Keith Humphreys is a professor of psychiatry and director of mental health policy at Stanford University.
Few people who advocate for public health-oriented policies toward addiction look to the criminal justice system for inspiration. But a new study published Tuesday in the medical journal Lancet Psychiatry may change that. RAND Corp. researchers showed that the implementation of an innovative program for alcohol-involved offenders was followed by a reduction in the population death rate that would do any addiction treatment system proud.
The program, called 24/7 Sobriety, was created in South Dakota by Larry Long, a former state attorney general who is now a judge. Faced with a steady stream of offenders who were repeatedly arrested for assault, driving while intoxicated and other alcohol-fueled crimes, Long conceived a radical alternative to business as usual: Sentence offenders to mandatory abstinence.
Every day in South Dakota, about 2,000 participants of 24/7 Sobriety are subject to monitoring by breathalyzers or alcohol-sensing bracelets. Those who drink are arrested immediately and suffer a swift but modest consequence, typically a night in the local jail. Of the 8.1 million scheduled breath tests mandated by the program over the past decade, offenders have shown up sober more than 99 percent of the time. The program has spread to other states and received federal funding in the massive transportation bill that President Obama signed two months ago.
Prior research by the RAND investigators suggested that 24/7 Sobriety delivers public safety benefits. In counties that adopted the program, repeat DUI arrests fell by 12 percent, and domestic violence arrests dropped by 9 percent. The just-released study looked beyond crime to ask a question more commonly associated with public health programs: Did the state’s death rate decline because of 24/7 Sobriety?
The ingenious approach of the scientists was to exploit the fact that counties in South Dakota established the program at different points in time, creating a natural experiment. Once a county had the program up and running, its mortality rate could be compared both with its pre-24/7 Sobriety level and with that of counties that had yet to start the program.
Remarkably, the death rate of adults dropped by an estimated 4.2 percent after 24/7 Sobriety was established, equal to saving about 300 South Dakotans a year. The researchers speculated that the deaths averted included not only some 24/7 Sobriety participants but also individuals who would otherwise have lost their lives to alcohol-related crimes (e.g., drunk-driving accidents).
Because they were examining county-level data and participants were not randomized to attend 24/7 Sobriety, the researchers could not rule out other explanations for the results. That said, a randomized clinical trial of a similar program for drug-involved offenders in Hawaii found that regular drug testing coupled with swift, certain and modest sanctions for positive drug tests dramatically reduced drug use and crime, making it more plausible that the 24/7 Sobriety had the same effect in South Dakota.
The impressive results of 24/7 Sobriety should encourage reformers who worry that the criminal justice system will always stand in the way of health-oriented approaches to addiction. The RAND study suggests that when the system deploys its resources wisely, it can be a powerful force for public health.