Wayne Hall and Adrian Carter University of Queensland Centre for Clinical Research

1. How may addiction neuroscience affect the way that courts deal with addicted offenders? Wayne Hall and Adrian Carter University of Queensland Centre for Clinical Research

2. Competing Models of Addiction • Medical model: addiction is a (brain) disease • Addicted persons not responsible for their drug use • Treatment rather than punishment • Moral model: all drug use is voluntary • Drug users are legally responsible for their actions • Drug use and possession • If their actions harm others (e.g. theft, assault) • Criminal penalties should be imposed

3. Evidence for a Disease Model • Clinical evidence • Chronicity of treated addiction • Ineffectiveness of incarceration • Effectiveness of maintenance treatment • Animal self-administration models • Drugs produce addictive-like behaviour in animals • Brain imaging studies of addicted persons • Differ from normal persons in responses to drugs • These differences persist long after abstinence • Neurocognitive deficits in addicted persons • Impaired ability to learn from negative reinforcement • Increased salience of drug-related cues • Difficulty inhibiting impulses

4. Arguments for a Moral Model • Scepticism about concept of addiction • Reliance upon self-interested self-report • Intentional actions not reflexes • Most heavy users quit without assistance • Drug use can be changed by contingency management e.g. rewards for clean urines

5. Reconciling the “two worlds” of addiction • Addictive disorders vary greatly in severity • Mild to moderate disorders common in young adults • Most remit: marriages, mortgages and children • They can nonetheless cause harm and harm others • Chronic addictive disorders most common in: • Antisocial males: early initiators, with drug using peers • Poorly educated, few relationships, reduced life choices • Self-medication of comorbid anxiety and depression • Those who seek treatment are: • Users in early to mid 30s who have failed at self quitting • Often coerced into treatment by: partners, family; courts • These disorders are often chronic & relapsing

6. Current Legal Practice with Addicted Offenders • Addiction not accepted as an excuse • For dealing or stealing • But often seen as a mitigating factor in sentencing • Coerced community treatment instead of gaol • Coerced treatment instead of imprisonment • Usually after conviction or guilty plea • Addiction treatment instead of imprisonment • Compulsory treatment much rarer: • For own good: Inebriates Act • Sentenced to treatment: no element of choice • NSW Compulsory Drug Treatment Program

7. Arguments for Coerced Addiction Treatment • Drug dependence among offenders is: • common & often causally related to their offences • High costs of imprisonment • Community treatment is much cheaper • Risks of BBV infection among IDU • while in prison and post-release • High rates of relapse after release from gaol • Effective treatment can reduce recidivism

8. Ethical Coerced Treatment According to WHO (1986) Ethical to coerce drug dependent person into treatment if: • offence to which drug dependence contributed • there is judicial oversight of process • offenders are given constrained choices • treatment or imprisonment • type of treatment (if treatment accepted) • humane and effective treatment is provided

9. Effectiveness of Legally Coerced Treatment • Limited evidence from RCTs • Cultural challenges in doing RCTs in CJS • Observational evidence from USA • coerced treatment has better retention • no worse outcome than voluntary treatment • most studies on TCs & outpatient counselling • Supported by some evidence • In Europe and Australia

10. Problems with Implementation • Limited menu of treatment options • Preference for abstinence-oriented treatment • Often exclude agonist maintenance treatment • Funding and resourcing • Good to start with but often erodes with time • So does staff training, support and morale • Can displace places in voluntary treatment system • Cultural issues between treatment and courts • Punitive vs therapeutic orientation • Duties to client vs Criminal Justice System

11. Drug Courts in USA • Began in late 1980s in response to • increase in imprisonment of drug offenders • prison overcrowding and revolving door • Quickly grew into a “movement” • Rapidly proliferated across US with local variations • in absence of rigorous evaluation • Quasi-experimental evaluations came later: • poorly constructed comparison groups • short term follow ups

12. Drug Courts Evaluations • A few RCTs showing modest positive effects • Retention rates 40-60% • Less drug use during program • Reduced recidivism • Meta-analyses of quasi-experiments • Generally supportive: retention rates 40-60% • Reduced recidivism: 8% below 50% base rate • Variations in effectiveness between courts • Experience in Europe • Less positive but some benefits

13. How May Neuroscience Change Practice? • Radical change is unlikely • Brain disease model not widely accepted by courts • Rationalising current practice • Coerced treatment a reasonable compromise • Mitigation rather than exculpation • Supporting the case for coerced treatment • More effective than imprisonment in reducing crime • Less expensive and more humane than imprisonment

14. Effects on Treatment Options? • Expanding access to agonist maintenance • Remove restriction to drug free treatments • Allow agonist treatment to be a choice • Coerced use of antagonists & vaccines • Advocated by some bioethicists (Caplan, 2008) • Cocaine vaccine undergoing trials in USA • Concerns about their use • safety and efficacy when used under coercion • counterproductive effects: use of other drugs

15. Possible Adverse Effects on Treatment Options • May bias courts towards • More coercive forms of treatment • More intensive residential treatment • Away from less coercive and potentially more effective approaches: • coerced abstinence (Kleiman, 2009) • Behavioural triage to • Coerced abstinence • Coerced community based treatment • Drug courts

16. Behavioural Triage(Kleiman, 2009) • US courts too punitive and ineffective • Set draconian penalties that are usually contested • So rarely imposed, usually after long delays • More humane and effective to use less punitive, more immediate sanctions: • Coerced abstinence for minor drug offenders • Supervised treatment for those who fail at this • Drug courts only for most recidivist drug offenders • Analogy to drink driving countermeasures

17. Conclusions 1 • Strong case for treating addicted offenders • High rates of problem drug use in prisoners • Drug dependent prisoners offend at high rates • At high risk of recidivism if untreated • Treatment can reduce recidivism • Case for treatment supported by • Human rights: access to addiction treatment • Community safety: reducing drug related crime • Public health: reducing deaths and BBV infections • Addiction neuroscience research

18. Conclusions 2 • Neuroscience unlikely to radically change practice • Current practice has evolved independently • Brain disease model has not been widely accepted • Could be seen as rationalising • Mitigation rather than exculpation • Coerced treatment as alternative to imprisonment • Effect on treatment options less clear • More agonist treatment? • More coerced implantable antagonists? • Less intensive forms of coercion?