Effectiveness of coerced addiction treatment (alternative consequences): a review of the clinical research

Providing substance use disorder treatment in correctional settings: knowledge gaps and proposed research priorities-overview and commentary

This manuscript is the product of the authors' discussions, literature overview, and consultation with experts in the field, and identifies important gaps in the evidence base for substance use disorder (SUD) treatment effectiveness within criminal justice (CJ) settings. Lacking from the extant literature are longitudinal investigations of treatment related outcomes during and after incarceration. Such studies could provide rich contextual data about treatment delivery and effectiveness across the CJ continuum, and would provide important insight into individual characteristics (e.g., motivation, treatment modality preferences, treatment completion rates, etc.) as well as institutional and environmental factors (e.g., appropriate staffing, space limitations for individual treatment sessions, distribution of medications, etc.). We also identified the importance of reproducibility within CJ research, and the unfortunate reality of too many single studies conducted in single (or relatively few) correctional facilities. Some of this has been because the studies designed to produce that evidence are not prioritized for funding, which has continually placed researchers in a position where we cannot make firm conclusions or recommendations based on available evidence. The importance of replicating the foundational studies in this field cannot be overstated. We hope this article spurs other researchers to join in the healthy process of questioning the existing state of the CJ-based SUD treatment research, what should be re-examined, and how we can lay a stronger foundation for the future.

Escalated Oxycodone Self-Administration and Punishment: Differential Expression of Opioid Receptors and Immediate Early Genes in the Rat Dorsal Striatum and Prefrontal Cortex

Opioid use disorder (OUD) is characterized by compulsive drug taking despite adverse life consequences. Here, we sought to identify neurobiological consequences associated with the behavioral effects of contingent footshocks administered after escalation of oxycodone self-administration. To reach these goals, Sprague-Dawley rats were trained to self-administer oxycodone for 4 weeks and were then exposed to contingent electric footshocks. This paradigm helped to dichotomize rats into two distinct behavioral phenotypes: (1) those that reduce lever pressing (shock-sensitive) and (2) others that continue lever pressing (shock-resistant) for oxycodone during contingent punishment. The rats were euthanized at 2-h after the last oxycodone plus footshock session. The dorsal striata and prefrontal cortices were dissected for use in western blot and RT-qPCR analyses. All oxycodone self-administration rats showed significant decreased expression of Mu and Kappa opioid receptor proteins only in the dorsal striatum. However, expression of Delta opioid receptor protein was decreased in both brain regions. RT-qPCR analyses documented significant decreases in the expression of c-fos, fosB, fra2, junB, egr1, and egr2 mRNAs in the dorsal striatum (but not in PFC) of the shock-sensitive rats. In the PFC, junD expression was reduced in both phenotypes. However, egr3 mRNA expression was increased in the PFC of only shock-resistant rats. These results reveal that, similar to psychostimulants and alcohol, footshocks can dichotomize rats that escalated their intake of oxycodone into two distinct behavioral phenotypes. These animals also show significant differences in the mRNA expression of immediate early genes, mainly, in the dorsal striatum. The increases in PFC egr3 expression in the shock-resistant rats suggest that Egr3 might be involved in the persistence of oxycodone-associated memory under aversive conditions. This punishment-driven model may help to identify neurobiological substrates of persistent oxycodone taking and abstinence in the presence of adverse consequences.

A Comparison Between the Involuntary and Voluntary Treatment of Patients With Alcohol Use Disorder in a Residential Rehabilitation Treatment Program

OBJECTIVE

The purpose of the study was to determine if there was a significant difference between veterans who received treatment voluntarily versus involuntarily in regard to length of sobriety.

METHOD

A sample of 120 veterans being treated for alcohol use disorder in a residential rehabilitation treatment program was used for this study. Veterans who were admitted under recommendation by court order (n = 60) were matched with veterans who were admitted without recommendation of court order (n = 60). Success of the program was determined by the number of days of sobriety postdischarge.

RESULTS

The study revealed that there was no significant difference between types of motivation for residential treatment (i.e., voluntary vs. involuntary treatment) and length of sobriety for veterans with alcohol use disorder posttreatment.

CONCLUSIONS

Findings revealed that there was no significant relationship when comparing types of motivation for treatment in a residential treatment program for veterans in regard to length of sobriety posttreatment. Therefore, a veteran's motivation for treatment may not necessarily be an accurate indicator of treatment outcomes (i.e., length of sobriety posttreatment) for residential treatment settings.

Therapists' and Patients' Perspectives on Therapeutic Dynamics Leading to Therapy Failure in Forensic Addiction Treatment

Background: Among drug- or alcohol-addicted offenders under forensic treatment, therapy failure is a potent predictor of substance-related re-delinquency. Given this evidence, high drop-out rates pose a major problem in forensic addiction treatment in Germany. Legal preconditions for a premature discharge due to therapy failure are defined, and behavioral correlates are well described, but the precedent dynamics between patients and therapists have rarely been analyzed. The present study intended to shed light upon the subjective perception of the treatment course prior to therapy failure. Methods: Applying parallel questionnaires and structured interviews, patients' and therapists' perspectives on perceived reasons for therapy failure were retrospectively investigated and compared to each other on a dyadic level. Following this predominantly qualitative and explorative approach, the examination of 32 dyads could be realized; 13 patients with regular (i.e., successful) therapy termination served as controls. All patients had been treated within two specialized forensic addiction hospitals in the German federal state of Baden-Württemberg and were assessed shortly before discharge took place. Results: As expected, patients' and therapists' perspectives differed largely on perceived reasons for failure. In most cases, they appeared to have very different views on what happened during treatment and why therapy eventually failed. Patients mentioned psychological tension and aggressiveness, frequent quarrels with fellow patients, and a bad therapeutic environment as most important reasons for therapy failure. Therapists highlighted patients' unwillingness to make an effort or to change behavior. The analysis of patients' narratives regarding how to explain the negative treatment course confirmed pre-assumptions on predominantly negative feelings and attitudes towards the clinic. The precedent dynamics of therapy failure were shown to be highly individual. However, despite varying notably, a cluster analysis revealed that they seemed to follow "typical patterns" that could partially be linked to patients' characteristics. Conclusions: A better understanding of treatment dynamics during forensic addiction therapy is a prerequisite for the avoidance of therapy failure with negative effects on re-delinquency. It seems that the incapacity to establish a common frame of reference for assessing the therapy process could be one of the major reasons why treatment dynamics take on a life of their own towards a disruption of the therapeutic relationship, leading to therapy failure. The knowledge of "typical" risk patterns towards therapy failure could facilitate early therapeutic measures.

Attitudes toward defendants with substance-related charges: An analysis of a national sample of criminal defense attorneys

BACKGROUND AND OBJECTIVES

While a large percentage of criminal offenders suffer from substance use disorders (SUDs), virtually nothing is known about the attitudes criminal defense attorneys possess toward their clients who are facing substance-related charges. This is a serious concern, as the burden of steering individuals with SUDs into treatment often falls to criminal defense attorneys. The goal of this study was to examine the attitudes of criminal defense attorneys toward individuals who have been accused of drug crimes.

METHODS

A questionnaire was sent to criminal defense attorneys (N = 1,933) from all 50 U.S. states and the District of Columbia. It was comprised of (i) demographic information and (ii) a version of the 11-item Medical Condition Regard Scale (MCRS).

RESULTS

Criminal defense attorneys held generally positive attitudes toward clients with substance-related charges, but there was a significant divergence in attitudes between private and public attorneys, with the latter showing both greater familiarity with and better attitudes toward this same group of clients. These differences were impactful: worse attitudes toward clients strongly correlated with greater predictions that the clients would reoffend.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Given the magnitude of the incarcerated population with SUDs and the centrality of defense attorneys in the treatment process, especially its initiation, the divergence in attitudes between private and public criminal defense attorneys is concerning. There is a clear need for increased collaboration between physicians and attorneys, with an aim of increasing the number of individuals with SUDs receiving proper treatment (Am J Addict 2018;XX:1-7).

The Effects of the Addiction Programme of Probation on Treatment Motivation, Abstinence and Quality of Life: a Comparative Study with Motivational Interviewing and Individual Intervention

Introduction

The aim of this study is to evaluate the effectiveness of Addiction Programme of Probation (APP) created by the Substance Abuse Treatment Commission of Ministry of Health.

Methods

The sample was consisted of probationers who were referred to Ege University by probation offices in February 2010. Literate probationers aged above 18, who fulfilled the SCID-I criteria for substance dependence, or had positive urine sample for illegal drugs were included. The probationers were allocated respectively to three treatment groups: APP (n=28); Motivational Interviewing (MI; n=30); Individual Intervention (II; n=30). The effectiveness of the treatment modalities was assessed by the State Anxiety Inventory; the WHO Quality of Life-Brief form; the Treatment Motivation Questionnaire. Visual analogue and Likert-type scales were used to assess the sense of the importance and the readiness of quitting drugs also the levels of craving. Urine toxicological analyses were performed fortnightly.

Results

The APP increased the readiness of quitting drugs. The MI increased both the sense of importance and readiness of quitting drugs, decreased the frequency and severity of craving. The II improved the mental and physical health, increased the confidence in treatment also readiness of quitting drugs. Additionally, II decreased the level of anxiety, the severity, frequency and duration of craving. There was a significant decrease in positive urine samples of all groups.

Conclusion

Because of changing only "the level of being ready to quit substance abuse", APP is considered as an inadequate program compared with MI and II.

Diversion evaluations: a specialized forensic examination

Diversion programs screen justice-involved individuals for the presence of psychiatric disorders, and after negotiations take place with attorneys and treatment providers, these programs link participants with community-based treatment programs in lieu of incarceration. As the number of diversion programs, including mental health courts, continues to rapidly grow, so does the need for "diversion evaluations". Diversion evaluations are a type of forensic mental health assessment (FMHA) conducted to assist the courts in making decisions regarding diversion eligibility. As a result, they should follow the general principles of FMHA and the American Academy of Psychiatry and Law Practice Guideline for Forensic Assessment. Diversion evaluations also require application of specific areas of knowledge and experience, as court-based diversion is a unique, therapeutically focused context that is purposefully non-adversarial. The diversion evaluator is a role that combines objective decision-making with clinical consultation. The purpose of this article is to apply generally accepted forensic report standards to diversion evaluations, with a particular focus on the unique issues of diversion-specific forensic evaluations.

Should violent offenders be forced to undergo neurotechnological treatment? A critical discussion of the 'freedom of thought' objection

In this paper we examine one reason for rejecting the view that violent offenders should be forced to undergo neurotechnological treatments (NTs) involving such therapies as psychoactive medication to curb violent behaviour. The reason is based on the concern that forced treatment violates the offender's right to freedom of thought. We argue that this objection can be challenged. First, we present some specifications of what a right to freedom of thought might mean. We focus on the recently published views of Jared Craig, and Jan Cristopher Bublitz and Reinhard Merkel. Second, we argue that forcing violent offenders to undergo certain kinds of NTs may not violate the offender's right to freedom of thought as that right is specified by Craig, and Bublitz and Merkel. Third, even if non-consensual NT is used in a way that does violate freedom of thought, such use can be difficult to abandon without inconsistency. For if one is not an abolitionist, and therefore accepts traditional state punishments for violent offenders like imprisonment-which, the evidence shows, often violate the offender's right to freedom of thought-then, it is argued, one will have reason to accept that violent offenders can legitimately be forced to undergo NT even if doing so denies them the right to freedom of thought.

Examining the Relationship between Psychological Functioning, Childhood Trauma, and Types of Perceived Coercion Among Drug Court Enrollees: Results from A Pilot Study

Background:

Drug court interventions produce positive results—especially among mandated populations. Many criminal justice-involved persons, including drug court enrollees, have cooccurring substance abuse and childhood trauma disorders associated with psychological dysfunction. Given the coercive nature of mandated drug court treatment, it is important to understand whether childhood trauma and psychological functioning influence perceived coercion to enter treatment.

Objectives:

The purpose of this study was to describe the degree to which adverse childhood trauma and psychological functioning were associated with six domains of perceived coercion— self, family, legal, financial, health, and work—among a population of drug court enrollees.

Methods:

Data from 54 enrollees in a drug court pilot study were used to examine the relationship between childhood trauma, psychological functioning, and perceived coercion.

Results:

The pilot study data showed that psychological dysfunction and traumatic experiences in childhood were associated with higher perceived coercion to treatment, explaining 29% of the variance in coercion, controlling for gender and pre-arrest alcohol and drug use. Results indicated that the associations between psychological dysfunction and trauma were driven by non-legal types of coercion. In particular, childhood trauma was correlated with family (r = .32), financial (r = .32), and health (r = .47) types of coercion.

Conclusions:

Based on these preliminary findings, drug court practitioners are urged to assess perceived coercion, in addition to the behavioral health and childhood trauma of their clients, and to utilize non-legal types of coercion such as family, health, and financial impact to enhance treatment engagement.

Recidivism Among Drug Offenders Following Exposure to Treatment

The contemporary debate about punishment versus treatment for drug-using criminal offenders often revolves around the pragmatic issue of the extent to which treatment is more effective than punishment at reducing the probability of subsequent criminal behavior. Although there is growing evidence that treatment works, it is equally apparent that the effects of exposure to treatment vary by offender characteristics, offense characteristics, and the degree of program involvement. Using data on 3,328 drug-using offenders eligible for diversion from prosecution to a community treatment program, multivariate survival models indicate significant differences in the time of rearrest during a 5-year follow-up period, suggesting that the act of entering treatment is a signal of the offender’s readiness for treatment and that the time to rearrest is affected by exposure to treatment. The findings are discussed in terms of current efforts to use the threat of legal sanction to motivate criminal offenders into drug treatment.

"I Don't See Myself as Prison Material": Motivations for Entering a Rural Drug Court

Since the inception of drug court in the late 1980s, it has become a widely used alternative to incarcerating drug offenders. Previous research has detailed the effectiveness of programming on recidivism, participants' perceptions of the service delivery model, and cost-effectiveness. The scholarship related to drug offender motivations to participate in drug court has largely discussed family obligations and the sense of loss stemming from drug abuse, and only two studies have discussed the fear of prison as a primary motivator. This research utilized semi-structured interviews with former drug court participants from a rural county in California to ascertain their motivation for engaging in drug court (N = 29). The results show 79% of participants were trying to avoid prison or jail, while 62% were motivated to end the cycle of drug abuse in their lives. The conclusion has policy implications for future drug court design; however, additional research is needed.

Treatment Resistant and Resistant to Treatment? Evaluation of 40 Alcohol Dependent Patients Admitted for Involuntary Treatment

AIMS

To describe the clinical outcomes for a group of patients with severe alcohol dependence discharged from an Involuntary Drug and Alcohol Treatment (IDAT) program.

METHODS

Forty patients admitted to an inpatient IDAT program were prospectively followed up over 6 months using standardized questionnaires.

RESULTS

Patients had high rates of mental health comorbidities (97.5%), cortical atrophy (40%) and socioeconomic disadvantage (92.5% were beneficiaries). Six months after discharge, 25% of patients were abstinent and living in the community and 17.5% had notably reduced alcohol use. A further 7.5% were abstinent due to involuntary hospitalization. A total of 10% of patients were deceased and 40% of patients had relapsed or were lost to follow-up. Number of admissions and admission days reduced by 51 and 45% respectively for the 17 abstinent or improved community-based patients. A total of 82% of this patient group were actively engaged with an Assertive Community Treatment (ACT) team.

CONCLUSIONS

While patient numbers are small, treatment responsiveness was evident for 42.5% of patients, most of whom were followed up with ACT. Evaluation with a comparator group is required to determine whether outcomes are a function of involuntary treatment or an assertive treatment approach.

Effectiveness of Choice Theory Connections: a cross-sectional and comparative analysis of California female inmates

In the past 30 years, the rates of incarceration and recidivism for women in the United States have increased dramatically. Choice Theory® Connections (CTC) is a gender-tailored pre-release intervention program based on Choice Theory® (Glasser, 1999), and designed to achieve meaningful and sustainable cognitive and behavioral change. This evaluation examines CTC among 96 female participants in a California state prison enrolled in an introductory (n = 58) or advanced (n = 38) course. CTC significantly improved perceived stress, mindfulness, emotion regulation, impulsivity, and well-being on completion; effects were stronger for the introductory cohort, but significant effects also emerged for the advanced cohort. In addition, participants in the advanced cohort reported better scores at baseline, demonstrating the effects of prolonged engagement with the intervention. Results suggest that CTC can improve incarcerated women's well-being pre-release, a strong predictor of recidivism post-release. Further study and wider use of CTC are encouraged.

Current advances in the treatment of adolescent drug use

Research on the development and efficacy of drug abuse treatment for adolescents has made great strides recently. Several distinct models have been studied, and these approaches range from brief interventions to intensive treatments. This paper has three primary aims: to provide an overview of conceptual issues relevant to treating adolescents suspected of drug-related problems, including an overview of factors believed to contribute to a substance use disorder, to review the empirical treatment outcome literature, and to identify areas of need and promising directions for future research.

Workplace effectiveness and psychotherapy for mental, substance abuse, and subsyndromal conditions

While it is known that psychiatric illness and subclinical psychiatric illness can be very disabling, their impact on workers' productivity has been little appreciated or appropriately addressed. Complex variables are involved in fashioning an appropriate policy to ameliorate the impact of mental illness on productivity including the identification of effective treatments and potential negative effects of controlling patients' access to them. The cost-effectiveness of such treatments is considered from the differing perspectives and goals of the various stakeholders involved, including employers, insurers, and workers with psychiatric illness. Depression in workers leads to significant absenteeism, "presenteeism" (diminished capacity due to illness while still present at work), and significantly increased medical expenses in addition to the costs of psychiatric care. In addition to the specific usefulness of psychotropic medication, there are a variety of studies on the cost-effectiveness of different psychotherapeutic treatments that improve health and productivity in psychiatrically ill workers. Research indicates the usefulness of approaches including employee assistance programs, specialized cognitive-behavioral treatments, and brief and longer term psychodynamic interventions. It is clear that substance abuse disorders and especially depression and subsyndromal depression have a profound negative effect on work productivity and increases in medical visits and expenses. The current system of mental health care suffers from ignorance of the negative effects of psychiatric illness in workers, from a lack of subtle awareness of which treatments are most appropriate for which diagnoses and from the reluctance by payers to invest in them. Access to evidence-based appropriate treatment can improve the negative impact on productivity as well as workers' health. This article considers these issues and argues for a role of psychotherapy in the treatment of mental illness and substance abuse from the perspective of worker productivity.

Effect of criminal justice mandate on drug treatment completion in women

BACKGROUND

Drug and alcohol abuse among women is a growing problem in the United States. Drug treatment is an effective way to manage the psychological, biological, financial, and social cost of drug abuse. Prior research has identified criminal justice referrals or coercion as a predictor of treatment completion among men but questions remain about the same effect in women.

OBJECTIVES

This study uses the Treatment Episodes Datasets Discharge 2006-2008 (TEDS-D) to explore the association between coercion and treatment completion among women.

METHODS

Analysis compared primary treatment episodes of coerced women to those who entered treatment voluntarily. A logistic model of the odds of treatment success was performed controlling for race/ethnicity, age, education, employment, primary substance of abuse, number of substances reported at admission, referral source, treatment setting, and treatment duration.

RESULTS

582 671 primary treatment episodes were analyzed comparing women with coercion referrals (n = 196 660) to those who entered treatment voluntarily (n = 390 054). Results of multivariable logistic modeling showed that coerced women had better odds of completion or transfer than women who entered voluntarily. However, this association was modified by treatment setting with better odds in ambulatory (OR = 1.49 [1.47, 1.51]) than in inpatient (OR = 1.06 [1.03, 1.10]) and worst outcomes in detoxification (OR = 0.89 [0.84, 0.96]).

CONCLUSION

These results dispute the broad effectiveness of legal mandates across all drug treatment settings among women. They show the need for further recognition of female-specific characteristics that can affect motivation and treatment success to better inform healthcare and judicial policies on drug treatment services for women.

Termination of parental rights for parents with substance use disorder: for whom and then what?

The purpose of this study is to investigate the correlates of termination of parental rights (TPR) for parents with substance use disorder (SUD) and to determine what happens with regard to permanency once a TPR decision is made. Bivariate techniques and hierarchical nonlinear modeling are used. Parents of older youth, boys, and Hispanics were less likely, whereas parents who failed to make progress in substance use treatment and parenting skills are more likely to experience TPR. At follow up, 85% of the children were adopted, 7% remained in a substitute care settings, and 7% were reunified with their parents. Concerns remain for children without a permanent home setting.

[Perception of crack users in relation to use and treatment]

The aim was to know the perception of crack/cocaine users about the use and treatment in a midsize general hospital, located in Rio Grande do Sul. It is a qualitative, descriptive and exploratory research that used semi-structured interviews with eight crack users,from September to October 2010. To analyze the data, we used content analysis from which two semantic categories emerged: drug use and seeking treatment. It was evidenced that drug use initiation in adolescence is related to social access or easy economic access, excessive load on studies and work, stress and not knowing about the possibility of chemical dependency, friends and family members influences, who also influence them on seeking treatment. We conclude that it is necessary to investigate the issue of crack users better and support actions on consume reduction, prevention and education to users.

Offender Perceptions of Mandated Substance Abuse Treatment

Offenders with a substance abuse diagnosis are often ordered to participate in treatment. However, little is known about how offenders perceive this mandate or how the criminal justice system should be involved. The procedural justice orientation suggests that offenders who view the mandate as legitimate and useful will be more likely to comply. In-depth interviews with probationers and parolees are analyzed to explore this issue. Overall, offenders held conflicting opinions about the mandate to attend treatment. Although offenders disliked being ordered to complete drug treatment, they understood the benefit of attending as a part of their reintegration and sobriety. Offenders felt their supervising officers were fair, but their role in drug treatment was to ensure program completion. This study adds to the literature by providing insight into offender perceptions of mandated treatment and the dimensions of the offender–officer relationship. Implications for procedural justice, future research, and policy are discussed.

Do cultural and linguistic competence matter in Latinos' completion of mandated substance abuse treatment?

BACKGROUND

Increasing evidence suggests that culturally and linguistically responsive programs may improve substance abuse treatment outcomes among Latinos. However, little is known about whether individual practices or culturally and linguistically responsive contexts support efforts by first-time Latino clients to successfully complete mandated treatment.

METHODS

We analyzed client and program data from publicly funded treatment programs contracted through the criminal justice system in California. A sample of 5,150 first-time Latino clients nested within 48 treatment programs was analyzed using multilevel logistic regressions.

RESULTS

Outpatient treatment, homelessness, and a high frequency of drug use at intake were associated with decreased odds of treatment completion among Latinos. Programs that routinely offered a culturally and linguistically responsive practice-namely, Spanish-language translation-were associated with increased odds of completion of mandated treatment.

CONCLUSIONS

These preliminary findings suggest that concrete practices such as offering Spanish translation improve treatment adherence within a population that is at high risk of treatment dropout.

Predictors of treatment response in adolescents with comorbid substance use disorder and attention-deficit/hyperactivity disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) frequently co-occurs with substance use disorder (SUD) and is associated with poor substance-use treatment outcomes. A trial evaluating osmotic-release oral system methylphenidate (OROS-MPH) for adolescents with ADHD and SUD, concurrently receiving behavioral therapy, revealed inconsistent medication effects on ADHD or SUD. Clinical care for this population would be advanced by knowledge of treatment outcome predictors. Data from the randomized placebo-controlled trial (n = 299) were analyzed. Significant treatment predictors included: 1) Substance use severity, associated with poorer ADHD and SUD outcomes, 2) ADHD severity, associated with better ADHD and SUD outcomes, 3) comorbid conduct disorder, associated with poorer ADHD outcomes, and 4) court-mandated status, associated with better SUD outcomes but poorer treatment completion. An interaction effect showed that OROS-MPH improved SUD outcomes in adolescents with comorbid conduct disorder compared to placebo. While severe SUD may require more intensive psychosocial treatment, OROS-MPH may improve substance treatment outcomes in adolescents with co-morbid attention and conduct problems.

Pathways to treatment retention for individuals legally coerced to substance use treatment: the interaction of hope and treatment motivation

BACKGROUND

Although several states have adopted policies diverting individuals convicted of non-violent drug offenses to substance use treatment, in lieu of incarceration or as a condition of probation, previous research has produced inconsistent findings on the effectiveness of such programs when comparing outcomes for legally coerced individuals to more voluntary entrants. Less studied in these populations is within group variation in treatment expectations and motivation influences, which have been shown to affect retention as well.

METHODS

As motivation has traditionally been viewed as contributing to treatment retention and higher levels of hope (the perception that goals can be met) are viewed as an asset in treatment, the role of these factors in predicting better retention between legally coerced and more voluntary clients were examined in a sample of 289 treatment admissions in California.

RESULTS

Results found that motivation mediates the relationship between hope and retention for participants in general. Although the differences in mediation between the legally coerced and the non-legally coerced were not significant, when examining the groups separately, there was a significant mediation of the relationship between hope and retention by motivation only for those individuals who were not legally coerced into treatment (p<.05).

CONCLUSION

The findings imply that while being legally coerced may lead to different pathways to treatment retention, for individuals who were not legally coerced, higher levels of hope may play an important role in determining treatment retention.

Drugs use by adolescents and their perceptions about specialized treatment adherence and dropout

Drugs use in adolescence is an important issue to be discussed, due to the early damage it causes. This study investigated adolescent drugs use, ranging from the first trial to perceptions about treatment adherence. Based on qualitative research, the researchers aimed to understand the problem from the subjects' viewpoint. Data were analyzed through thematic categorization. Fourteen teenagers were interviewed: mostly males, 14 to 19 years old and low education. Marijuana was the most used drug upon the first trial. Friends, free time and "parties" favored drugs use. Teenagers also used drugs to escape from conflicts and feelings. Different intrinsic and extrinsic factors were reported as favorable to treatment adherence and dropout. The findings can contribute to establish therapeutic intervention proposals for adolescent drug users.

Confirmatory Factor Analysis and Test-Retest Reliability of the Alcohol and Drug Confrontation Scale (ADCS)

The addiction field lacks an accepted definition and reliable measure of confrontation. The Alcohol and Drug Confrontation Scale (ADCS) defines confrontation as warnings about the potential consequences of substance use. To assess psychometric properties, 323 individual entering recovery houses in U.S. urban and suburban areas were interviewed between 2003 and 2005 (20% women, 68% white). Analyses included test-retest reliability, confirmatory factor analysis, and measures of internal consistency. Findings support the ADCS as a reliable way of assessing two factors: Internal Support and External intensity. Confrontation was experienced as supportive, accurate and helpful. Additional studies should assess confrontation in different contexts.

Does mandatory inpatient alcohol detoxification reduce emergency department recidivism, hospital admissions, and emergency medical services transports for patients with chronic, severe alcohol dependence?

BACKGROUND

In Massachusetts, patients with chronic alcohol dependence can be committed to 30 days of mandatory inpatient alcohol detoxification (MAD).

STUDY OBJECTIVES

To examine the effects of MAD on the number of emergency department (ED) visits, hospital admissions, and emergency medical service (EMS) transports.

METHODS

This retrospective study identified patients in our urban ED committed to MAD. We compared the number of ED visits and admissions to our hospital and Boston EMS transports to any facility in the 1, 3, and 6 months pre- and post-MAD, excluding the 30-day MAD period. Paired t tests were used for analysis of mean values across time.

RESULTS

Ten subjects were enrolled. Comparing pre- and post-MAD, the mean number of ED visits fell 6.5 to 2.7 (p = 0.05) in the first month, 14.2 to 9.3 (p = 0.18) in 3 months, and 25.6 to 17.7 (p = 0.15) in 6 months. Mean number of hospital admissions declined: 1.3 to 0.1 (p = 0.03) in 1 month, 2.3 to 0.9 (p = 0.06) in 3 months, and 3.2 to 1.9 (p = 0.08) in 6 months. Mean number of EMS transports fell 4.6 to 2.3 (p = 0.21) in the first month, 9.2 to 5.6 (p = 0.14) in 3 months, and 13.9 to 10.0 (p = 0.26) in 6 months pre- and post-MAD.

CONCLUSIONS

MAD was associated with an immediate reduction in ED visits and hospital admissions that did not remain statistically significant long term, and a non-significant reduction in EMS transports.

An examination of mandated versus voluntary referral as a determinant of clinical outcome

A literature review was undertaken to examine evidence for the effectiveness of psychotherapy with mandated clients. The primary question addressed was whether or not clients mandated to therapy, whether by court order or by order of their employers, show poorer outcomes than clients who enter therapy voluntarily. To this end, research on client resistance and motivational readiness to change was reviewed. This was followed by an examination of research on the effectiveness of mandated treatment. The question of the potential influence of relationship factors such as the therapeutic alliance was also addressed. The literature review was followed by suggestions for future research on the effectiveness of treatment for clients with mandated or voluntary referral status.

Outcomes of mandated treatment for women with histories of abuse and co-occurring disorders

Although there is much momentum for behavioral health policies supporting mandated treatment, there is little evidence supporting its safety and effectiveness for individuals with complex issues. The authors used a national study of women with co-occurring psychiatric, substance use disorders and histories of trauma to compare mandated and voluntary treatment by examining psychiatric, substance use, and trauma-related outcomes following treatment. This quasi-experimental study included 2,726 women, with measures completed at baseline, 6-month, and 12-month follow-up. Two-way analyses of covariance examined the main and interactive effects of coercive status (mandated vs. voluntary) and condition (integrated treatment vs. services as usual) on psychiatric distress, trauma-related symptoms, and substance use outcomes. Women did better with integrated treatment and with mandated treatment regardless of treatment condition for psychiatric, trauma, and substance use outcomes at both follow-ups. Further research clarifying unintended side effects and change mechanisms of mandated treatment is needed to inform policy decisions.

Identifying client-level indicators of recovery among DUI, criminal justice, and non-criminal justice treatment referrals

This study is part of a mandated treatment outcome study on all government-funded programs in a rural state. This naturalistic study included a sample of 888 clients who served between July 2003 and June 2004 in a state-funded treatment for substance misuse and were included in a follow-up interview 12 months after treatment. To examine differences in treatment outcome, clients were examined in three referral conditions: (1) driving under the influence (DUI) referral; (2) criminal justice referral; and (3) non-criminal justice referral. While more DUI referrals reported alcohol use at 12-month follow-up, there were no other differences between referral conditions. Instead, controlling for factors like age, gender, and race, recovery intent at intake, and 12-step program participation at follow-up predicted positive treatment outcomes, while persistent depression predicted negative outcomes. This study of clients in state-funded treatment for substance misuse provides additional evidence that referral condition does not predispose clients toward positive or negative outcomes. Secondly, client-level factors related to recovery practices and intent to reduce or stop using substances may need closer attention in the clinical process. Study limitations included data being collected by clinicians during intake, which may have resulted in reliability questions about how data are entered.

The influence of legal coercion on dropout from substance abuse treatment: results from a national survey

Legal coercion is frequently used to leverage substance abuse treatment upon persons who would otherwise not seek it voluntarily. Various methodological and conceptual problems of the existing research have prevented a clear understanding of its effectiveness. The influence of legal coercion on retention in substance abuse treatment was examined using a national survey of programs in the public sector of care and three different treatment modalities including short-term residential (N=756), long-term residential (N=757), and outpatient treatment (N=1181). Legal coercion was found to reduce the risk of dropout across all three treatment modalities. The greatest effect was among persons in short-term residential treatment. The smallest effect was observed in outpatient treatment. This study shows that legal coercion significantly reduces the risk of dropout in substance abuse treatment. However, the differential effects across treatment conditions must be carefully considered when using coercion to involve individuals in treatment.

Cannabis treatment outcomes among legally coerced and non-coerced adults

Background

Treatment seeking for cannabis dependence in general, and particularly the number of criminal justice referrals to cannabis treatment, has increased over the past decade. This study aims to compare the characteristics, psychosocial functioning and treatment outcome of those legally coerced into cannabis treatment compared to those entering treatment without legal coercion.

Methods

This study is a retrospective audit of the administrative clinical records of 27,198 adults presenting to public Texas treatment programs with cannabis as their primary drug problem between 2000 and 2005.

Results

Of the 69% legally coerced into treatment, there was less psychological distress and greater likelihood of having completed treatment compared with non-coerced clients. Participants who were legally coerced into treatment were also more likely to have received less intensive forms of treatment and to have not used cannabis in the month prior to 90-day post-treatment follow-up.

Conclusion

More public health information is needed on cannabis dependence and increased availability of subsidised early and brief interventions in a variety of primary health care settings would reduce the late presentations of the more severely impaired voluntary clients. The limitations of this dataset are discussed.

Research note: ethics of drug treatment research with court-supervised subjects

The last two decades have seen an acceleration of clinical research on, and treatment advances in, addictive illness. Much important research in this area requires the participation of subjects who themselves suffer from drug dependence and have a strong likelihood of becoming involved in the criminal justice system at some point. However, using court-supervised persons with addictive disorders in drug research raises a number of significant ethical issues. These include, among others, worries about the individual's ability to provide capable, voluntary, informed consent and the obligation of researchers to safeguard sensitive clinical information. A variety of potentially coercive factors can influence court-supervised persons in their decision whether to enter research and can compromise their ability to provide informed consent. In this paper, we explore the ethical issues arising in this research and offer some suggestions for approaches to address these concerns.

Substance misuse and substance-related disorders in forensic psychiatry

There is a broad range of substance-related problems that arise for the forensic psychiatrist. For many, what is most challenging about addressing these issues are the complex behavioral, biological, clinical, and social phenomena involved. Substance- related illnesses are on the cutting edge of brain research. Substance-related behavior that brings individuals to the attention of forensic psychiatrists involves a wide spectrum of substance use patterns, but even substance misuse may have profound and relevant effects, forensically. The social forces that mold our laws and attitudes toward addictive drug use are at work in almost every forensic context. Substance-related issues provide a rich medium for the application of forensic psychiatric principles and practice. As in all of forensic psychiatric work, the psychiatrist should be familiar with each forensic context in which addiction issues arise. They should become familiar with the relevant definitions, criteria, and legal requirements that apply in each specific area of their practice, rather than assume that clinical definitions and clinical reasoning will carry them. Comfort and effectiveness with addiction issues requires willingness to continually educate oneself about this rapidly changing field, and familiarity with one's own attitudes and beliefs regarding addictive illness.

Depot naltrexone in lieu of incarceration: a behavioral analysis of coerced treatment for addicted offenders

This article is part of a series of articles examining a proposal to offer depot naltrexone to certain nonviolent opiate-addicted criminal offenders in exchange for release from incarceration or diversion from prosecution. This "negative-reinforcement" behavioral paradigm could have a better chance of success than what has heretofore been attempted with drug-abusing offenders. Traditional correctional efforts have been largely unsuccessful due to the complexities of implementation and the side effects of punishment. Although positive reinforcement can be more efficacious, it has often been strenuously resisted on the ground that it is inequitable to reward antisocial individuals for doing what is minimally expected of most citizens. Negative reinforcement steers between these hurdles by avoiding the iatrogenic effects of punishment, while also being palatable to stakeholders. More research is needed to identify the effects, costs, and side effects of negative-reinforcement arrangements for drug offenders. The current proposal provides an excellent platform for conducting this research because the target intervention (depot naltrexone) is demonstrably efficacious, nonpsychoactive, and has few, if any, side effects. Therefore, use of this medication would be unlikely to invoke the same types of legal and ethical objections that have traditionally been levied against the use of psychoactive medications with vulnerable populations of institutionalized offenders. Specific recommendations are offered for questions that must be addressed in future research studies.

Perceived need for alcohol, drug, and mental health treatment

BACKGROUND

To investigate determinants of perceived need for alcohol, drug, and mental (ADM) health treatment and differences in ADM treatment patterns between individuals with perceived need and those without.

METHODS

We used data from a nationally representative telephone survey of 9585 adults conducted in 1997-1998. Logistic regression was used to study the determinants of perceived need and the correlation between perceived need and any ADM treatment, specialty ADM treatment, appropriate care, and medication adherence.

RESULTS

Just fewer than 37% of individuals with an ADM disorder perceived a need for treatment, while 4.6% of those without an ADM disorder perceived a need for treatment. Women, the young and middle aged, the better educated, those with greater emotional support, and those with greater psychiatric morbidity were more likely to perceive need for ADM services. Perceived need was strongly correlated with receiving ADM treatment, although almost 44% of individuals in ADM treatment did not perceive a need for treatment. Among individuals in ADM treatment, those with perceived need were significantly more likely to receive specialty ADM treatment, but not more likely to be treatment adherent, or to receive appropriate care.

CONCLUSION

Substantial levels of unmet need are likely to persist as long as perceived levels of need remain low. Interventions targeting perceived need may hold promise for decreasing unmet need.

Artikel

In 2002, an extensive follow-up of a 1996 alcohol survey was undertaken in Denmark. A mail-distributed questionnaire was sent to a representative population of 3120 adult Danes with a response rate of 56.4%. The questionnaire comprised 37 questions on alcohol (subdivided) and 6 on illegal substances. The present article focuses on three questions on the compulsory treatment for alcoholics and one question about the compulsory removal of children from alcoholic families. The results show a that a majority of 53% support compulsory treatment of alcoholics and that percentages as high as 80, 83 and 79% are supporting respectively compulsory treatment of pregnant alcoholics, alcoholics who have children, and compulsory removal of children from alcoholics. The results are broken down according to sex (no differences), age (no differences), education (the higher the education the less support, but still a majority) and economics (the better economy the less support, but still a majority). For average consumption the results demonstrate a correlation between high consumption and low levels of support for compulsory treatment, while a majority of those respondents who themselves drink more than 21 units per week disapproved of compulsory treatment. The survey responses on the issue of the removal of children from alcoholics demonstrate a considerable rise in restrictiveness since 1996.

The role of coercion in the treatment of women with co-occurring disorders and histories of abuse

Debate continues on issues of involuntary treatment for individuals with behavioral healthcare problems. Women with co-occurring disorders and histories of abuse are an especially vulnerable population. This study seeks to increase our knowledge about the experiences of coercion for women in the behavioral healthcare system. Patterns of coercion are explored. This study did not find the predicted relationship between high levels of interpersonal violence and frequent involuntary treatment experiences. The results do offer support for the hypothesis that women are more likely to be currently mandated to treatment if they have been recently arrested, and that being mandated to treatment does not appear to be related to clinical issues such as recidivism and acute symptoms. As expected, women currently required to be in treatment report having less choice in other aspects of their care. Implications for future research in the current climate of increasingly coercive policies are presented.

The use of legal coercion in the treatment of substance abusers: an overview and critical analysis of thirty years of research

Drug and alcohol use presents a serious social problem for most countries in the world. Of particular concern is the well-documented relationship between substance use and crime, which has contributed to an increased popularity and willingness to utilize more forceful means to pressure substance users into treatment. Although compulsory/legally mandated treatment is appealing, it has been one of the most fiercely debated topics in the addiction field, raising a number of issues including ethical concerns and motivational considerations. In this context, the most important question to be answered is whether or not compulsory treatment is effective in the rehabilitation of addicted offenders. Regrettably, three decades of research into the effectiveness of compulsory treatment have yielded a mixed, inconsistent, and inconclusive pattern of results, calling into question the evidence-based claims made by numerous researchers that compulsory treatment is effective in the rehabilitation of substance users. The present paper provides an overview of the key issues concerning the use and efficacy of legal coercion in the rehabilitation of substance users, including a critique of the research base and recommendations for future research.

Quasi-compulsory treatment of drug dependent offenders: an international literature review

This paper reports on a review of the literature on the quasi-compulsory treatment (QCT) of drug dependent offenders in five languages; English, German, French, Italian and Dutch. The findings of this review on previous reviews and on the availability, process, and outcomes of QCT are summarized. The review found that previous, anglophone reviews have tended to present positive outcomes from QCT, but that there are some problems with this research. QCT is increasingly available internationally, but may be applied at different stages of the criminal justice process, and to different types of offender. Research on the process of QCT is comparatively rare. The available research does suggest problems of system integration between criminal justice and treatment agencies in implementing QCT. The research in languages other than English shows a wider range of outcomes (including negative effects) for QCT than was found in the English literature. We conclude that the international literature shows that QCT does not inevitably produce worse outcome than voluntary treatment, but that we need more multimethod, multisite studies of QCT in order to inform policy and practice, which is currently being made in the absence of reliable evidence in many countries.

Forensic and medical legal issues in addiction psychiatry

There is a broad range of forensic issues in addiction psychiatry. For many psychiatrists, what is most challenging about addressing these issues is their origin in the law, which is a system and a way of thinking that may feel foreign to the medical practitioner. To address forensic issues, addiction psychiatrists should learn and understand the specific legal questions that arise in each forensic context. They should become familiar with the relevant definitions, criteria, and legal requirements that apply in each specific area of their practice, rather than assume that clinical definitions and reasoning will carry them. If they perform forensic evaluations, addiction psychiatrists must distance themselves from the wish to help the examinee, focusing on the role of neutral examiner. Comfort and effectiveness with forensic issues require familiarity with, knowledge of, and ultimately respect for the forensic contexts of addiction psychiatric practice.