1. Keith Humphreys Professor of Psychiatry, Stanford University Visiting Professor of Psychiatry, Kings College London Research Career Scientist, VA Health Care System knh@stanford.edu Presented at 2012 NDASG, Llandrindod Wells, Wales

3. Public Safety Threats Stemming from Alcohol/Drug Use Street Violence Driving while Impaired Spousal Battering and Child Abuse Home Invasion, Property Theft Mass Transit Accidents Substandard or Reckless Medical Practice

4. Criminologist James Q. Wilsons analogy for how we respond to criminal offenders

5. New paradigm Traditional ParadigmNew Paradigm Make rules complex and covertMake rules simple and transparent Assume long-term orientation in offenderAssume short-term orientation in offender Punish unpredictablyPunish with certainty Punish harshlyPunish proportionately Punish slowlyPunish swiftly Use Imprisonment indiscriminantlyEmploy behavioral triage to reserve prison for appropriate offenders Mandate treatment, hope for abstinenceMandate abstinence, offer treatment

6. Exemplars of the New Paradigm Physician Health Plans HOPE Probation 24/7 Sobriety

8. Physician Health Plans Rate of physician addiction equal to general population Historically, doctors could get away with it until an undeniable catastrophe occurred PHPs designed to change this through intensive monitoring

9. Content of PHP Can temporarily or permanently remove license Not treatment, though they arrange treatment All conditions specified in a contract Comprehensive, random drug and alcohol testing Immediate, graduated reaction to positive test

10. Outcome Data on 802 Physicians over five years 80.7% (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.

12. The World of Probation Low social capital offenders More serious co-occurring problems Overwhelmed staff Unclear rules, inconsistent rewards and punishments

13. HOPE Probation for Drug- involved offenders in Hawaii All 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 Inexpensive because it reduces return to prison

14. Randomized evaluation of HOPE Included all probation officers, average caseload 87 clients, average years of experience 4.3 years 493 Felony Probationers, average 17 prior arrests Primary drug: Crystal meth

15. Major 1-year trial findings of HOPE versus usual probation 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.

17. Drink drivers in the U.S. Northern Plains Over 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

18. 24/7 Sobriety for repeat drink drivers in South Dakota All 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

19. Alcohol-Impaired Motor Vehicle Fatalities/Vehicle Miles Traveled Source: U.S. National Highway Safety and Transportation Agency

20. Other key data points on 24/7 Over 99% of tests collected are negative 66% of offenders have perfect compliance Recidivism rates less than half of non-24/7 offenders

21. In summary, all three programs Give offenders simple, transparent rules, which encourages responsibility and a sense of fairness Use swift, certain and modest consequences Mandate abstinence for all, treatment or prison only as appropriate Have evidence of effectiveness and of cost- effectiveness

22. Political Process Came to attention of Scottish VRU and London Deputy Mayor Attracted Cross-Party interest in Parliament Passed as Amendment in House of Lords in March Law of the England and Wales as of May 1

23. What does the success of these programmes tell us about drink problems? The Role of Treatment in Problem Resolution The Role of Self-Control in Drinking Cant versus Wont versus Its Hard

24. Thank you for your attention!