protocols to help them understand how their problems are related to their substance use and that they are solvable Residential, IOP and other types of structured environments to reduce short term risk of relapse Detoxification and medication to reduce pain/risk of withdrawal and relapse, including tobacco cessation Evaluation of antecedents and consequences of use Community Reinforcement Approaches (CRA) Relapse Prevention Planning Cognitive Behavioral Therapy (CBT) Proactive urine monitoring Motivational Incentives / Contingency Management Access to communities of recovery for long term support, including 12-step, recovery coaches, recovery schools, recovery housing, workplace programs Continuing care, phases for multiple admission

40 Other Specific Services that are Screened for and Needed by People in Treatment: Trauma, suicide ideation, and para-suicidal behavior Child maltreatment and domestic violence interventions (not just reporting protocols) Psychiatric services related to depression, anxiety, ADHD/Impulse control, conduct disorder/ ASPD/ BPD, Gambling Anger Management HIV Intervention to reduce high risk pattern of behavior (sexual, violence, & needle use) Tobacco cessation Family, school and work problems Case management and work across multiple systems of care and time

41 Number of Problems by Level of Care (Triage) * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824) Clients entering Short Term Residential (usually dual diagnosis) have 5.5 times higher odds of having 5+ major problems*

42 No. of Problems* by Severity of Victimization Severity of Victimization * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824) Those with high lifetime levels of victimization have 13 times higher odds of having 5+ major problems*

43 Components of Comprehensive Drug Addiction Treatment Recommended by NIDA

44 Two Key Resources Available from NIDA ( )

45 Major Predictors of Bigger Effects 1. A strong intervention protocol based on prior evidence 2. Quality assurance to ensure protocol adherence and project implementation 3. Proactive case supervision of individual 4. Triage to focus on the highest severity subgroup

46 Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice Studies in Lipsey Meta Analysis Source: Adapted from Lipsey, 1997, 2005 Average Practice The more features, the lower the recidivism

47 Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing Juvenile Recidivism (29% vs. 40%) Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving MET/CBT combinations and Other manualized CBT Multisystemic Therapy (MST) Functional Family Therapy (FFT) Multidimensional Family Therapy (MDFT) Adolescent Community Reinforcement Approach (ACRA) Assertive Continuing Care Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004 NOTE: There is generally little or no differences in mean effect size between these brand names

48 Impact of Simple On-site Urine Protocol with Feedback On False Negative Urines Source: Scott & Dennis (in press) On-site Urine Feedback Protocol associated with Lower False Negatives (19 v 3%)

49 Implementation is Essential ( Reduction in Recidivism from.50 Control Group Rate) The effect of a well implemented weak program is as big as a strong program implemented poorly The best is to have a strong program implemented well Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005

Less than half stay the 90 or more days Recommended by Research Source: Office of Applied Studies 2007Discharge – Treatment Episode Data Set (TEDS) 50

Less than Half are Positively Discharged Source: Office of Applied Studies 2007 Discharge – Treatment Episode Data Set (TEDS) Transfer rates from higher levels of care are dismal 51

52 Programs often LACK Evidenced Based Assessment to Identify and Practices to Treat: Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidal thoughts) Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime) HIV risk behaviors (needle use, sexual risk, victimization) Child maltreatment (physical, sexual, emotional) Recovery environment and peer risk

53 Summary of Key Points Over half the people present to substance abuse treatment with 5 or more overlapping problems that require a range of interventions The best predictors of outcome are the use of evidenced based assessment and practice that have worked for others, have strong quality assurance, strong case supervision, and good triage of services to well defined problems. Conversely, the lack of evidenced based assessment, treatment practices and resources leads to high drop out

54 Part 4. What makes Drug Treatment Courts Effective?

55 Describe rational and key components associated with Drug Treatment Court Success Evaluate the state of the evidence on the effectiveness of drug treatment courts Highlight the most recent findings on the effectiveness of juvenile treatment drug courts (JTDC) in general versus the more comprehensive/ trauma focused Reclaiming Futures JTDC Science Learning Objectives

Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 in 2009 dollars The Cost of Treatment Episode vs. Consequences $22,000 / year to incarcerate an adult $30,000/ child-year in foster care $70,000/year to keep a child in detention $750 per night in Medical Detox $1,115 per night in hospital $13,000 per week in intensive care for premature baby $27,000 per robbery $67,000 per assault SBIRT models popular due to ease of implementation and low cost 56

Return on Investment (ROI) 57 Source: Bhati et al., (2008); Ettner et al., (2006) This also means that for every dollar treatment is cut, it costs society more money than was saved within the same year Substance abuse treatment has been shown to have a ROI within the year of between $1.28 to $7.26 per dollar invested Best estimates are that Treatment Drug Courts have an average ROI of $2.14 to $2.71 per dollar invested 57

Key Components Adult & Juvenile Treatment Drug Courts 1. Formal screening process for early identification and referral for substance use and other disorders/needs 2. Multidimensional standardized assessment to guide clinical decision-making related to diagnosis, treatment planning, placement and outcome monitoring 3. Interdisciplinary-treatment drug court team 4. Comprehensive non-adversarial team-developed treatment plan, including youth and family 5. Continuum of substance-abuse treatment and other rehabilitative services to address the youths needs 6. Use of evidence-based treatment practices 58

6. Monitoring progress through urine screens and weekly interdisciplinary-treatment drug court team staffings 7. Feedback to the judge followed by graduated performance-based rewards and sanctions 8. Reducing judicial involvement from weekly to monthly with evidence of favorable behavior change over a year or longer 9. Advanced agreement between parties on how on assessment information will be used to avoid self- incrimination 10. Use of information technology to connect parties and proactively monitor implementation at the client and program level Source: National Association of Drug Court Professionals, 1997; Henggeler et al., 2006; Ives et al., Key Components Treatment Drug Court (cont.) 59

Level of Evidenced is Available on Drug Treatment Courts Meta Analyses of Experiments/ Quasi Experiments (Summary v Predictive,Specificity, Replicated, Consistency) Dismantling/ Matching study (What worked for whom) Experimental Studies (Multi-site, Independent, Replicated, Fidelity, Consistency) Quasi-Experiments (Quality of Matching, Multi- site, Independent, Replicated, Consistency) Pre-Post (multiple waves), Expert ConsensusCorrelation and Observational studiesCase Studies, Focus GroupsPre-data Theories, Logic ModelsAnecdotes, Analogies Beyond a Reasonable Doubt Clear and Convincing Evidence Preponderance of the Evidence Probable Cause Reasonable Suspicion Law Science STRONGER Source: Marlowe 2008, Ives et al

Meta Analyses of Experiments/ Quasi Experiments (Summary v Predictive,Specificity, Replicated, Consistency) Dismantling/ Matching study (What worked for whom) Experimental Studies (Multi-site, Independent, Replicated, Fidelity, Consistency) Quasi-Experiments (Quality of Matching, Multi- site, Independent, Replicated, Consistency) Pre-Post (multiple waves), Expert ConsensusCorrelation and Observational studiesCase Studies, Focus GroupsPre-data Theories, Logic ModelsAnecdotes, Analogies Beyond a Reasonable Doubt Clear and Convincing Evidence Preponderance of the Evidence Probable Cause Reasonable Suspicion Law Science STRONGER Source: Marlowe 2008, Ives et al 2010 Adult Drug Treatment Courts: 5 meta analyses of 76 studies found crime reduced 7-26% with $1.74 to $6.32 return on investment Juvenile Drug Treatment Courts – one 2006 experiment, one 2010 large multisite quasi- experiment, & several small studies with similar or better effects than regular adolescent outpatient treatment DWI Treatment Courts: one quasi experiment and five observational studies positive findings Family Drug Treatment Courts: one multisite quasi experiment with positive findings for parent and child 61 Level of Evidenced is Available on Drug Treatment Courts

Change in Days of Abstinence* * Days of abstinence from alcohol and other drugs while living in the community; If coming from detention at intake, based on the 90 days before detention. \a p<.05 that post minus pre change is statistically significant \b p<.05 that change for Reclaiming Futures JTDC is better than the average for other JTDC Source: CSAT 2010 SA Data Set subset to 1+ Follow ups 62

Change in Days of Victimization* *Number of days victimized (physically, sexually, or emotionally ) in past 90 \a p<.05 that post minus pre change is statistically significant CSAT 2010 SA Data Set subset to 1+ Follow ups 63

Change in Average Number of Crimes Reported \a p<.05 that post minus pre change is statistically significant \b p<.05 that change for Reclaiming Futures JTDC is better than the average for other JTDC CSAT 2010 SA Data Set subset to 1+ Follow ups 64

Change in Average Number of Crimes Reported by Type* *Sum of all crimes reported by type \a p<.05 that post minus pre change is statistically significant \b p<.05 that change for Reclaiming Futures JTDC is better than the average for other JTDC CSAT 2010 SA Data Set subset to 1+ Follow ups 65

Change in Cost of Crime to Society* *Based on the frequency of crime times the average cost to society of that crime estimated by McCollister et al (2010) in 2010 dollars; distribution capped at 99 th percentile to minimize the impact of outliers.. \a p<.05 that post minus pre change is statistically significant \b p<.05 that change for Reclaiming Futures JTDC is better than the average for other JTDC CSAT 2010 SA Data Set subset to 1+ Follow ups 66

Return on Investment \a Based on change in youth reported cost of service utilization and other short term costs; DOES NOT include other real costs for implementing JTDC and/or RF-JTDC model and is therefor likely an underestimate \b Based on the frequency of crime times the average cost to society of that crime estimated by McCollister et al (2010) in 2010 dollars; distribution capped at 99 th percentile to minimize the impact of outliers.. CSAT 2010 SA Data Set subset to 1+ Follow ups Other JTDCRF-JTDC Increased Cost of Service Utilization\a + $1,673+ $4,022 Reduced Cost of Crime to Society\b - $67,449- $310,202 Return on Investment 40 to 177 to 1 67

68 Summary of Key Points Comprehensive, integrated, and collaborative drug courts are generally more effective While they are often small and cost more in services, drug treatment courts can produce high returns on investment relative to reduced costs to society More comprehensive models (like Reclaiming Futures) that focused on evidenced based assessment and treatment and providing more trauma/mental health services cost more but work even better and have even higher rates of return.

Other Resources you can use now Cost-Effective evidence-based practices A-CRA & MET/CBT tracks here, more at or Most withdrawal symptoms appeared more appropriate for ambulatory/outpatient detoxification, see Trauma informed therapy and sucide prevention at and Externalizing disorders medication & practices Tobacco cessation protocols for youth o_cessation/index.htm o_cessation/index.htm HIV prevention with more focus on sexual risk and interpersonal victimization at or For individual level strengths see For improving customer services 69

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