Lessons to Be Drawn from U.S. Drug Control Policies

While threats of severe punishment distant in time and sporadically imposed have consistently failed to deter continued drug use among dependent users, threats of immediate and certain, albeit much less drastic, sanctions can have strong effects, if those threats are made credible by being carried out consistently. That approach is now referred to as “swift-certain-fair” (SCF) sanctioning. This can be in addition to or instead of, coercive referral to treatment; ideally treatment would be made available if requested, but not imposed at first. The operating elements of an SCF program are:
– A clear rule against using illicit drugs, imposed on a specific list of offenders, who could be people arrested but released pending trial, people convicted of crimes and subject to community supervision in lieu of incarceration, or incarcerated offenders after release;
– A clear explanation of those rules to each offender, including a warning that behavior will be closely monitored and each violation sanctioned;
– Actually carrying out the promised close monitoring, usually through urine screening;
– Delivering modest sanctions — no more than a day or two in jail, and in some cases less than that — for every detected violation (or as close to that goal as administratively feasible) and doing so swiftly, with delays measured in hours, or at most days, rather than weeks;
– Diminishing (and eventually terminating) supervision as a reward for sustained compliance.
Large numbers of most user/offender populations appear to respond well to the abstinence mandate, and cease or substantially reduce their drug use without treatment. However, some require treatment in addition to testing and sanctions. Treatment can be offered to those who want it, and may need to be imposed on those who do not want it but who prove unable to abstain even in the face of swift-certain-fair sanctioning. The advantage of this approach over a universal mandate to treatment is that it focuses scarce treatment resources on those who need them most. The testing-and-sanctions process could be thought of as a screening mechanism to identify those in greatest need of treatment, avoiding the expensive and not-very-reliable process of clinical assessment. Angela Hawken (2010) has called this approach “behavioral triage.”
Swift-certain-fair programs have shown impressive results in some places, suppressing drug use compared to matched control groups and halving the return-to-prison rate in long-term follow up with a randomized intent-to-treat design (Hawken et al. 2016). One such program in South Dakota, directed primarily at people arrested repeatedly for driving while intoxicated, appears to have not only suppressed impaired driving but also reduced domestic violence and all-cause mortality (Kilmer et al. 2013; Nicosia et al. 2016). However, operating swiftly, certainly, and fairly is a substantial administrative challenge. The details of such programs will need to be custom-designed to ensure that they fit the cultural, legal, and administrative situation in each jurisdiction that adopts them, and success is not universal (O’Connell et al. 2013; Hamilton et al. 2016; Lattimore et al. 2016; O’Connell et al. 2016; Hawken 2016; Kleiman 2016; Kleiman et al. 2016).