Douglas B. Marlowe, J.D., Ph.D. Treatment Research Institute at the University of Pennsylvania TRI science addiction Targeting Dispositions by Risks & Needs

Dispositions for Drug Offenders Diversion (ARD)Incarceration Probation w/o verdict Drug / DWI Courts Intermediate sanctions Psychosocial Functioning $$$$$$ Costs $$$$$$$$$ Public Safety Risks

Prognostic Risks TRI science addiction Current age < 25 yearsCurrent age < 25 years Delinquent onset < 16 yearsDelinquent onset < 16 years Substance abuse onset < 14 yearsSubstance abuse onset < 14 years Prior rehabilitation failuresPrior rehabilitation failures History of violenceHistory of violence Antisocial Personality DisorderAntisocial Personality Disorder PsychopathyPsychopathy Familial history of crime or addictionFamilial history of crime or addiction Criminal or substance abuse associationsCriminal or substance abuse associations

Criminogenic Needs Substance Dependence or Addiction Substance Dependence or Addiction TRI science addiction

Criminogenic Needs Substance Dependence or Addiction Substance Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms TRI science addiction

Criminogenic Needs Substance Dependence or Addiction Substance Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms TRI science addiction } Abstinence is a distal goal

Criminogenic Needs Substance Dependence or Addiction Substance Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms Substance Abuse TRI science addiction } Abstinence is a distal goal

Criminogenic Needs Substance Dependence or Addiction Substance Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms Substance Abuse TRI science addiction } Abstinence is a distal goal Abstinence is a proximal goal }

Criminogenic Needs Substance Dependence or Addiction Substance Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms Substance Abuse Collateral needs Collateral needs –Dual diagnosis –Chronic medical condition (e.g., HIV+, HCV, diabetes) –Homelessness, chronic unemployment TRI science addiction } Abstinence is a distal goal Abstinence is a proximal goal }

Criminogenic Needs Substance Dependence or Addiction Substance Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms Substance Abuse Collateral needs Collateral needs –Dual diagnosis –Chronic medical condition (e.g., HIV+, HCV, diabetes) –Homelessness, chronic unemployment TRI science addiction } Abstinence is a distal goal Abstinence is a proximal goal } } Regimen compliance is proximal

TRI science addiction High Risk Low Risk HighNeeds LowNeeds Risk & Needs Matrix

TRI science addiction High Risk Low Risk HighNeeds LowNeeds Accountability, Treatment & Habilitation

Risk & Needs Matrix TRI science addiction High Risk Low Risk HighNeeds LowNeeds Treatment&Habilitation Accountability, Treatment & Habilitation

Risk & Needs Matrix TRI science addiction High Risk Low Risk HighNeeds LowNeeds Accountability &Habilitation Treatment&Habilitation Accountability, Treatment & Habilitation

Risk & Needs Matrix TRI science addiction High Risk Low Risk HighNeeds LowNeeds Prevention Accountability &Habilitation Treatment&Habilitation Accountability, Treatment & Habilitation

Practice Implications TRI science addiction High Risk Low Risk HighNeeds LowNeeds Status hearings Status hearings Treatment & habilitation Treatment & habilitation Compliance is proximal Compliance is proximal Restrictive consequences Restrictive consequences Positive reinforcement Positive reinforcement Agonist medication Agonist medication Noncompliance hearings Noncompliance hearings Treatment & habilitation Treatment & habilitation Treatment is proximal Treatment is proximal Positive reinforcement Positive reinforcement Agonist medication Agonist medication v.o.p. / status calendar v.o.p. / status calendar Abstinence is proximal Abstinence is proximal Psychosocial habilitation Psychosocial habilitation Restrictive consequences Restrictive consequences No AA or MET No AA or MET Antagonist medication Antagonist medication Secondary prevention Secondary prevention Abstinence is proximal Abstinence is proximal No AA or MET No AA or MET Individual counseling Individual counseling or stratified groups or stratified groups

Dispositions for Drug Offenders Diversion (ARD)Incarceration Probation w/o verdict Drug / DWI Courts Intermediate sanctions Low risk Low needs Low risk High needs High risk High needs High risk Low needs Risk of Dangerousness

Ok, Mr. Big Shot... PROVE IT!

“Key Components” Judicial status hearings Graduated sanctions & rewards Urine drug screens Drug abuse treatment Case management Nolle prosse or conditions-served Expunged record (diversion) TRI science addiction (NADCP, 1997)

“Key Components” Judicial status hearings Graduated sanctions & rewards Urine drug screens Drug abuse treatment Case management Nolle prosse or conditions-served Expunged record (diversion) TRI science addiction (NADCP, 1997)

Matching Design TRI science addiction High RiskLow Risk Matched Unmatched Bi-Weekly (n = 42) As Needed (n = 95) As Usual (monthly) (n = 50)(n = 92)

% Drug-free Urines by Group TRI science addiction p <.001

% Drug-free Urines by Group TRI science addiction p <.001

% Drug-free Urines by Group TRI science addiction p <.001

% Drug-free Urines by Group TRI science addiction p <.001

Drug-Positive Urines: 6 Mos. TRI science addiction * * p <.05 * *

Graduation Rates: 12 mos. TRI science addiction * * p <.05 *

“Key Components” Judicial status hearings Graduated sanctions & rewards Urinalyses Drug abuse treatment Case management Nolle prosse or time served Expunged record (diversion) TRI science addiction (NADCP, 1997)

“Key Components” Judicial status hearings Graduated sanctions & rewards Urinalyses Drug abuse treatment Case management Nolle prosse or time served Expunged record (diversion) TRI science addiction (NADCP, 1997)

Months of compliance STANDARD REWARDS 1 Applause; hat / candle; framed certificate; travel Applause; keychain; ↓ certificate; ↓hearings & UA ↓ Applause; certificate; travel; ↓ hearings & UA Grad ceremony; framed plaque; dismissal Total Rewards

Months of compliance STANDARD REWARDS ESCALATING REWARDS 1 Applause; hat / candle; framed certificate; travel $5.00 gift certificate 2$10.00 gift certificate 3 $15.00 gift certificate 4 Applause; keychain; ↓ certificate; ↓hearings & UA $20.00 gift certificate 5 $25.00 gift certificate 6$30.00 gift certificate 7 $35.00 gift certificate 8 ↓ Applause; certificate; travel; ↓ hearings & UA $40.00 gift certificate 9 $45.00 gift certificate 10$50.00 gift certificate 11$55.00 gift certificate 12 Grad ceremony; framed plaque; dismissal $60.00 gift certificate Total $ Rewards

Months of compliance STANDARD REWARDS ESCALATING REWARDS THINNING REWARDS 1 Applause; hat / candle; framed certificate; travel $5.00 gift certificate $30.00 gift certificate 2$10.00 gift certificate $30.00 gift certificate 3 $15.00 gift certificate $30.00 gift certificate 4 Applause; keychain; ↓ certificate; ↓hearings & UA $20.00 gift certificate Eligible for $50.00 gift certificate if compliant one additional month 5 $25.00 gift certificate $50.00 gift certificate 6$30.00 gift certificate Eligible for $50.00 gift certificate if compliant one additional month 7 $35.00 gift certificate $50.00 gift certificate 8 ↓ Applause; certificate; travel; ↓ hearings & UA $40.00 gift certificate Eligible for $75.00 gift certificate if compliant one additional month 9 $45.00 gift certificate $75.00 gift certificate 10$50.00 gift certificate Eligible for $ gift certificate if compliant two additional months 11$55.00 gift certificate Eligible for $ gift certificate if compliant one additional month 12 Grad ceremony; framed plaque; dismissal $60.00 gift certificate $ gift certificate Total $ Rewards

# Drug-Free Urines (13 mos.) TRI science addiction n=61n=60n=60 p = n.s.

Mean % Sessions Attended TRI science addiction n=61n=60n=60 p = n.s.

Mean % Drug-Free Urines TRI science addiction *p <.05 n=34 n=29 n=34 n=29 n=26 n=24

Remaining Concerns Measurement errorMeasurement error DissimulationDissimulation Treatment needs vs. supervision needsTreatment needs vs. supervision needs Changing circumstancesChanging circumstances Non-compliance vs. non-responsivenessNon-compliance vs. non-responsiveness Individualized vs. standard responsesIndividualized vs. standard responses

ADAPTIVE INTERVENTION

Baseline Risk Assessment

ADAPTIVE INTERVENTION Baseline Risk Assessment BI-WEEKLY COURT HEARINGS High Risk

ADAPTIVE INTERVENTION AS-NEEDED COURT HEARINGS Baseline Risk Assessment BI-WEEKLY COURT HEARINGS High Risk Low Risk

ADAPTIVE INTERVENTION Monthly Progress Assessments AS-NEEDED COURT HEARINGS Baseline Risk Assessment BI-WEEKLY COURT HEARINGS High Risk Low Risk

ADAPTIVE INTERVENTION Monthly Progress Assessments AS-NEEDED COURT HEARINGS Baseline Risk Assessment BI-WEEKLY COURT HEARINGS High Risk Low Risk NON-COMPLIANT   ≥ 2 missed counseling sessions and/or   ≥ 2 missed urine specimens

If As-Needed: BI-WEEKLY COURT HEARINGS ADAPTIVE INTERVENTION Monthly Progress Assessments AS-NEEDED COURT HEARINGS Baseline Risk Assessment BI-WEEKLY COURT HEARINGS High Risk Low Risk NON-COMPLIANT   ≥ 2 missed counseling sessions and/or   ≥ 2 missed urine specimens

If As-Needed: BI-WEEKLY COURT HEARINGS ADAPTIVE INTERVENTION If Bi-Weekly: JEOPARDY CONTRACT Monthly Progress Assessments AS-NEEDED COURT HEARINGS Baseline Risk Assessment BI-WEEKLY COURT HEARINGS High Risk Low Risk NON-COMPLIANT   ≥ 2 missed counseling sessions and/or   ≥ 2 missed urine specimens

If As-Needed: BI-WEEKLY COURT HEARINGS ADAPTIVE INTERVENTION If Bi-Weekly: JEOPARDY CONTRACT Monthly Progress Assessments AS-NEEDED COURT HEARINGS Baseline Risk Assessment BI-WEEKLY COURT HEARINGS High Risk Low Risk NON-COMPLIANT   ≥ 2 missed counseling sessions and/or   ≥ 2 missed urine specimensNON-RESPONSIVE   ≥ 2 drug-positive urines

If As-Needed: BI-WEEKLY COURT HEARINGS ADAPTIVE INTERVENTION INTENSIVE CLINICAL CASE MANAGEMENT If Bi-Weekly: JEOPARDY CONTRACT Monthly Progress Assessments AS-NEEDED COURT HEARINGS Baseline Risk Assessment BI-WEEKLY COURT HEARINGS High Risk Low Risk NON-COMPLIANT   ≥ 2 missed counseling sessions and/or   ≥ 2 missed urine specimensNON-RESPONSIVE   ≥ 2 drug-positive urines

If As-Needed: BI-WEEKLY COURT HEARINGS ADAPTIVE INTERVENTION INTENSIVE CLINICAL CASE MANAGEMENT If Bi-Weekly: JEOPARDY CONTRACT Monthly Progress Assessments AS-NEEDED COURT HEARINGS Baseline Risk Assessment BI-WEEKLY COURT HEARINGS High Risk Low Risk NON-COMPLIANT   ≥ 2 missed counseling sessions and/or   ≥ 2 missed urine specimensNON-RESPONSIVE   ≥ 2 drug-positive urines RESPONSIVE & COMPLIANT

If As-Needed: BI-WEEKLY COURT HEARINGS ADAPTIVE INTERVENTION INTENSIVE CLINICAL CASE MANAGEMENT If Bi-Weekly: JEOPARDY CONTRACT CONTINUE AS PREVIOUSLY ASSIGNED Monthly Progress Assessments AS-NEEDED COURT HEARINGS Baseline Risk Assessment BI-WEEKLY COURT HEARINGS High Risk Low Risk NON-COMPLIANT   ≥ 2 missed counseling sessions and/or   ≥ 2 missed urine specimensNON-RESPONSIVE   ≥ 2 drug-positive urines RESPONSIVE & COMPLIANT

If As-Needed: BI-WEEKLY COURT HEARINGS ADAPTIVE INTERVENTION INTENSIVE CLINICAL CASE MANAGEMENT RESPONSIVE & COMPLIANT NON-RESPONSIVE   ≥ 2 drug-positive urines If Bi-Weekly: JEOPARDY CONTRACT CONTINUE AS PREVIOUSLY ASSIGNED Monthly Progress Assessments AS-NEEDED COURT HEARINGS Baseline Risk Assessment Low Risk High Risk BI-WEEKLY COURT HEARINGS NON-COMPLIANT   ≥ 2 missed counseling sessions and/or   ≥ 2 missed urine specimens

Graduated: 20 Weeks p =.14 ES = 0.6 (moderate) n=6n=6n=10n=16n=8n=14

On Warrant Status p =.27 ES = 0.4 (moderate) n=6n=6n=10n=16n=8n=14

% Drug-Free Urines p =.28 ES = 0.4 (moderate) n=6n=6n=10n=16n=8n=14

Ultimately Graduated p =.43 ES = 0.12 (small)

Days to Graduation (73.75) (168.93) p =.03 ES = 0.92 (large)

Days to Case Resolution (74.74) (194.18) p =.01 ES = 0.96 (large)

Response Ordered

Days to a Response

Cost Implications Avg. annual cost per participant *Avg. annual cost per participant * – administration = $ 4, – outpatient treatment = +$ 7, $11, Resolution in 4 fewer mos. ÷ 1/3 yr.Resolution in 4 fewer mos. ÷ 1/3 yr. Potential costs savings = $ 3,700.00Potential costs savings = $ 3, * Urban Institute, 2008

Cost Implications Avg. annual cost per participant *Avg. annual cost per participant * – administration = $ 4, – outpatient treatment = +$ 7, $11, Resolution in 4 fewer mos. ÷ 1/3 yr.Resolution in 4 fewer mos. ÷ 1/3 yr. Potential costs savings = $ 3,700.00Potential costs savings = $ 3, Per participant per year! * Urban Institute, 2008

Summary One size does not fit allOne size does not fit all Drug courts are best suited for high risk and high needs offendersDrug courts are best suited for high risk and high needs offenders When possible, separate court calendars and treatment tracks should be held for high risk vs. low risk clientsWhen possible, separate court calendars and treatment tracks should be held for high risk vs. low risk clients You may need to be nicest to the clients you might like the leastYou may need to be nicest to the clients you might like the least TRI science addiction

Summary (cont.) Adaptive algorithms consistently outperform individualized professional judgmentAdaptive algorithms consistently outperform individualized professional judgment Better outcomes in less timeBetter outcomes in less time Time = $$$$!Time = $$$$!

References TRI science addiction Marlowe, DB et al. (2008). Adaptive interventions in drug court: A pilot experiment. Criminal Justice Review, 33, Marlowe, DB et al. (in press). Adaptive interventions may optimize outcomes in drug courts: A pilot study. Current Psychiatry Reports. Marlowe, DB et al. (2007). Adapting judicial supervision to the risk level of drug offenders: Discharge and six-month outcomes from a prospective matching study. Drug & Alcohol Dependence, 88S, Marlowe, DB et al. (2006). Matching judicial supervision to clients’ risk status in drug court. Crime & Delinquency, 52,

Acknowledgment National Institute on Drug Abuse National Institute on Drug Abuse Grant #R01-DA-13096