Next week London Deputy Mayor Kit Malthouse and I will be co-presenters at the City of London Drug and Alcohol Policy Forum. We will discuss how coerced abstinence programs could help reduce alcohol-fueled violence in the UK. Planning for the event has helped me organize my thoughts about coerced abstinence programs, which include HOPE probation, 24/7 Sobriety and Physicians Health Plans. These are my nine summary points as a cheat sheet for those of you who are interested (the embedded links may also be useful), and I particularly invite Mark to elaborate if he so chooses.
1. In terms of populations, these programs have wide applicability, having evidence of benefit with serial drink driving offenders, substance dependent physicians and airline pilots, and methamphetamine-using felony probationers. The strongest evidence is for HOPE probation, which has been studied by Angela Hawken and Mark Kleiman in a randomized trial. All the programs reduce substance use and the proximal harm that brought the person to the program, e.g., violence, impaired driving.
2. There is as yet no international comparison of these programs. It has to be said though that Hawaii (HOPE) and South Dakota (24/7 Sobriety) are pretty different places even though they are both in the U.S.
3. The substance addressed by these programs is irrelevant, as is the legal status of that substance. I suspect they will primarily be used with people who use alcohol and stimulants, but that is just a guess.
4. The prototypic person in these programs is someone who has done something harmful and criminal while intoxicated, e.g., someone who uses meth and then attempts sexual assault, an alcoholic who gets drunk and beats his wife or drives his car the wrong way on the interstate, a stoned surgical resident who leaves his non-sterilized locker key in a patient and causes a near-fatal infection. The people in these programs are thus not just “people in need”, they are also people who have done something wrong and are a public safety risk. The programs are therefore not intended solely to help them (though they do) but also to protect society.
5. The critical features of these programs are that they all use testing combined with swift, certain but modest sanctions in response to substance use. This is the inverse of the environment in which most substance-involved offenders live: Responses to use are unpredictable, delayed and frequently harsh. The former environment promotes learning whereas the latter environment impedes it.
6. These programs generally offer treatment, but entry to treatment per se is not the point: Abstinence is. As a clinician, I would be delighted to have a caseload composed entirely of people who were in a coerced abstinence program.
7. These programs all show evidence of producing a critical outcome: Keeping people out of prison. Every state with overcrowded prisons should be piloting coerced abstinence models of community supervision right now.
8. When these programs are done properly, the people in them will understand the rules and feel fairly treated. If they don’t, something is wrong.
9. The “brands” of these various programs are not the point. The UK or any other country can make up its own version to suit local needs and traditions, as long as it follows the basic principles, which are of obvious worth to anyone who has studied human learning or has had success shaping behavior (e.g., been a good parent).