What works in substance misuse treatments for offenders?

[What is effective in forensic addiction treatment? A non-systematic look into the evidence base for treatment approaches and interventions in the context of Sect. 64 of the German Criminal Code]

Forensic addiction treatment according to Section 64 of the German Criminal Code is playing an increasingly important role in the German system of correctional institutions. In recent years, the question of the effectiveness of treatment as a whole has been the focus of numerous studies. Less frequently, however, research has addressed the evidence base of therapeutic interventions and efficacy factors. Since this article takes a non-systematic look into the current state of knowledge on specific interventions and factors that play a role in the effective treatment of addicted offenders, the question of what exactly works can only be answered in a rudimentary way. The concept of Therapeutic Community appears to be largely empirically supported. Based on such evidence as is currently available, motivational interviewing and dialectical-behavioral therapy can be considered the most promising forms of therapy. The effectiveness of forensic addiction treatment lies possibly less in the application of individual approaches than in questions of the setting and the attitude of those providing treatment.

A meta-analysis on the effects of incarceration-based opioid substitution treatment

Objective: Opioid substitution treatment (OST) is a common treatment for individuals who use opioids; however, empirical evidence on the effects of OST during incarceration is scarce. Our aim was to conduct a meta-analysis on the effects of incarceration-based OST on substance use, treatment engagement post-release and re-incarceration. Method: We searched for studies on individuals who were incarcerated and treated with OST, compared to a comparison group. Studies were only included if they reported data post-release. Results: N = 15 studies met the inclusion criteria. We found less opioid use, less other drug use, higher treatment engagement post-release and less re-incarceration among treated individuals compared to the comparison group. Moderator analyses showed some influence of length of follow-up period and study quality. Conclusions: Incarceration-based OST reduces drug use, re-incarceration and leads to higher treatment engagement after release. More research is needed on the effects of incarceration-based OST on secondary outcomes (e.g. health and social integration) and on factors that moderate these effects.

The Experiences of People Who Quit Khat and the Health Care Professionals Who Support them

Background

This study aimed to explore the barriers and enablers to quitting khat from the perspective of users and the barriers and enablers to supporting users to quit from the perspective of healthcare professionals (HCPs).

Methods

The present qualitative study was conducted using semi-structured interviews and the Theoretical Domains Framework (TDF) to collect and analyse data.

Findings

Overall, 10 khat users and 3 professionals were interviewed. Beliefs about the consequences of continued use facilitated user’s decisions to quit. Social influences were both a barrier and an enabler. For professionals, the social influence of other colleagues and working together was key in enabling them to support clients. Social/professional role and identity was also an important enabler, as professionals saw supporting users to quit as an integral part of their role. A range of behaviour change techniques was identified as potential ways in which quitting attempts could be more successful, from the perspective of users and professionals.

Conclusion

The study reveals the complexity of khat chewing and quitting from the perspective of khat users, such as the varied influence of family and friends. It also identifies the many barriers and enablers that professionals experience when supporting individuals to quit, such as working with other professionals. There is little evidence for the effectiveness of current services provided for quitting khat or little information outlining how they were developed. Current services would benefit from evaluating the effectiveness of the interventions using established methodology. Recommendations have been provided for practice in the field of substance misuse.

Court as a health intervention to advance Canada's achievement of the sustainable development goals : a multi-pronged analysis of Vancouver's Downtown Community Court

Background

The increase in problematic substance use is a major problem in Canada and elsewhere, placing a heavy burden on health and justice system resources given a spike in drug-related offences. Thus, achievement of Sustainable Development Goal (SDG) Target 3.5 to ‘Strengthen the prevention and treatment of substance abuse’ is important for Canada’s overall realization of the SDGs, including SDG 3 (Good Health and Wellbeing). Since 2008, Vancouver’s Downtown Community Court (DCC) has pioneered an innovative partnership among the justice, health and social service systems to address individuals’ needs and circumstances leading to criminal behaviour. While researchers have examined the DCC’s impact on reducing recidivism, with Canada’s SDG health commitments in mind, we set out to examine the ways health and the social determinants of health (SDH) are engaged and framed externally with regard to DCC functioning, as well as internally by DCC actors. We employed a multi-pronged approach analyzing (1) publicly available DCC documents, (2) print media coverage, and (3) health-related discourse and references in DCC hearings.

Results

The documentary analysis showed that health and the SDH are framed by the DCC as instrumental for reducing drug-related offences and improving public safety. The observation data indicate that judges use health and SDH in providing context, understanding triggers for offences and offering rationale for sentencing and management plans that connect individuals to healthcare, social and cultural services.

Conclusions

Our study contributes new insights on the effectiveness of the DCC as a means to integrate justice, health and social services for improved health and community safety. The development of such community court interventions, and their impact on health and the SDH, should be reported on by Canada and other countries as a key contribution to SDG 3 achievement, as well as the fulfillment of other targets under the SDG framework that contain the SDH. Consideration should be given by Canada as to how to capture and integrate the important data generated by the DCC and other problem-solving courts into SDG reporting metrics. Certainly, the DCC advances the SDGs’ underlying Leave No One Behind principle in a high-income country context.

Is substance abuse treatment actually 'treating'? The effectiveness of pre- and post-release substance abuse programming within the reentry process

The process of reintegrating back into society can be a difficult time for formerly incarcerated individuals in desisting from substance use. Although prior work has shown that experiences like securing employment or abstaining from criminal peers can help individuals desist from substance use, one aspect about which criminologists know considerably less concerns the role of substance abuse treatment programming during reentry. Using the Serious and Violent Offender Reentry Initiative data, we explore the role of substance treatment programming on substance use through multiple avenues. Namely, we investigate the impact of substance abuse treatment during prison, during reentry, and over time. Results of longitudinal models demonstrate that individuals who participated in pre-release substance abuse treatment programming report significantly lower levels of substance use than those who did not participate in pre-release substance programming. Yet, we find that individuals who participated in substance treatment programming post-release reported significantly higher levels of substance use than those who did not participate in post-release programming. Finally, we find no evidence that substance use treatment programming relates to decreases in substance use across time.

Doing time on a TC: how effective are drug-free therapeutic communities in prison? A review of the literature

Purpose

Therapeutic communities (TC’s) are consciously designed, living-learning environments designed to evoke social, psychological and behavioural change. The success of the residential TC model saw these community-led, self-help environments for addicts move into custodial settings and early evidence suggests this transition was effective. The purpose of this paper is to examine the evidence relevant to the effectiveness of prison based, drug-free TCs.

Design/methodology/approach

In order to establish their true efficiency, particular focus has been placed on studies conducted over the last ten years (2007-2017).

Findings

To date, the TC remains superior to other forms of drug treatment in reducing recidivism and drug relapse amongst addicts who offend.

Originality/value

Outcomes of this review highlighted the importance of aftercare in providing transitional support; a fundamental aspect of treatment necessary for success and for maintaining long-term recovery post release.

Association Between Prescription of Major Psychotropic Medications and Violent Reoffending After Prison Release

Importance

Individuals released from prison have high rates of violent reoffending, and there is uncertainty about whether pharmacological treatments reduce reoffending risk.

Objective

To investigate the associations between major classes of psychotropic medications and violent reoffending.

Design, Setting, and Participants

This cohort study included all released prisoners in Sweden from July 1, 2005, to December 31, 2010, through linkage of population-based registers. Rates of violent reoffending during medicated periods were compared with rates during nonmedicated periods using within-individual analyses. Follow-up ended December 31, 2013.

Exposures

Periods with or without dispensed prescription of psychotropic medications (antipsychotics, antidepressants, psychostimulants, drugs used in addictive disorders, and antiepileptic drugs) after prison release. Prison-based psychological treatments were investigated as a secondary exposure.

Main Outcomes and Measures

Violent crime after release from prison.

Results

The cohort included 22 275 released prisoners (mean [SD] age, 38 [13] years; 91.9% male). During follow-up (median, 4.6 years; interquartile range, 3.0-6.4 years), 4031 individuals (18.1%) had 5653 violent reoffenses. The within-individual hazard ratio (HR) associated with dispensed antipsychotics was 0.58 (95% CI, 0.39-0.88), based on 100 events in 1596 person-years during medicated periods and 1044 events in 11 026 person-years during nonmedicated periods, equating to a risk difference of 39.7 (95% CI, 11.3-57.7) fewer violent reoffenses per 1000 person-years. The within-individual HR associated with dispensed psychostimulants was 0.62 (95% CI, 0.40-0.98), based on 94 events in 1648 person-years during medicated periods and 513 events in 4553 person-years during nonmedicated periods, equating to a risk difference of 42.8 (95% CI, 2.2-67.6) fewer violent reoffenses per 1000 person-years. The within-individual HR associated with dispensed drugs for addictive disorders was 0.48 (95% CI, 0.23-0.97), based on 46 events in 1168 person-years during medicated periods and 1103 events in 15 725 person-years during nonmedicated periods, equating to a risk difference of 36.4 (95% CI, 2.1-54.0) fewer violent reoffenses per 1000 person-years. In contrast, antidepressants and antiepileptics were not significantly associated with violent reoffending rates (HR = 1.09 [95% CI, 0.83-1.43] and 1.14 [95% CI, 0.79-1.65], respectively). The most common prison-based program was psychological treatments for substance abuse, associated with an HR of 0.75 (95% CI, 0.63-0.89), which equated to a risk difference of 23.2 (95% CI, 10.3-34.1) fewer violent reoffenses per 1000 person-years.

Conclusions and Relevance

Among released prisoners in Sweden, rates of violent reoffending were lower during periods when individiduals were dispensed antipsychotics, psychostimulants, and drugs for addictive disorders, compared with periods in which they were not dispensed these medications. Further research is needed to understand the causal nature of this association.

Implementing evidence-based psychological substance misuse interventions in a high secure prison based personality disorder treatment service

Purpose

This paper aims to describe: the need for substance misuse treatment with high risk, personality disordered prisoners, and the implementation of two evidence-based psychological interventions aimed at addressing substance misuse within a high secure, personality disorder treatment unit and potential future evaluation options.

Design/methodology/approach

In addition to the literature base evidencing the need for substance misuse treatment with this population, the Iceberg and ‘InsideOut’ interventions are presented. These interventions adopt a risk reduction and health intervention approach respectively. This includes explanations of how they came to be implemented within a prison based personality disorder treatment service and potential ways to evaluate these services.

Findings

Evidence-based psychological interventions can be implemented for this population whilst being responsive to changing government priorities for substance misuse treatment. The organisation’s research strategy includes an intention to evaluate these interventions in order to inform future delivery.

Practical implications

The high levels of co-morbidity between personality disorder and substance misuse disorders in the high security prison estate highlights the need for substance related treatment for this population. Given the responsivity issues relevant to personality disordered offenders, the format of delivery of evidence-based psychological interventions has to be considered.

Originality/value

This paper discusses the application of evidence-based psychological interventions for substance use within a high secure, personality disordered population which has developed as a result of ministerial changes within the treatment of both substance misuse and personality disorder.

Node-link mapping, an asset?

Purpose

– The purpose of this paper is to evaluate the use of node-link mapping (NLM) on the effectiveness of a structured treatment for dual diagnosis for men living in a low-secure environment.

Design/methodology/approach

– In total, 15 participants were recruited and randomly allocated to one of two conditions. The control group, treatment as usual (TAU) or the treatment group, TAU with NLM. Outcome measures used were: a qualitative evaluation form, The Alcohol and Illegal Drugs Decisional Balance Scale and the Brief Situational Confidence Questionnaire.

Findings

– Results indicate no statistically significant difference for either group on the pre- and post-treatment outcome measures used. Qualitative data indicated that those using NLM reported the intervention as useful and instructive more often.

Research limitations/implications

– The results gained were only a snapshot of the intervention straight after treatment and did not take into account any long-term benefits of therapy such as substance use relapse rates. The outcome measures used may not have been properly understood by all respondents, or reflect practical change. The NLM tool may not have been used as confidently as TAU. The TAU condition needs to be reviewed to improve effectiveness, and NLM to be included to improve the accessibility. A study comparing other outcome tools needs to be completed. Training for staff using NLM may require coaching.

Originality/value

– This paper has a high/low originality. It highlights a number of advantages to NLM when comparing this to TAU.

Therapeutic Community Treatment of an Inmate Population with Substance Use Disorders: Post-Release Trends in Re-Arrest, Re-Incarceration, and Drug Misuse Relapse

This systematic literature review maps the evidence for the effectiveness of the therapeutic community interventions (TCI) in reducing re-arrest, re-incarceration or drug misuse following release from prison, including the extent to which these effects are retained over time. The databases searched for the review included PsychINFO, Medline and Scopus and reference lists from relevant articles published between 2007 and 2014. Only quantitative studies that examined the effectiveness of TCI for a prisoner population with drug dependence at the time of initial incarceration were considered. Fourteen studies were identified for inclusion in the review. Three-quarters of the studies reported TCI were effective in reducing rates of re-incarceration. About 70% of studies that examined follow-up rates of drug misuse relapse found TCI effective in reducing rates of drug misuse amongst participants. TCI participation reduced re-arrests events in 55% of the studies. Results suggest TCI effective in the short-term rather than longer term for reducing rates of re-incarceration among participants, and to a slightly lesser extent, drug misuse relapse.

Dropping out of therapeutic community treatment; when is “unsuccessful”, successful?

Purpose

– It is common for people to view dropping out of substance misuse treatment as an unsuccessful attempt at recovery. The existing literature emphasises that those who drop out of treatment do worse than those who complete their treatment programme. More recently, however, those who discharge early are faring better than ever before.

Design/methodology/approach

– In total, 13 service users who discharged early from three residential therapeutic communities were interviewed over the phone to discuss life after treatment. Interview transcripts were analysed using thematic analysis and found four main themes evidencing that “unsuccessful” really can be successful.

Findings

– The study unearthed significant findings in the area of motivation for continued recovery in that 85 per cent of the sample were actively accessing further substance misuse treatment after leaving the service early. Five participants who had entered treatment as opiate users were all abstaining from Class A drugs at the time of interview; indeed 100 per cent of the sample were opiate free. Furthermore, self-reported psychological health had improved following discharge by 78 per cent.

Practical implications

– Recent changes in policy and treatment design within drug treatment services may explain such positive outcomes in that a more responsive programme allows people to gain skills and make changes in a shorter time frame.

Social implications

– Indeed, improved early discharge procedures and increased links to aftercare and follow on treatment may have impacted on this finding.

Originality/value

– This study therefore proposes the notion of “right dose of treatment” as opposed to “time in treatment” and highlights the importance of exit procedures and aftercare.

“Take home” naloxone: what does the evidence base tell us?

Purpose

– Opiod users are at high risk of suffering from drug overdoses. Naloxone has been used for decades in emergency treatment settings to reverse the symptoms of opioid overdose. Pilot studies and regional programmes have been rolled out to make naloxone more widely available. This review of user/carer administration of naloxone – so-called “take home naloxone” – aims to provide health professionals and interested readers with an up-to-date evidence base, clinical implications and practical concern considerations for such community management. The paper aims to discuss these issues.

Design/methodology/approach

– A review and analysis of the recent literature on naloxone.

Findings

– The evidence base suggests training and education is effective in preparing users for wider naloxone distribution. Furthermore, studies of varying quality indicate that naloxone may prove useful in reducing overdose-related deaths. However, even after implementation ineffective response techniques continued to be used at times and there remained a heistance to call medical services post overdose. Intranasal naloxone may reduce some of the risks associated with intramuscular naloxone. Ethical considerations, including provision of a needle and syringe kit to the community, should be considered. Studies suffered from a lack of follow-up data and methodological difficulties are associated with establishing opioid-related deaths post implementation. Two running trials in the UK might mitigate these concerns.

Research limitations/implications

– Future research is needed to address wider context of an overdose and targeting associated risk factors.

Originality/value

– Clinicians and other professionals will be informed on the most up-to-date evidence base and which areas are improtant to consider when take-home naloxone is introduced in their services.

Substance misuse subtypes among women convicted of homicide

BACKGROUND

The proportion of women incarcerated is growing at a faster pace than that for men. The reasons for this important increase have been mainly attributed to drug-using lifestyle and drug-related offenses. About half of female inmates have history of substance misuse and one third demonstrate high impulsiveness levels. The objectives of this study were to (a) identify subtypes of alcohol and drug problems and impulsiveness among women convicted of homicide, and (b) examine the association between psychosocial and criminological features and the resulting clusters.

METHODS

Data come from 158 female inmates serving a sentence for homicide in the Penitentiary of Sant'Ana in São Paulo State, Brazil. Latent class analysis was used to group participants into substance misuse and impulsiveness classes.

RESULTS

Two classes were identified: nonproblematic (cluster 1: 54.53%, n = 86) and problematic (cluster 2: 45.57%, n = 72) ones. After controlling for several psychosocial and criminological variables, cluster 2 inmates showed an earlier beginning of criminal activities and a lower educational level than their counterparts.

CONCLUSIONS

To recognize the necessities of specific groups of female offenders is crucial for the development of an adequate system of health politics and for the decrease of criminal recidivism among those offenders who have shown higher risk.

Service user involvement in the evaluation of psycho-social intervention for self-harm: a systematic literature review

Background

The efficacy of interventions and treatments for self-harm is well researched. Previous reviews of the literature have highlighted the lack of definitively effective interventions for self-harm and have highlighted the need for future research. These recommendations are also reflected in clinical guidelines published by the National Institute for Health and Clinical Excellence ( NICE, 2004 ) which also call for service user involvement in studies of treatment efficacy.

Aims

A systematic review was undertaken to determine: a) what contributions service users have made to the evaluation of psycho-social interventions; b) by what methods have service users been involved; c) in what ways could service user involvement supplement empirical evidence for interventions.

Methodology

Electronic searches were completed on the 28th January 2011 of the Medline (1950–present), Web of Science (1898–Present), Web of Science (including Science Citation Index and the Social Science Citation Index), the Cochrane database of systematic reviews, and Psychinfo (1979–present) databases using a combination of 13 search terms. References were independently sifted according to set criteria by two of the authors to ensure inter-rater reliability.

Results

Sixty-five references were included in the review. Of these, 59% of studies were empirically based, and 26% used qualitative data collection methods to gather service user narratives. Only 8% of studies used a mixed-methodology to combined qualitative and quantitative data collection. No studies featured service user involvement.

Conclusion

Service user involvement is a rarity in the evaluation of psycho-social interventions, despite its use being mandated by the National Institute for Health and Clinical Excellence and evidenced as effective in other areas of mental health ( Leader, 1998 ). The authors make a number of recommendations for future involvement in future self-harm research.

Evaluation of the addressing substance-related offending (ASRO) program for substance-using offenders in the community: a reconviction analysis

This article reports an evaluation of the Addressing Substance-Related Offending program in the English and Welsh Probation Service. Participants were 319 adult male offenders who had a history of substance use and were serving community sentences. A quasi-experimental design was used to compare the reconviction rates of offenders who completed the program, offenders who started but did not complete the program, and a comparison group of offenders who were not allocated to the program. Multivariate analysis showed that at one-year follow-up the completers had a significantly lower rate of reconviction and longer time to reconviction than the non-completers, and the non-completers had a significantly higher rate of reconviction and shorter time to reconviction than the comparison group. No differences were found in reconviction between the completers and comparison group.

A review of the use of therapeutic communities with sexual offenders

Sexual offender treatment programmes are often facilitated in secure settings such as prisons or psychiatric hospitals, which are not ideal environments for such treatment. Arguably, however, when these environments are structured as therapeutic communities (TCs), opportunities are created to enhance the effectiveness of treatment. This article describes the concept of a TC, its operating principles and rationale, as well as the benefits and rationale for establishing TCs in conjunction with cognitive-behavioural treatment with sexual offenders. This is discussed in terms of the potential of TCs to improve targeting of treatment content, to enhance treatment process, to provide optimal environments for therapeutic gain, and to provide a broad therapeutic framework for treating sexual offenders. The article reviews and summarizes what evidence exists for the use of TCs with both non-sexual offenders and sexual offenders. Finally, it highlights the gaps in our knowledge of the use of TCs to inspire further empirical and conceptual consideration of these issues.

Hepatitis infection in the treatment of opioid dependence and abuse

Many new and existing cases of viral hepatitis infections are related to injection drug use. Transmission of these infections can result directly from the use of injection equipment that is contaminated with blood containing the hepatitis B or C virus or through sexual contact with an infected individual. In the latter case, drug use can indirectly contribute to hepatitis transmission through the dis-inhibited at-risk behavior, that is, unprotected sex with an infected partner. Individuals who inject drugs are at-risk for infection from different hepatitis viruses, hepatitis A, B, or C. Those with chronic hepatitis B virus infection also face additional risk should they become co-infected with hepatitis D virus. Protection from the transmission of hepatitis viruses A and B is best achieved by vaccination. For those with a history of or who currently inject drugs, the medical management of viral hepatitis infection comprising screening, testing, counseling and providing care and treatment is evolving. Components of the medical management of hepatitis infection, for persons considering, initiating, or receiving pharmacologic therapy for opioid addiction include: testing for hepatitis B and C infections; education and counseling regarding at-risk behavior and hepatitis transmission, acute and chronic hepatitis infection, liver disease and its care and treatment; vaccination against hepatitis A and B infection; and integrative primary care as part of the comprehensive treatment approach for recovery from opioid abuse and dependence. In addition, participation in a peer support group as part of integrated medical care enhances treatment outcomes. Liver disease is highly prevalent in patient populations seeking recovery from opioid addiction or who are currently receiving pharmacotherapy for opioid addiction. Pharmacotherapy for opioid addiction is not a contraindication to evaluation, care, or treatment of liver disease due to hepatitis virus infection. Successful pharmacotherapy for opioid addiction stabilizes patients and improves patient compliance to care and treatment regimens as well as promotes good patient outcomes. Implementation and integration of effective hepatitis prevention programs, care programs, and treatment regimens in concert with the pharmacological therapy of opioid addiction can reduce the public health burdens of hepatitis and injection drug use.