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Douglas B. Marlowe, J.D., Ph.D.
Treatment Research Institute at the
University of Pennsylvania
TRIscience
addiction
Targeting Targeting Dispositions by Risks Dispositions by Risks
& Needs & Needs
Dispositions for Drug Dispositions for Drug OffendersOffenders
Diversion (ARD) Incarceration
Probation w/o verdict
Drug / DWI Courts
Intermediatesanctions
Psychosocial Psychosocial FunctioningFunctioning
$$$$$$ Costs $$$$$$$$
$$$$$$ Costs $$$$$$$$
$$Public Safety
Public Safety RisksRisks
Prognostic RisksPrognostic Risks
TRIscience
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 NeedsCriminogenic Needs
Substance Dependence or AddictionSubstance Dependence or Addiction
TRIscience
addiction
Criminogenic NeedsCriminogenic Needs
Substance Dependence or AddictionSubstance Dependence or Addiction1.1. Binge patternBinge pattern2.2. Cravings or compulsionsCravings or compulsions3.3. Withdrawal symptomsWithdrawal symptoms
TRIscience
addiction
Criminogenic NeedsCriminogenic Needs
Substance Dependence or AddictionSubstance Dependence or Addiction1.1. Binge patternBinge pattern2.2. Cravings or compulsionsCravings or compulsions3.3. Withdrawal symptomsWithdrawal symptoms
TRIscience
addiction
} Abstinence is a distal goal
Criminogenic NeedsCriminogenic Needs
Substance Dependence or AddictionSubstance Dependence or Addiction1.1. Binge patternBinge pattern2.2. Cravings or compulsionsCravings or compulsions3.3. Withdrawal symptomsWithdrawal symptoms
Substance AbuseSubstance Abuse
TRIscience
addiction
} Abstinence is a distal goal
Criminogenic NeedsCriminogenic Needs
Substance Dependence or AddictionSubstance Dependence or Addiction1.1. Binge patternBinge pattern2.2. Cravings or compulsionsCravings or compulsions3.3. Withdrawal symptomsWithdrawal symptoms
Substance AbuseSubstance Abuse
TRIscience
addiction
} Abstinence is a distal goal
Abstinence is a proximal goal}
Criminogenic NeedsCriminogenic Needs
Substance Dependence or AddictionSubstance Dependence or Addiction1.1. Binge patternBinge pattern2.2. Cravings or compulsionsCravings or compulsions3.3. Withdrawal symptomsWithdrawal symptoms
Substance AbuseSubstance Abuse
Collateral needsCollateral needs– Dual diagnosisDual diagnosis– Chronic medical condition (e.g., HIV+, HCV, diabetes)Chronic medical condition (e.g., HIV+, HCV, diabetes)– Homelessness, chronic unemployment Homelessness, chronic unemployment
TRIscience
addiction
} Abstinence is a distal goal
Abstinence is a proximal goal}
Criminogenic NeedsCriminogenic Needs
Substance Dependence or AddictionSubstance Dependence or Addiction1.1. Binge patternBinge pattern2.2. Cravings or compulsionsCravings or compulsions3.3. Withdrawal symptomsWithdrawal symptoms
Substance AbuseSubstance Abuse
Collateral needsCollateral needs– Dual diagnosisDual diagnosis– Chronic medical condition (e.g., HIV+, HCV, diabetes)Chronic medical condition (e.g., HIV+, HCV, diabetes)– Homelessness, chronic unemployment Homelessness, chronic unemployment
TRIscience
addiction
} Abstinence is a distal goal
Abstinence is a proximal goal}
} Regimen compliance is proximal
TRIscience
addiction
High RiskHigh Risk Low RiskLow Risk
High High NeedsNeeds
Low Low NeedsNeeds
Risk & Needs MatrixRisk & Needs Matrix
Risk & Needs MatrixRisk & Needs Matrix
TRIscience
addiction
High RiskHigh Risk Low RiskLow Risk
High High NeedsNeeds
Low Low NeedsNeeds
Accountability,Accountability,Treatment &Treatment &HabilitationHabilitation
Risk & Needs MatrixRisk & Needs Matrix
TRIscience
addiction
High RiskHigh Risk Low RiskLow Risk
High High NeedsNeeds
Low Low NeedsNeeds
TreatmentTreatment&&
HabilitationHabilitation
Accountability,Accountability,Treatment &Treatment &HabilitationHabilitation
Risk & Needs MatrixRisk & Needs Matrix
TRIscience
addiction
High RiskHigh Risk Low RiskLow Risk
High High NeedsNeeds
Low Low NeedsNeeds
AccountabilityAccountability&&
HabilitationHabilitation
TreatmentTreatment&&
HabilitationHabilitation
Accountability,Accountability,Treatment &Treatment &HabilitationHabilitation
Risk & Needs MatrixRisk & Needs Matrix
TRIscience
addiction
High RiskHigh Risk Low RiskLow Risk
High High NeedsNeeds
Low Low NeedsNeeds
PreventionPrevention AccountabilityAccountability
&&HabilitationHabilitation
TreatmentTreatment&&
HabilitationHabilitation
Accountability,Accountability,Treatment &Treatment &HabilitationHabilitation
Practice ImplicationsPractice Implications
TRIscience
addiction
High RiskHigh Risk Low RiskLow Risk
High High NeedsNeeds
Low Low NeedsNeeds
Status hearingsStatus hearings Treatment & habilitationTreatment & habilitation ComplianceCompliance is proximal is proximal Restrictive consequencesRestrictive consequences Positive reinforcementPositive reinforcement Agonist medicationAgonist medication
Noncompliance hearingsNoncompliance hearings Treatment & habilitationTreatment & habilitation TreatmentTreatment is proximal is proximal
Positive reinforcementPositive reinforcement Agonist medicationAgonist medication
v.o.p. / status calendarv.o.p. / status calendar AbstinenceAbstinence is proximal is proximal Psychosocial habilitationPsychosocial habilitation Restrictive consequencesRestrictive consequences NoNo AA or MET AA or MET Antagonist medicationAntagonist medication
Secondary prevention Secondary prevention AbstinenceAbstinence is proximal is proximal NoNo AA or MET AA or MET Individual counselingIndividual counseling oror stratified groups stratified groups
Dispositions for Drug Dispositions for Drug OffendersOffenders
Diversion (ARD) Incarceration
Probation w/o verdict
Drug / DWI Courts
Intermediatesanctions
Low riskLow riskLow Low needsneeds
Low riskLow riskHigh High needsneeds
High riskHigh riskHigh High needsneeds High riskHigh risk
Low Low needsneeds
Risk ofRisk ofDangerousnesDangerousnesss
Ok, Mr. Big Shot . . .Ok, Mr. Big Shot . . .
PROVE IT!PROVE IT!
““Key Components”Key Components”
• Judicial status hearings
• Graduated sanctions & rewards
• Urine drug screens
• Drug abuse treatment
• Case management
• Nolle prosse or conditions-served
• Expunged record (diversion)
TRIscience
addiction
(NADCP, 1997)(NADCP, 1997)
““Key Components”Key Components”
Judicial status hearings
• Graduated sanctions & rewards
• Urine drug screens
• Drug abuse treatment
• Case management
• Nolle prosse or conditions-served
• Expunged record (diversion)
TRIscience
addiction
(NADCP, 1997)(NADCP, 1997)
Matching DesignMatching Design
TRIscience
addiction
High Risk Low Risk
Matched
Unmatched
Bi-Weekly(n = 42)
As Needed(n = 95)
As Usual(monthly)
(n = 50)
(n = 92)
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week in Drug Court
% d
rug
-fre
e u
rin
e sa
mp
les
matchedlow-riskmatchedhigh-risknonmatchedhigh-risknonmatchedlow-risk
a
a
a
b
% Drug-free Urines by % Drug-free Urines by GroupGroup
TRIscience
addiction
p p < .001< .001
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week in Drug Court
% d
rug
-fre
e u
rin
e sa
mp
les
matchedlow-riskmatchedhigh-risknonmatchedhigh-risknonmatchedlow-risk
a
a
a
b
% Drug-free Urines by % Drug-free Urines by GroupGroup
TRIscience
addiction
p p < .001< .001
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week in Drug Court
% d
rug
-fre
e u
rin
e sa
mp
les
matchedlow-riskmatchedhigh-risknonmatchedhigh-risknonmatchedlow-risk
a
a
a
b
% Drug-free Urines by % Drug-free Urines by GroupGroup
TRIscience
addiction
p p < .001< .001
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week in Drug Court
% d
rug
-fre
e u
rin
e sa
mp
les
matchedlow-riskmatchedhigh-risknonmatchedhigh-risknonmatchedlow-risk
a
a
a
b
% Drug-free Urines by % Drug-free Urines by GroupGroup
TRIscience
addiction
p p < .001< .001
Drug-Positive Urines: 6 Drug-Positive Urines: 6 Mos.Mos.
TRIscience
addiction
50%
8%
44%
64%
0%
20%
40%
60%
80%
100%
UA
Dru
g P
osit
ive
Matched Unmatched
Low riskHigh risk
* * p < .05
**
**
Graduation Rates: 12 Graduation Rates: 12 mos.mos.
TRIscience
addiction
72% 75% 75%
56%
0%
20%
40%
60%
80%
100%
Gra
du
ati
on
Rate
Matched Unmatched
Low riskHigh risk
* * p < .05
**
““Key Components”Key Components”
Judicial status hearings
• Graduated sanctions & rewards
• Urinalyses
• Drug abuse treatment
• Case management
• Nolle prosse or time served
• Expunged record (diversion)
TRIscience
addiction
(NADCP, 1997)(NADCP, 1997)
““Key Components”Key Components”
Judicial status hearings
Graduated sanctions & rewards
• Urinalyses
• Drug abuse treatment
• Case management
• Nolle prosse or time served
• Expunged record (diversion)
TRIscience
addiction
(NADCP, 1997)(NADCP, 1997)
Months of compliance
STANDARDREWARDS
1 Applause; hat / candle;
framed certificate; travel
2
3
4Applause; keychain;
certificate; ↓↓hearings & UA
5
6
7
8Applause; certificate; travel; ↓↓ hearings & UA
9
10
11
12 Grad ceremony; framed plaque; dismissal
Total
RewardsRewards
Months of compliance
STANDARDREWARDS
ESCALATING REWARDS
1 Applause; hat / candle;
framed certificate; travel$5.00 gift certificate
2 $10.00 gift certificate
3 $15.00 gift certificate
4Applause; keychain;
certificate; ↓↓hearings & UA
$20.00 gift certificate
5 $25.00 gift certificate
6 $30.00 gift certificate
7 $35.00 gift certificate
8Applause; 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 $390.00
RewardsRewards
Months of compliance
STANDARDREWARDS
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
4Applause; keychain;
certificate; ↓↓hearings & UA
$20.00 gift certificateEligible for $50.00 gift certificate if compliant one additional month
5 $25.00 gift certificate $50.00 gift certificate
6 $30.00 gift certificateEligible for $50.00 gift certificate if compliant one additional month
7 $35.00 gift certificate $50.00 gift certificate
8Applause; certificate; travel; ↓↓ hearings & UA
$40.00 gift certificateEligible for $75.00 gift certificate if compliant one additional month
9 $45.00 gift certificate $75.00 gift certificate
10 $50.00 gift certificateEligible for $125.00 gift certificate if compliant two additional months
11 $55.00 gift certificateEligible for $125.00 gift certificate if compliant one additional month
12 Grad ceremony; framed plaque; dismissal
$60.00 gift certificate$125.00 gift certificate
Total $390.00 $390.00
RewardsRewards
# Drug-Free Urines (13 mos.)# Drug-Free Urines (13 mos.)
TRIscience
addiction
33.5 34.837.6
0
10
20
30
40
50
60
To
tal D
rug
-Fre
e U
rin
es
As Usual Escalating Thinningn=61n=61 n=60n=60 n=60n=60
p = n.s.
Mean % Sessions AttendedMean % Sessions Attended
TRIscience
addiction
87%82%
88%
0%
25%
50%
75%
100%
As Usual Escalating Thinningn=61n=61 n=60n=60 n=60n=60
p = n.s.
Mean % Drug-Free UrinesMean % Drug-Free Urines
TRIscience
addiction
77%
82%84% 84%
90%
80%
60%
70%
80%
90%
As Usual Escalating Thinning
High risk
Low risk
*p < .05n=3n=344
n=2n=299
n=3n=344
n=2n=299
n=2n=266
n=2n=244
Remaining ConcernsRemaining Concerns• Measurement errorMeasurement error
• DissimulationDissimulation
• Treatment needs vs. supervision needs Treatment 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
ADAPTIVE INTERVENTION
Baseline Risk Assessment
ADAPTIVE INTERVENTION
Baseline Risk Assessment
BI-WEEKLY COURT HEARINGS
High RiskHigh Risk
ADAPTIVE INTERVENTION
AS-NEEDED COURT HEARINGS
Baseline Risk Assessment
BI-WEEKLY COURT HEARINGS
High RiskHigh Risk Low RiskLow Risk
ADAPTIVE INTERVENTION
Monthly Progress
Assessments
AS-NEEDED COURT HEARINGS
Baseline Risk Assessment
BI-WEEKLY COURT HEARINGS
High RiskHigh Risk Low RiskLow Risk
ADAPTIVE INTERVENTION
Monthly Progress
Assessments
AS-NEEDED COURT HEARINGS
Baseline Risk Assessment
BI-WEEKLY COURT HEARINGS
High RiskHigh Risk Low RiskLow Risk
NON-COMPLIANTNON-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 RiskHigh Risk Low RiskLow Risk
NON-COMPLIANTNON-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 RiskHigh Risk Low RiskLow Risk
NON-COMPLIANTNON-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 RiskHigh Risk Low RiskLow Risk
NON-COMPLIANTNON-COMPLIANT ≥ 2 missed counseling sessions
and/or ≥ 2 missed urine specimens
NON-RESPONSIVENON-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 RiskHigh Risk Low RiskLow Risk
NON-COMPLIANTNON-COMPLIANT ≥ 2 missed counseling sessions
and/or ≥ 2 missed urine specimens
NON-RESPONSIVENON-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 RiskHigh Risk Low RiskLow Risk
NON-COMPLIANTNON-COMPLIANT ≥ 2 missed counseling sessions
and/or ≥ 2 missed urine specimens
NON-RESPONSIVENON-RESPONSIVE
≥ 2 drug-positive urines
RESPONSIVE & RESPONSIVE & COMPLIANTCOMPLIANT
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 RiskHigh Risk Low RiskLow Risk
NON-COMPLIANTNON-COMPLIANT ≥ 2 missed counseling sessions
and/or ≥ 2 missed urine specimens
NON-RESPONSIVENON-RESPONSIVE
≥ 2 drug-positive urines
RESPONSIVE & RESPONSIVE & COMPLIANTCOMPLIANT
If As-Needed:
BI-WEEKLY COURT
HEARINGS
ADAPTIVE INTERVENTION
INTENSIVE CLINICAL CASE MANAGEMENT
RESPONSIVE & RESPONSIVE & COMPLIANTCOMPLIANT
NON-RESPONSIVENON-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 RiskLow RiskHigh RiskHigh Risk
BI-WEEKLY COURT HEARINGS
NON-COMPLIANTNON-COMPLIANT ≥ 2 missed counseling sessions
and/or ≥ 2 missed urine specimens
Graduated: 20 WeeksGraduated: 20 Weeks
33%
0%
60%
38%
50%
21%
0%
20%
40%
60%
80%
High Risk Low Risk Total
Adaptive
As-Usual
p = .14ES = 0.6 (moderate)
n=6n=6 n=6n=6 n=10n=10 n=16n=16n=8n=8 n=14n=14
On Warrant StatusOn Warrant Status
17%
50%
10% 13% 13%
29%
0%
20%
40%
60%
80%
High Risk Low Risk Total
Adaptive
As-Usual
p = .27ES = 0.4 (moderate)
n=6n=6 n=6n=6 n=10n=10 n=16n=16n=8n=8 n=14n=14
% Drug-Free Urines% Drug-Free Urines
48%
40%
74%
54%
64%
48%
0%
20%
40%
60%
80%
High Risk Low Risk Total
Adaptive
As-Usual
p = .28ES = 0.4 (moderate)
n=6n=6 n=6n=6 n=10n=10 n=16n=16n=8n=8 n=14n=14
Ultimately GraduatedUltimately Graduated
79%88%
0%
20%
40%
60%
80%
100%
Adaptive As-Usual p = .43ES = 0.12 (small)
Days to GraduationDays to Graduation
0
40
80
120
160
200
240
280
Adaptive As-Usual
161.79
(73.75)
277.91277.91(168.9(168.9
3)3)
p = .03ES = 0.92 (large)
Days to Case ResolutionDays to Case Resolution
0
40
80
120
160
200
240
280
320
Adaptive As-Usual
171.50
(74.74)
307.64307.64(194.1(194.1
8)8)
p = .01ES = 0.96 (large)
Response OrderedResponse Ordered
31%
88%
0%
20%
40%
60%
80%
100%
Adaptive As-Usual
Days to a ResponseDays to a Response
89.67 (79.61)
16.25 (24.66)
0
20
40
60
80
100
Adaptive As-Usual
Cost ImplicationsCost Implications
• Avg. annual cost per participant Avg. annual cost per participant **– administration =administration = $ 4,000.00 $ 4,000.00 – outpatient treatment =outpatient treatment = + + $ 7,000.00$ 7,000.00
$11,000.00$11,000.00• Resolution in 4 fewer mos. Resolution in 4 fewer mos. ÷ ÷ 1/3 yr. 1/3 yr. • Potential costs savings = Potential costs savings = $ 3,700.00$ 3,700.00
* * Urban Institute, Urban Institute, 20082008
Cost ImplicationsCost Implications
• Avg. annual cost per participant Avg. annual cost per participant **– administration =administration = $ 4,000.00 $ 4,000.00 – outpatient treatment =outpatient treatment = + + $ 7,000.00$ 7,000.00
$11,000.00$11,000.00• Resolution in 4 fewer mos. Resolution in 4 fewer mos. ÷ ÷ 1/3 yr. 1/3 yr. • Potential costs savings = Potential costs savings = $ 3,700.00$ 3,700.00
Per participant per Per participant per year!year!
* * Urban Institute, Urban Institute, 20082008
SummarySummary
• One size does One size does notnot fit all fit all
• Drug courts are best suited for high risk Drug courts are best suited for high risk and high needs offendersand high needs offenders
• When possible, separate court calendars When possible, separate court calendars and treatment tracks should be held for and treatment tracks should be held for high risk vs. low risk clientshigh risk vs. low risk clients
• You may need to be nicest to the clients You may need to be nicest to the clients you might like the leastyou might like the least
TRIscience
addiction
Summary (cont.)Summary (cont.)
• Adaptive algorithms consistently Adaptive algorithms consistently outperform individualized professional outperform individualized professional judgmentjudgment
• Better outcomes in less timeBetter outcomes in less time
• Time = $$$$!Time = $$$$!
References References
TRIscience
addiction
Marlowe, DB et al. (2008). Adaptive interventions in drug court: A pilot Marlowe, DB et al. (2008). Adaptive interventions in drug court: A pilot experiment. experiment. Criminal Justice Review, 33Criminal Justice Review, 33, 343-360., 343-360.
Marlowe, DB et al. (in press). Adaptive interventions may optimize Marlowe, DB et al. (in press). Adaptive interventions may optimize outcomes in drug courts: A pilot study. outcomes in drug courts: A pilot study. Current Psychiatry ReportsCurrent Psychiatry Reports..
Marlowe, DB et al. (2007). Adapting judicial supervision to the risk level Marlowe, DB et al. (2007). Adapting judicial supervision to the risk level of drug offenders: Discharge and six-month outcomes from a of drug offenders: Discharge and six-month outcomes from a prospective matching study. prospective matching study. Drug & Alcohol Dependence, 88SDrug & Alcohol Dependence, 88S, 4-13., 4-13.
Marlowe, DB et al. (2006). Matching judicial supervision to clients’ risk Marlowe, DB et al. (2006). Matching judicial supervision to clients’ risk status in drug court. status in drug court. Crime & Delinquency, 52Crime & Delinquency, 52, 52-76. , 52-76.
AcknowledgmentAcknowledgment
National Institute on Drug AbuseNational Institute on Drug Abuse
Grant #R01-DA-13096