Download Prison Health Research Network Website

Systematic Review of the
Effectiveness of Alcohol
Treatments in Offender
Populations
Amanda Roberts
www.phrn.nhs.uk
Background
The PHRN commissioned reviews of
existing literature for four work streams:
Dentistry, Mental Health, Primary Care
and Substance Misuse.
Part of a larger PHRN review
commissioned and funded by Offender
Health.
Entitled: ‘Drug and Alcohol Treatments in
Prison and Community Settings’
(Roberts A, Hayes A, Carlisle J and Shaw
J, 2007)
www.phrn.nhs.uk
Rationale
Substance misuse is a major problem in
the general population as well as in
prisons and the wider CJS.
Large body of evidence for community
based drug treatments.
Far less research in CJS.
Also, alcohol not often considered
separately but assimilated into the larger
category of substance misuse.
www.phrn.nhs.uk
Policy
NOMS
strategy for problematic drug users in
correctional services (NOMS, 2005).
HM Prison Service
drug and alcohol strategies (HMPS,
2002; 2003; 2006)
good practice guide for alcohol
treatment and interventions (HMPS,
2004)
www.phrn.nhs.uk
Policy
National Probation Service
strategy for working with alcohol
misusing offenders (National Probation
Service, 2006).
‘Safe. Sensible. Social’ (2007)
National alcohol strategy including
offender populations
www.phrn.nhs.uk
Aims of the SR
To summarise the research evidence on
the effectiveness of treatment and
prevention interventions which aim to
reduce;
(i) Alcohol use/abuse
AND/OR
(ii) criminal behaviours
in offender populations.
www.phrn.nhs.uk
Search Sources
Nine databases (April 10th-14th 2007)
Comprehensive range of Criminological,
Psychological and Social Science journals.
www.phrn.nhs.uk
Search Terms
 Combination of search terms relating to
both alcohol and offending;
(i) alcohol* or drink* or drunk* AND
(ii) jail* or inmate* or criminal* or
offender* or incarcerat* or penitentiar*
 Terms adapted for each search engine to
exploit the database most effectively.
www.phrn.nhs.uk
Search Results
7003 journals retrieved.
Duplicates removed.
Book reviews (19), discussion and opinion
pieces removed (54).
Studies with dual reporting of drugs and
alcohol (13), and for not evaluating an
intervention (8).
www.phrn.nhs.uk
Search Results
28 journals met the final stage criteria.
4 further excluded after further inspection.
Final total 24 studies.
www.phrn.nhs.uk
Methodological
Quality
In order to evaluate the effectiveness of
interventions, a degree of scientific
certainty was required.
Review employed a ‘methodological rigour
rating scale’ (Scientific Methods Scale,
(SMS) Sherman et al, 1997)
www.phrn.nhs.uk
Methodological
Quality
Sliding scale from 1 to 5 (from 1=
correlation to 5=RCT ‘gold standard’). The
higher the SMS level the more able the
study is to infer a ‘cause and effect’
relationship.
www.phrn.nhs.uk
Analysis
Heterogeneity of studies prevented any
quantitative statistical analysis.
Quantitative Narrative Review was
conducted.
Studies presented in tables of treatment
type detailing: country, SMS level, total n,
age, offence type, follow-up lengths,
baseline differences present, outcomes on
alcohol use and recidivism.
www.phrn.nhs.uk
Analysis
Studies classified also by type of study i.e
T0,T1,T2,T3. T0=treatment group
compared with control, T1= treatment
group compared with another
intervention.
www.phrn.nhs.uk
Demographics
Country of Origin: 19 USA; 2 UK; 1
Germany; 1 New Zealand; 1 Canada.
SMS Levels: 7 level 5; 6 level 4; 10 level
3; 1 level 2.
Sample sizes: ranged from 18 to 148,632
Ages: 4 studies YOs; 10 adults; 8 mixed;
2 not reported.
Offence Type: 17 DWI; 5 mixed; 1
Violence; 1 unreported
www.phrn.nhs.uk
Evaluated
Interventions
Type of Intervention
Psycho-Social-Behavioural
Number of Studies
12
VIPs
6
Legal Sanctions (II)
3
TCs
2
Psycho-Social-Behavioural
with Legal Sanctions (II)
1
Psycho-Social-Behavioural
with Legal Sanctions and Victim Impact Panels
(VIPs)
1
Psycho-Social-Behavioural
with Therapeutic Communities (TCs)
1
Psycho-Social-Behavioural with VIP
1
Other (Vipassana Meditation)
1
Total Studies
www.phrn.nhs.uk
28
Examples of
Interventions
PSB
Alcohol education courses (AECs)
Self help manuals
AA
CBT
Psychological Interventions (individual or
family)
Group dynamic interventions
www.phrn.nhs.uk
Examples of
Interventions
PSB+Legal Sanctions
Jail term and PSB
Ignition Interlock and/or Licence
suspensions and PSB
www.phrn.nhs.uk
Research Question
‘Which interventions help to decrease
alcohol use/abuse and/or recidivism?’
Reported by treatment type
Reported by study quality
www.phrn.nhs.uk
Results by Treatment
Type
PSB
4:16 effective in reducing alcohol use and
recidivism.
* One study showed increased alcohol use
and 2 studies reported increased rates
recidivism post intervention
PSB and Legal Sanctions
2:16, one effective in reducing alcohol not
recidivism; one effective in reducing
recidivism but did not report alcohol
outcomes.
www.phrn.nhs.uk
Results by
treatment type
PSB, Legal Sanctions and VIP
1:16, reduction in criminal activity not
alcohol
PSB and TC
1:16, reduction in criminal activity and
alcohol use
www.phrn.nhs.uk
Results by Treatment
Type
TCs
2 studies evaluated the effectiveness of
TCs only one reduced later alcohol use
Legal Sanctions and Licence Suspension
(II)
2 studies both reduced later alcoholrelated driving offences
www.phrn.nhs.uk
Results by
treatment type
VIPs
On the whole ineffective. One study
showing positive effect on recidivism. Only
one reported alcohol outcomes and found
no differences.
Other (VP)
One study, effective in reducing alcohol
use but not recidivism.
www.phrn.nhs.uk
Results by study
quality
 6 RCTs (SMS level 5)
 For recidivism:
- only 2 effective (PSB and Legal Sanctions/II)
- other 4 reported no differences
 For alcohol:
- 2 effective (PSB and TC)
- 3 showed no differences (PSB/VIP (2), VIP)
- 1 didn’t evaluate alcohol outcomes (LS)
* one PSB intervention found increased alcohol
use post intervention
www.phrn.nhs.uk
SR Conclusions
Limited conclusions can be drawn
No consistently conclusive evidence
for the effectiveness of a single
intervention.
SR difficult when methodological
quality of studies are poor.
www.phrn.nhs.uk
Caveats
Impact of CJS structural obstacles (i.e:
random allocation not possible and/or
control groups not possible) on research
quality.
Non-equivalence limits ability to make
causal inferences. Consequently, tried to
implement comparison groups but this
introduces baseline differences. (13 24
studies had such differences)
www.phrn.nhs.uk
Caveats
Mandatory/voluntary problem. (Coerced
by virtue of a reduction in sentence)
Introducing research ethical dilemmas.
Differential affect of being mandated to an
intervention in a prison environment as
oppose to in the community; what works
in a prison setting may not work in the
community and vice versa.
www.phrn.nhs.uk
Discussion
Cultural factors, design of interventions
that can be implemented in multi-cultural
settings.
Do different interventions work for
different types of offenders?
www.phrn.nhs.uk
Discussion
Research needed that evaluates the
effectiveness of interventions by individual
characteristics and by offence type.
Some interventions are effective at
differing follow up periods i.e long term
not short term and vice versa. Therefore,
research needed that evaluates
interventions that have a long term
sustainable effect
www.phrn.nhs.uk
Drug and Alcohol
Review
‘Drug and Alcohol Treatments in Prison
and Community Settings’
(Roberts A, Hayes A, Carlisle J and Shaw
J, 2007)
Full review can be found at
www.phrn.nhs.uk/prison/SMreview.pdf
www.phrn.nhs.uk