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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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Conclusions 1
• Strong case for treating addicted offenders
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•
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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
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•
•
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Human rights: access to addiction treatment
Community safety: reducing drug related crime
Public health: reducing deaths and BBV infections
Addiction neuroscience research
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?