Evidence-based principles for prison-based alcohol and drug treatment
Dr Jillian Mullen
Principal Adviser Alcohol and Other Drugs, Department of Corrections
Author biography:
Jillian has a Masters in Research Methods and a PhD in Psychology. She joined the Department in June 2016 and was previously working in academia where she has published widely on the design, implementation and evaluation of substance use treatment programmes as well as methods of alcohol use detection.
Alcohol and drug use
The misuse of alcohol and other drugs (AOD) has considerable impact on health, public safety, productivity, and crime, and causes a significant economic burden to society. In New Zealand, prisoners are seven times more likely to have a substance use disorder diagnosis compared to the general population (New Zealand Department of Corrections, 2016). But New Zealand is not alone, as international research indicates that this is true in many other countries, with studies consistently showing that a high proportion of prisoners are dependent on alcohol and/or drugs (e.g., Lo & Stephens, 2000; Pernanen, Cousineau, Brochu, & Sun, 2002). Recently published research by the Department shows that the majority of prisoners sampled in New Zealand had a lifetime diagnosis of a substance use disorder diagnosis (87%), and approximately half (47%) had a current substance use disorder diagnosis (New Zealand Department of Corrections, 2016). Imprisonment therefore offers a unique opportunity to provide treatment to a high need population, which could have profound effects on society.
Evidence-based principles of treatment
Substance use treatments are commonly delivered within prisons. Considering the positive impact that treating alcohol and substance misuse within prison could have, it is important that the treatments being delivered are effective. Considerable research has been conducted over the past two decades examining which components of substance use treatment for prisoners are likely to reduce use and re-offending. This research has resulted in a growing consensus within the sector on what are considered evidence-based principles for effective substance use treatment for individuals within the criminal justice system (e.g., Belenko, Hiller & Hamilton, 2013; Fletcher & Chandler, 2006; Friedmann, Taxman & Henderson, 2007). Twelve key principles are outlined below.
Principle 1: Treatment duration should be 90 days or more
The length of time an individual is in AOD treatment is one of the most reliable predictors of reductions in AOD use. It is generally accepted that treatment lasting 90 days or longer is most effective, however, the optimum duration is dependent on individual needs. Delivering treatment within prison to meet these time periods is not always feasible due to sentence length, sentence type (i.e. remand), and other competing rehabilitation needs. In these instances, prison still presents the opportunity to adopt Screening, Brief Intervention, and Referral to Treatment (SBIRT) programmes. SBIRT programmes allow for the identification of those in need of treatment and provide the opportunity to engage them in treatment.
Principle 2: A comprehensive assessment should be conducted prior to treatment
Implementing standardised assessment tools and measures that have been empirically validated is an important first step in the treatment process for two main reasons. First, assessments of substance use and risk of re-offending can be used to identify the most appropriate prisoners for treatment (i.e., those of highest risk and highest need). Second, an in-depth comprehensive assessment allows not only for the identification of AOD problems, but also to gauge the extent of these problems and identify any other co-existing issues that might impact on the person’s recovery. The results of a comprehensive assessment therefore enables treatment plans to be developed that match the needs of the individual.
Principle 3: Tailoring services to the needs of the individual
People differ on many factors: age, sex, culture, co-occurring psychiatric disorders, treatment motivation level, severity of AOD misuse, cognitive ability, housing status, and employment status among others. These factors influence AOD treatment outcomes. As such, it is important to use comprehensive assessments to guide treatment planning to meet the needs of the individual.
Principle 4: Monitor drug use
Breathalysers and urinalysis provide objective measures of AOD use. Monitoring a prisoner’s AOD use during treatment allows both treatment and custodial staff to examine a prisoner’s progress. Lapses are a normal part of recovery and monitoring substance use enables unreported use to be identified. This is important, as detected AOD use is a key teachable moment for therapeutic intervention. It has to be acknowledged, however, that given the environment, prison-based AOD treatment programmes offer only a limited opportunity to work with lapses. For example, an initial lapse may be addressed therapeutically (depending on the risk to the unit as determined by the principal corrections officer) but clear consequences and parameters could then be put in place to address any future use.
Principle 5: Target factors associated with criminal behaviour
This principle suggests that AOD treatment should also incorporate components addressing factors associated with criminal behaviour to reduce the likelihood of re-offending. Research has shown that there are a variety of factors that predict criminal behaviour. The Risk Needs and Responsivity model (Andrews & Bonta, 2006) is a widely regarded model for guiding offender assessment and treatment and is the model adopted by the Department. This model indicates that antisocial attitudes, antisocial personality, antisocial behaviour and antisocial associates, referred to as the “big four”, are key predictors of re-offending and therefore should be key targets.
Principle 6: Co-ordinating correctional supervision requirements and treatment
When identified as a need, substance use treatment should be incorporated into correctional supervision requirements. Research has shown that individuals referred to treatment as part of correctional supervision requirements have similar, if not better, treatment outcomes compared to those who self refer (e.g., Miller & Flaherty, 2000).
Principle 7: Continuity of care
Those receiving AOD treatment in prison are vulnerable to relapse upon release. The gains made during prison-based AOD treatment are less likely to be maintained without continued support for the offender to manage issues and barriers to their recovery in the community. Research has consistently shown that participation in a continuum of treatment is the most effective strategy for alcohol and other drug involved prisoners (e.g., Butzin, Martin & Inciardi, 2002).
Principle 8: Rewards and sanctions
The systematic application of rewards and sanctions can shape behaviour. For example, contingency management has been shown to be an effective practice that shapes behaviour in community settings (e.g., Kirby, Benishek & Tabit, 2016; Prendergast, Podus, Finney, Greenwell & Roll, 2006). This involves rewarding individuals for achieving objectively measured behaviours; it is more effective when the reward is delivered as close as possible to the behaviour. Behaviours typically targeted are abstinence from drugs, treatment attendance, treatment engagement, and medication compliance. Within prison, however, it is important to also include sanctions for negative behaviours.
Principle 9: Integrating mental health treatment
The presence of co-occurring psychiatric disorders is a key predictor of poor AOD treatment outcomes (e.g., Compton III, Cottler, Jacobs, Ben-Abdallah & Spitznagel, 2003). We know that the prevalence of psychiatric disorders within the prison population is higher than in the general population; recent research from the Department shows that in New Zealand, one in five prisoners sampled had a diagnosis for both a substance use disorder and other psychiatric disorder, which was higher for women than men (New Zealand Corrections Department, 2016). It is therefore important to ensure that individuals engaging in substance use treatment are at least screened for psychiatric disorders. If a co-occurring psychiatric disorder is present, an integrated treatment approach may be required to meet the individual’s needs.
Principle 10: Medication-assisted treatment
Psychotherapy is most often the primary approach taken to treat substance use disorders. However, for more severe cases medications may be used. Several medications have been approved internationally to treat substance use disorders. For example, Methadone and Buprenorphine have been shown to be effective for treating opiate/heroin use disorder and Naltrexone and Acamprosate have been shown to be effective for alcohol use disorder, particularly when augmented with behavioural therapies.
Principle 11: Identifying appropriate individuals for treatment
It is important that resources are focused on the people who need them. Through screening and comprehensive assessments it is possible to identify those who need treatment, identify the level of treatment suitable for that individual and prioritise treatment for those who need it most. AOD treatment, although associated with reductions in re-offending, offers other considerable benefits in terms of harm reduction and health enhancement. As such, AOD treatment intensity should be matched to the offender’s AOD use severity and therefore, should not only be prioritised for those at higher risk of re-offending.
Principle 12: Treatment engagement and motivation
Motivational interviewing (Rollnick & Miller, 1991) is a prominent client-centered counselling style used to elicit motivation for behavioural change and has been shown to significantly improve rates of treatment engagement and retention. Irrespective of sentence length, motivational interviewing techniques can be incorporated at many intervention points within an offender’s prison journey and can be delivered by AOD treatment providers, healthcare professionals and Corrections staff.
Concluding remark
Treating AOD misuse among prisoners has significant implications for both public safety and public health. Prison provides a unique opportunity to reach a high risk, high need population but in order to capitalise on this it is vital that evidence-based principles for treating alcohol and drug misuse continue to be implemented. The Department is committed to taking an evidence-based approach to treatment; ensuring that these principles are being implemented across all Drug Treatment Units.
References
Andrews, D. A., & Bonta, J. (2006). The psychology of criminal conduct (4th ed.). Newark, NJ: LexisNexis.
Belenko, S., Hiller, M., & Hamilton, L. (2013). Treating substance use disorders in the criminal justice system. Current psychiatry reports, 15(11), 1-11.
Butzin, C. A., Martin, S. S., & Inciardi, J. A. (2002). Evaluating component effects of a prison-based treatment continuum. Journal of Substance Abuse Treatment, 22(2), 63-69.
Compton III, W. M., Cottler, L. B., Jacobs, J. L., Ben-Abdallah, A., & Spitznagel, E. L. (2003). The role of psychiatric disorders in predicting drug dependence treatment outcomes. American Journal of Psychiatry, 160(5), 890-895.
Fletcher, B. W., & Chandler, R. K. (2006). Principles of drug abuse treatment for criminal justice populations. Washington, DC: National Institute on Drug Abuse.
Friedmann, P. D., Taxman, F. S., & Henderson, C. E. (2007). Evidence-based treatment practices for drug-involved adults in the criminal justice system. Journal of Substance Abuse Treatment, 32(3), 267-277.
Kirby, K. C., Benishek, L. A., & Tabit, M. B. (2016). Contingency management works, clients like it, and it is cost-effective. The American journal of drug and alcohol abuse, 42(3), 250-253.
Lo, C. C., & Stephens, R. C. (2000). Drugs and Prisoners: Treatment Needs on Entering Prison. The American journal of drug and alcohol abuse, 26(2), 229-245.
Miller, N. S., & Flaherty, J. A. (2000). Effectiveness of coerced addiction treatment (alternative consequences): A review of the clinical research. Journal of Substance Abuse Treatment, 18(1), 9-16.
Miller, W. R., & Rollnick, S. S.(1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford.
New Zealand Department of Corrections (2016). Comorbid substance use disorders and mental health disorders among New Zealand prisoners. Wellington: New Zealand Department of Corrections.
Pernanen, K., Cousineau, M. M., Brochu, S., & Sun, F.(2002). Proportions of crimes associated with alcohol and other drugs in Canada. Ottowa, Canada: Canadian Centre on Substance Abuse.
Prendergast, M., Podus, D., Finney, J., Greenwell, L., & Roll, J. (2006). Contingency management for treatment of substance use disorders: A meta-analysis. Addiction, 101(11), 1546-1560.