Commentary on Bainbridge (2019): Improving the evidence base for 24/7 Sobriety

Abstract

While the quasi-experimental evidence on 24/7 Sobriety is strong, much can be learned from experimental evaluations, especially those that vary sanctions and incorporate positive incentives for compliance.

As Bainbridge correctly notes, the transfer of 24/7 Sobriety from South Dakota to South London not only led to a name change, but also a change in implementation [1]. This raises questions about which aspects of the program matter most to reduce alcohol consumption and improve other outcomes for participants, their families and society.

In South Dakota, 24/7 Sobriety requires participants to abstain from alcohol and be tested for it at least twice per day, every day. There is a swift and certain sanction for those testing positive or missing a test, typically a night or two in jail [2,3]. Unlike treatment courts for drug use or driving under the influence (DUI), the program does not require that individuals participate in treatment. They are free to do so, but the program only mandates that they abstain from alcohol.

The peer-reviewed, quasi-experimental research on South Dakota’s 24/7 Sobriety program provides evidence that it is associated with county-level reductions in arrests for repeat DUI and domestic violence as well as all-cause mortality [4,5]. A review of these studies and others by the US National Academy of Sciences, Engineering, and Medicine (NASEM) concluded that the program has been shown to be effective for high-risk offenders in some rural areas; however, the panel noted:

[The] studies in this section report limitations such as failure to account for program fidelity, missing data, and reliance on aggregate analyses rather than individual-level data; additional research is needed using randomization or matched control groups to more completely assess the short- and long-term effects of the program among diverse jurisdictions and offenders ([6], p. 287).

Since the publication of the NASEM report, preliminary results from an individual-level analysis leveraging temporal variation in county-level adoption of 24/7 Sobriety in South Dakota were released, suggesting large and statistically significant reductions in the probability of re-arrest [7]. While promising, there is still a need for an experimental evaluation of this program. Indeed, there are many outstanding questions that can best be answered with randomized controlled trials (RCTs):

1. How long should individuals stay in the program to produce a lasting effect?

2. Do different types of alcohol testing work better for different types of individuals?

3. What is the minimum level of sanction needed to produce a deterrent effect? [8]

4. Would combining sanctions with positive incentives for compliance improve outcomes?

5. How does 24/7 participation affect the family members and intimates of participants?

6. Which intervention is most cost-effective at reducing future arrests, traffic crashes, mortality and other alcohol-related outcomes including domestic violence?

The last question could include other criminal justice approaches for addressing alcohol-involved offenses, such as treatment courts, incarceration or requiring ignition-interlock devices for those convicted of DUI. At this point, we do not know which intervention (or combination of interventions) produces the most ‘bang for the buck’.

The question about the appropriate level of sanction is especially pertinent, given Bainbridge’s description about how the program was piloted in London [1]. Whereas those in South Dakota were subject to an immediate night or two in jail for non-compliance, Bainbridge reports that in the South London pilot there was no possibility of ‘flash incarceration’ and the first violation was only met with a warning. However, even with the very low expected sanction for non-compliance, a preliminary analysis suggested that more than 90% of the 111 individuals in the pilot were fully compliant [9]. Even in the absence of a control group, this is a powerful figure that should further motivate RCTs to explore the role of sanction in 24/7 Sobriety and similar programs.

While requests-for-proposals from government agencies and foundations for multi-site RCTs of 24/7 would be most welcome, practitioners need not wait for a large investment to test whether this approach makes sense in their jurisdiction. There are a growing number of organizations (e.g. New York University’s BetaGov [10]) that provide free technical assistance to help agencies conduct and learn from their own RCTs. In either case, it will be important for those conducting the experiment to allow for a ‘burn-in’ transition period to get the program up and running before beginning the formal evaluation.

The idea of suspending an individual’s ‘license to drink’ because their alcohol consumption has led them to repeatedly threaten public health and public safety is not new [11]. The innovation with 24/7 Sobriety is holding participants accountable with swift, certain and modest sanctions for non-compliance. While the quasi-experimental evidence for South Dakota’s program is strong, much can be learned from experimental evaluations, especially those that vary sanctions and incorporate positive incentives [12].