Benjamin R. Nordstrom


Alcohol Medical Scholars Program



I.                   Overview (SLIDE 2)


A.    Drug use and crime are associated

B.     Drug use in crime

C.     No perfect way to manage this relationship

D.    Drug courts are relatively new approach

                                                            1.      Alternative method to manage drug-using offenders

                                                            2.      Incorporate substance use disorder (SUD) treatment

E.     This lecture will cover (SLIDE 3)

                                                            1.      Relationships between drugs and crime

                                                            2.      Effect of SUD treatment on crime

                                                            3.      How drug courts work

                                                            4.      Data showing they work well (SLIDE 3,4)

                                                            5.      Willie Nelson (SLIDE 5)

a.       Arrested for cannabis possession in 1974, 1994, and 2006.

b.      In 11/2010 he was arrested again

II.                Case Study (SLIDE 6)

A.    Mr. N 29 year old single man from Lebanon, NH

B.     SUD history +

                                                            1.      10 year history of cannabis dependence

                                                            2.      5 year history of cocaine dependence and alcohol dependence

C.     Arrested after

                                                            1.      Stealing AV equipment from a van

                                                            2.      Caught with 5 g cocaine

D.    Charged with grand larceny and possession of cocaine with intent to distribute (both felonies), potential for 3 years in prison

E.     No criminal history before his cocaine use disorder

III.             Drugs and Crime

A.    Illicit drug use is common in US

                                                            1.      22.5 million current drug-users [1]

                                                            2.      9% of population overall

B.     So are repetitive drug problems: SUD definition (SLIDE 7)

                                                            1.      Abuse: 1+ of following in same 12 months related to the substance

a.       Interpersonal problems

b.      Failure to live up to obligations

c.       Legal problems

d.      Substance used in hazardous situations

e.       Absence of lifetime dependence on that substance

                                                            2.      Dependence: 3+ in same 12 months for that substance (SLIDE 8)

a.       Withdrawal

b.      Tolerance

c.       Loss of control over amount used

d.      Increasing amount of time spent pursuing substance

e.       Unsuccessful attempts to quit or cut down on use

f.       Activities given up

g.      Use persists despite negative med or psych consequences

C.     Prevalence of SUDs (illicit drugs only) (SLIDE 9)

                                                            1.      3.9 million in USA have current abuse or dependence [1]

                                                            2.      Lifetime prevalence for SUD is 3% [2]

D.    Societal costs of illicit drug use/ problems are high

                                                            1.      U.S. $180 billion a year [3]

                                                            2.      Direct costs of crime: greatest cost of SUD [4]

                                                            3.      $30 billion of $38 billion for corrections are SUD-related [5]

E.     Are 3 types of drug-related crimes [6] (SLIDE 10)

                                                            1.      Acquisitive crime: get $ to buy drugs

a.       18% federal prisoners: crime to get drugs [7]

b.      17% state prisoners: crime to get drugs [7]

1. 30% incarcerated for property crimes

2. 11% incarcerated for violent crimes [8]

c.       25% county prisoners: crime to get drugs [9]

d.      These cause huge costs for prisons

                                                            2.      Distributive crime: associated with the sale of drugs (SLIDE 11)

a.       2011, drug violations = 12% of 12 million arrests [10]

1. 82% for drug possession

2. 18% for drug sale/ manufacture

b.      4 % of homicides drug related [11]

                                                            3.      Behavioral toxicity crimes: intoxication-related behavior (SLIDE 12)

F.      Do drugs crime or crime drugs?

                                                            1.      Most studies: drug use crime (more detail below)

                                                            2.      Drug using offenders have (SLIDE 13)

a.       15 x drug crime when using illegal drugs

b.      54% commit a property crime

c.       100% commit assault when drugs used [12]

                                                            3.      The more drugs used, the more crimes [13]

                                                            4.      88% crimes by drug offenders in periods of substance use [14]

                                                            5.      So, drug use should crime (SLIDE 14)

IV.             Drug Treatment Does Reduce Crime (SLIDE 15)

A.    Opioid Treatment (methadone maintenance) Programs crimes

                                                            1.      Long acting opiate [methadone] taken daily to street drug use

                                                            2.      So no longer need seek heroin etc. to avoid withdrawal symptoms

                                                            3.      So can hold jobs and keep relationships

                                                            4.      Crime more with time in methadone program [15]

                                                            5.      Acquisitive crime 87% in first month of methadone Rx [16]

B.     Rx opioid blocker in opioid dependence crime

                                                            1.      Naltrexone blocks brain opioid receptors

                                                            2.      Blocks the high from street opioids (e.g. heroin)

                                                            3.      If cant get high, no reason to take street opioids

                                                            4.      Comparison naltrexone to treatment as usual (TAU):

a.       Naltrexone vs TAU opioid + urine tests (8% vs. 30%)

b.      Naltrexone vs TAU probation revoke (29% vs 56 %) [17]

C.     General SUD Rx s crime (SLIDE 16)

                                                            1.      Overall SUD treatment crime 66% in drug-using juvenile [18]

                                                            2.      Inpatient Rx

a.       75% acquisitive crime

b.      66% in drug selling [19]

                                                              3.      Overall, SUD treatment crime by 26 % [20] (SLIDE 17)

V.                How Drug Courts Work

A.    History (SLIDE 18)

                                                            1.      Began in the 1980s

                                                            2.      Time when drug offenders in the criminal justice system

                                                            3.      Now > 2000 drug courts in the US [21]

B.     What are drug courts? (SLIDE 19)

                                                            1.      Offer SUD treatment as an alternative to jail

                                                            2.      Rewards/ graduated sanctions recovery [22, 23]

                                                            3.      Two main types [23]

a.       Pre-plea

1. Program entered before plea entered

2. Successful completion dismissal of charges

b.      Post-plea

1. After guilty plea, sentence held in abeyance

2. Program completion no incarceration

C.     Team members (SLIDE 20)

                                                            1.      Judge

                                                            2.      Prosecutor (a.k.a. district attorney)

                                                            3.      Public defender (the accuseds attorney)

                                                            4.      Court clerk

                                                            5.      Program coordinator

                                                            6.      Case manager(s)

                                                            7.      Supervision (e.g. probation officers)

                                                            8.      Treatment providers

                                                            9.      Community representative

D.    Ten key components to drug courts [24] (SLIDE 21)

                                                            1.      Integrate alcohol/ drug Rx with justice system processing

                                                            2.      Non-adversarial approach, prosecution + defense 2 goals

a.       Promote public safety

b.      Protect offenders rights

                                                            3.      ID participants early; quickly divert their case

                                                            4.      Give continuum alcohol/ drug/ other Rx and rehabilitation

                                                            5.      Monitor abstinence by frequent alcohol/ drug testing

                                                            6.      Coordinate justice officials & Rx to ensure compliance (SLIDE 22)

                                                            7.      Ongoing judicial interaction: use can jail

                                                            8.      Monitor/evaluate progress toward program goals

                                                            9.      Offer continuing education for team members

                                                        10.      Forge partnerships: drug court/ public agencies (SLIDE 23)

VI.             Drug Courts Are Effective

A.    Drug courts reoffending

B.     Example: Maricopa County, AZ Experiment [25] (SLIDE 24)

                                                            1.      Randomized controlled trial (RCT) of 630 people

                                                            2.      12 months of drug court vs. 36 months of TAU

                                                            3.      Drug court vs TAU reincarceration (9% vs 23 %)

C.     Example: Superior Court Drug Intervention Program [26] (SLIDE 25)

                                                            1.      Compared 2 versions of drug court vs. TAU

                                                            2.      Randomly assigned 1,022 people to

a.       Weekly drug testing/ monitoring/ graduated sanction

b.      Court-based drug treatment with weekly drug testing

c.       TAU

                                                            3.      Both experimental groups had < drug use than TAU at 1 year (SLIDE 26)

                                                            4.      Graduated sanction vs TAU rearrest (19% vs 27%)

D.    Example: Baltimore City Drug Treatment Court Experiment [27-30] (SLIDE 27)

                                                            1.      Randomized 235 people to drug court or TAU

                                                            2.      At 1 year:

a.       Drug court vs TAU rearrest (48% vs. 64%)

b.      Drug court 3 x less likely than TAU to reoffend, after controlling for opportunity

                                                            3.      At 2 years: (SLIDE 28)

a.       Drug court vs TAU rearrest (66% vs. 81%)

b.      Drug court vs TAU # arrests (1.6 vs. 2.3)

c.       Drug court vs TAU # charges (3.1 vs. 4.6)

                                                            4.      At 3 years: (SLIDE 29)

a.       Drug court vs TAU # arrests (2 vs. 3)

b.      Drug court vs TAU # charges (4 vs. 6)

E.        Example: New South Wales Adult Drug Court [31] (SLIDE 30)

                                                            1.      Randomized 468 people to drug court or TAU

                                                            2.      Drug court vs TAU frequency of drug offenses/ 2 years (0.08 vs. 0.62)

                                                            3.      Logistic regression

a.       increases time to re-offense

b.      decreases frequency of offending for drug, theft, larceny and possession charges.

F.      Meta-analyses (SLIDE 31)

                                                            1.      Large reviews of drug court outcomes [32-34]

                                                            2.      All show drug courts recidivism

                                                            3.      Overall drug courts recidivism 26% [32]

G.    Drug courts are cost effective (SLIDE 32)

                                                            1.      Federal report: drug courts save up to $47K per participant [35]

                                                            2.      Kentucky study: [36]

a.       Saved $3.83 for each $1 spent

b.      Even drop-outs saved $1.13 for $1 spent

                                                            3.      Maryland study- saved $5 for each $1 spent [37]

                                                            4.      If include crime costs, save up to $150,000 per person [38]

VII.          Case Study Revisited (SLIDE 33)

A.    Willlie Nelson

                                                            1.      November 2010 arrested with 6 ounces of cannabis

                                                            2.      Was going to be fined <$500 and told to sing for court

                                                            3.      Not everyone gets this kind of treatment

B.     Mr. N. enrolls in the Grafton County Drug Treatment Court (SLIDE 34)

C.     The Grafton County Drug Treatment Court

                                                            1.      Founded in 2007

                                                            2.      Only non-violent felonies considered

                                                            3.      Post-plea model

                                                            4.      Team consists of (SLIDE 35)

a.       Coordinator

b.      Clinical evaluator

c.       Case manager

d.      Supervision- 3 corrections officers

e.       County attorney (prosecutor)

f.       Public defender

g.      Judge

h.      Court Clerk

i.        Community Representative

                                                            5.      Referral to community-based SUD treatment

                                                            6.      Use graduated sanctions and incentives

a.       Brief incarcerations

b.      Chips for services e.g. gym memberships

                                                            7.      18-24 months long depending on progress

                                                            8.      54% graduation rate

                                                            9.      Recidivism data for graduates since 2007

a.       15% by arrest

b.      4% by conviction

D.    Mr. N.s progress (SLIDE 36)

                                                            1.      A few bumps in the road early on

a.       Complying with supervision

b.      Once cocaine and one cannabis positive urine

                                                            2.      Integrated well into SUD treatment

a.       Residential (live in Rx, non-hospital based) first

b.      Then outpatient

                                                            3.      Mandated to get a job

a.       Steady work in retail

b.      Got his own place with earnings

                                                            4.      Used chips for gym membership

                                                            5.      Reinvolved with 3 year old daughter

                                                            6.      Graduated program at 18 months

                                                            7.      No further contact with the criminal justice system

VIII.       Conclusions (SLIDE 37)

A.    Drugs and crime are costly to society

B.     Drug use can drive crime, and drug treatment can reduce crime

C.     Drug courts: effective SUD Rx in criminal justice setting

D.    Drug courts crime and money (SILDE 38)




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