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Systematic Review of the Effectiveness of Alcohol Treatments in Offender

Populations

Amanda Roberts

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BackgroundThe 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)

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RationaleSubstance 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.

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PolicyNOMS

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)

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PolicyNational Probation Service

strategy for working with alcohol misusing offenders (National Probation Service, 2006).

‘Safe. Sensible. Social’ (2007)National alcohol strategy including

offender populations

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Aims of the SRTo 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.

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Search SourcesNine databases (April 10th-14th 2007)

Comprehensive range of Criminological, Psychological and Social Science journals.

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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.

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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).

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Search Results 28 journals met the final stage criteria.

4 further excluded after further inspection.

Final total 24 studies.

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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)

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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.

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AnalysisHeterogeneity 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.

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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.

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DemographicsCountry 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 148,632Ages: 4 studies YOs; 10 adults; 8 mixed; 2

not reported.Offence Type: 17 DWI; 5 mixed; 1

Violence; 1 unreported

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Evaluated Interventions

Type of Intervention Number of StudiesPsycho-Social-Behavioural 12VIPs 6Legal Sanctions (II) 3TCs 2Psycho-Social-Behaviouralwith Legal Sanctions (II)

1

Psycho-Social-Behaviouralwith Legal Sanctions and Victim Impact Panels (VIPs)

1

Psycho-Social-Behaviouralwith Therapeutic Communities (TCs)

1

Psycho-Social-Behavioural with VIP 1Other (Vipassana Meditation) 1Total Studies 28

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Examples of Interventions

PSBAlcohol education courses (AECs)Self help manualsAACBTPsychological Interventions (individual or

family)Group dynamic interventions

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Examples of Interventions

PSB+Legal SanctionsJail term and PSB

Ignition Interlock and/or Licence suspensions and PSB

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Research Question

‘Which interventions help to decrease alcohol use/abuse and/or recidivism?’

Reported by treatment typeReported by study quality

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Results by Treatment Type

PSB4:16 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 Sanctions2:16, one effective in reducing alcohol not

recidivism; one effective in reducing recidivism but did not report alcohol outcomes.

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Results by treatment type

PSB, Legal Sanctions and VIP1:16, reduction in criminal activity not

alcohol

PSB and TC1:16, reduction in criminal activity and

alcohol use

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Results by Treatment Type

TCs2 studies evaluated the effectiveness of

TCs only one reduced later alcohol use

Legal Sanctions and Licence Suspension (II)

2 studies both reduced later alcohol-related driving offences

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Results by treatment type

VIPsOn 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.

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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

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SR ConclusionsLimited conclusions can be drawnNo consistently conclusive evidence

for the effectiveness of a single intervention.

SR difficult when methodological quality of studies are poor.

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CaveatsImpact 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)

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CaveatsMandatory/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.

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DiscussionCultural factors, design of interventions

that can be implemented in multi-cultural settings.

Do different interventions work for different types of offenders?

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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

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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