Substance abuse treatment and pressures from the criminal justice system: data from a provincial client monitoring system

Aims Compulsory treatment is discussed increasingly as a way to reduce the population burden of addictive behaviours. This study explores the extent to which social control strategies exercised through the criminal justice system are used to bring people into substance abuse treatment at a system level. We also assessed whether particular subgroups may be more or less likely to be brought into treatment in this manner. Design We employed a secondary analysis of data from a client‐based information system which captured demographic, referral and substance use characteristics from people seeking treatment for substance abuse. Participants A census of clients (n = 45123) entering specialized Ontario addiction treatment programmes between 1 April 1999 and 31 March 2000. Findings Some 28.9% of clients reported legal problems at treatment intake, and 13.9% had an explicit corrections‐related condition of treatment contact. Logistic regression analyses indicated that legal problems and corrections‐related conditions of treatment were more prevalent among younger, unmarried and unemployed males, who had not completed high school. A number of important interactions were identified between these factors and substance of abuse. Conclusions Implications for equity, accessibility and effectiveness of substance abuse treatment are discussed in relation to the tendency of treatment mandates from criminal justice system to disproportionately affect the entry of this segment of substance‐abusing clients.     

A comparison of voucher exchanges between criminal justice involved and noninvolved participants enrolled in voucher-based contingency management drug abuse treatment programs

This report compares requests for goods or services made by participants in two clinical trials of contingency management for the treatment of substance abuse. One trial was for participants involved with the criminal justice system and one was for participants who were not involved with the criminal justice system. In both trials, participants earned vouchers that could be exchanged for goods or services. Results indicated that the criminal justice group used the majority of their vouchers for paying fees or fines related to the criminal justice system while the other group used only a small portion of their vouchers for paying costs related to the criminal justice system. However, when the costs for the criminal justice system are removed, the proportion of vouchers exchanged for various goods and services are similar between the two groups. The results suggest that for those substance abusers involved in the criminal justice system, assistance in paying fines and fees related to their criminal justice system involvement may be a potentially powerful source of reinforcement that could be used in creative treatment strategies.     

The effect of time spent in treatment and dropout status on rates of convictions,cautions and imprisonment over 5 years in a primary care‐led methadone maintenance service

Background Methadone maintenance treatment (MMT) in primary care settings is used increasingly as a standard method of delivering treatment for heroin users. It has been shown to reduce criminal activity and incarceration over periods of periods of 12 months or less; however, little is known about the effect of this treatment over longer durations. Aims To examine the association between treatment status and rates of convictions and cautions (judicial disposals) over a 5‐year period in a cohort of heroin users treated in a general practitioner (GP)‐led MMT service. Design Cohort study. Setting The primary care clinic for drug dependence, Sheffield, 1999–2005. Participants The cohort comprised 108 consecutive patients who were eligible and entered treatment. Ninety were followed‐up for the full 5 years. Intervention The intervention consisted of MMT provided by GPs in a primary care clinic setting. Measurements Criminal conviction and caution rates and time spent in prison, derived from Police National Computer (PNC) criminal records. Findings The overall reduction in the number of convictions and cautions expected for patients entering MMT in similar primary care settings is 10% for each 6 months retained in treatment. Patients in continuous treatment had the greatest reduction in judicial disposal rates, similar to those who were discharged for positive reasons (e.g. drug free). Patients who had more than one treatment episode over the observation period did no better than those who dropped out of treatment. Conclusions MMT delivered in a primary care clinic setting is effective in reducing convictions and cautions and incarceration over an extended period. Continuous treatment is associated with the greatest reductions.     

Prevalence and characteristics of clients with co-occurring disorders in outpatient substance abuse treatment

This article reports on the prevalence of probable mental health disorders among clients entering outpatient substance abuse treatment, their clinical characteristics, and past access to substance abuse and mental health care. Four hundred fifteen individuals (74% of those eligible) entering three publicly funded outpatient substance abuse treatment facilities in Los Angeles County were screened for a probable mental health disorder. Of the 210 with a positive screener (just over 50% of those screened), 195 (93%) were interviewed. Depression and anxiety were the most common disorders, and more than a third had two or more probable disorders. Close to 70% reported using alcohol, and almost half reported using crack or cocaine. Half had never received any mental health treatment, and for a third this was their first episode of addiction treatment; 22% were on psychotropic medications. Levels of physical and mental health functioning were lower than the 25th percentile of the U.S. population norms. Our results indicate high rates of co-occurring mental health disorders among individuals entering these outpatient substance abuse treatment clinics in Los Angeles. Identifying people with probable mental health disorders as they enter treatment has the potential to increase access to care among those with limited prior access.     

Correlates of early substance use and crime among adolescents entering outpatient substance abuse treatment

Although many studies have examined the relationship between early deviant behavior and subsequent life problems among adolescents drawn from the general population, such relationships have not been examined for youth attending substance abuse treatment. Based on in-depth psychosocial assessments conducted with adolescents entering an outpatient substance abuse treatment program (N = 193), the current study examines individual characteristics, life circumstances, and other behavioral and psychological characteristics that are correlated with the age at which these youth initiated substance use and criminal activity. Early onset of substance use was associated with greater levels of family deviance and a variety of problems including school adjustment, drug use, criminal involvement, bullying and cruelty to people and animals, and involvement in risky sexual activities. In contrast, early onset of crime was related only to male gender, early onset of substance use, and cruelty to people. Findings suggest that treatment providers may need to consider the ages at which their adolescent clients initiated substance use given its association with illegal activity, other deviant behavior, and precocious and high-risk sexual behaviors.     

Engagement with opioid maintenance treatment and reductions in crime: a longitudinal national cohort study

Aims This study investigates changes in criminal involvement among patients in opioid maintenance treatment (OMT) over a 7‐year period prior to, during and after treatment, particularly in relation to differences in treatment engagement. Design, setting and participants Treatment data on all patients who started OMT in Norway between 1997 and 2003 (n = 3221) were cross‐linked with national criminal records. The period of observation was divided into four phases; pre‐treatment, in‐treatment, between treatments and post‐treatment. Findings During OMT, rates of criminal convictions for the cohort were reduced to fewer than half of waiting‐list levels [incidence rate (IR) 0.63 versus 1.57]. Patients in continuous treatment had the fewest convictions (IR 0.47) during treatment. The highest rates were found among patients out of treatment after several treatment episodes (IR 1.52). All groups had significantly fewer criminal convictions during treatment compared to before treatment. Staying in OMT for 2 years or more was associated with significantly reduced rates of convictions during treatment. Younger age and pre‐treatment criminal convictions were associated with significantly (P < 0.001) more convictions during treatment. Those who left treatment, permanently or temporarily, relapsed into high levels of convictions outside treatment. Conclusions Criminal activity appears to be reduced in Norway during opiate maintenance treatment. Younger age and prior history of criminal activity are important risk factors for continued criminal activity during treatment.     

Prevalence and Characteristics of Clients with Co‐Occurring Disorders in Outpatient Substance Abuse Treatment

This article reports on the prevalence of probable mental health disorders among clients entering outpatient substance abuse treatment, their clinical characteristics, and past access to substance abuse and mental health care. Four hundred fifteen individuals (74% of those eligible) entering three publicly funded outpatient substance abuse treatment facilities in Los Angeles County were screened for a probable mental health disorder. Of the 210 with a positive screener (just over 50% of those screened), 195 (93%) were interviewed. Depression and anxiety were the most common disorders, and more than a third had two or more probable disorders. Close to 70% reported using alcohol, and almost half reported using crack or cocaine. Half had never received any mental health treatment, and for a third this was their first episode of addiction treatment; 22% were on psychotropic medications. Levels of physical and mental health functioning were lower than the 25th percentile of the U.S. population norms. Our results indicate high rates of co‐occurring mental health disorders among individuals entering these outpatient substance abuse treatment clinics in Los Angeles. Identifying people with probable mental health disorders as they enter treatment has the potential to increase access to care among those with limited prior access.     

Social Disadvantage and Economic Hardship as Predictors of Follow-Up Addiction Severity after Substance Abuse Treatment: Does Referral to Treatment by the Criminal Justice System Matter?

Few studies have examined the effects of social disadvantage and economic hardship on addiction severity after treatment, and no known studies have examined these relationships in participants referred to treatment by the criminal justice system. This study used multiple regression analysis to examine the role of social disadvantage, economic hardship, and perceived stress on follow-up addiction severity among a group of substance abuse treatment participants referred by the criminal justice system and a comparison group. The hypothesized model was partially supported in both groups. Implications for treatment providers working with clients referred by the criminal justice system are discussed.     

Predictors of Prison-Based Treatment Outcomes: A Comparison of Men and Women Participants

The purpose of this study was to examine differences between men and women entering prison-based therapeutic community (TC) treatment and to explore the relationship of those differences to posttreatment outcomes (i.e., aftercare participation and reincarceration rates). Extensive treatment-intake interview data for 4,386 women and 4,164 men from 16 prison-based TCs in California were compared using chi-square analyses and t-tests. Logistic regression analyses were then conducted separately for men and women to identify gender-specific factors associated with post-treatment outcomes. Prison intake data and treatment participation data come from a 5-year process and outcome evaluation of the California Department of Corrections' (CDC) Prison Treatment Expansion Initiative. The return-to-custody data came from the CDC's Offender Based Information System. Bivariate results showed that women were at a substantial disadvantage compared with their male counterparts with regard to histories of employment, substance abuse, psychological functioning, and sexual and physical abuse prior to incarceration. In contrast, men had more serious criminal justice involvement than women prior to incarceration. After controlling for these and other factors related to outcomes, regression findings showed that there were both similarities and differences with regard to gender-specific predictors of posttreatment outcomes. Time in treatment and motivation for treatment were similar predictors of aftercare participation for men and women. Psychological impairment was the strongest predictor of recidivism for both men and women. Substantial differences in background characteristics and the limited number of predictors related to posttreatment outcomes for women suggests the plausibility of gender-specific paths in the recovery process.     

State policy and practice regarding substance abuse treatment services for medicaid recipients with disabilities

This article presents the results of an exploratory study conducted to identify best practice Medicaid managed care models for people with disabilities who need substance abuse treatment services. These results suggest that there is wide variation in the managed care strategies that states use to provide substance abuse treatment services to the SSI disabled population, that state policymakers are often focused on general program management issues rather than addressing specific issues related to providing substance abuse treatment services to people with disabilities, and that although managed care theoretically offers opportunities for creativity,this practice does not appear to be widespread under current Medicaid managed care arrangements for people with disabilities.     

Coerced treatment for methamphetamine abuse: differential patient characteristics and outcomes

Policymakers have responded to the increase in the prevalence of methamphetamine (MA) use and the associated social costs (such as crime and child abuse and neglect) by mandating a growing number of MA users to substance abuse treatment via the criminal justice system (CJS) and/or child protective service (CPS) agencies. However, empirical evidence remains sparse about treatment outcomes specifically for MA users who report that their treatment admission occurred under such pressures. This analysis uses natural history interview data from 350 clients treated for MA use in Los Angeles County to examine clients' self-reported CJS/CPS pressure to enter treatment, comparing background and treatment characteristics and selected treatment outcomes across groups defined by existence of such perceived pressure and source of pressure. Approximately half the clients reported legal pressure to enter the index (used for sampling) treatment episode. Those reporting pressure were younger, less likely to have received residential treatment, and had longer treatment episodes than those not reporting pressure. Outcomes (treatment completion, relapse within 6 months, time to relapse, and percentage of days with MA use in 24 months following treatment) did not differ significantly in simple comparisons between the pressured and nonpressured groups; however, when client and treatment characteristics were controlled, the short term outcome of relapse within 6 months was worse for those reporting legal pressure. Outcomes did not differ by source of pressure.     

The effect of a contingent monetary reward on probation referrals to a drug abuse program

Faced with reductions in public funds and calls for greater accountability, substance abuse programs can possibly increase revenues through patient fees by increasing referrals from the criminal justice system. Accountability can be improved through the use of organizational behavior management techniques. This study demonstrates the utility of behavioral techniques to increase referrals and revenue in an outpatient drug abuse program. The rate of criminal justice referrals increased substantially when counselors were offered "commissions" based on patient fees. These results are discussed with respect to the practicality of behavioral techniques in the management of drug abuse programs and with regard to policy implications.     

Increased HIV Risk Associated with Criminal Justice Involvement among Men on Methadone

This paper examines the relationship between HIV risk and criminal justice involvement among a random sample of 356 men enrolled in methadone maintenance treatment programs in New York City. Bivariate and logistic regression analyses were performed to estimate the associations between measures of criminal justice involvement and participant HIV risk, controlling for socio-demographic variables. A lifetime history of incarceration was significantly associated with being HIV positive (Adjusted OR = 5.08). Recent arrest was associated with unprotected vaginal sex and having multiple female sexual partners. Sex trading was associated with both arrest and incarceration, and the strongest association was found between selling sex and recent incarceration (Adjusted OR = 5.69). Results suggest that recent criminal justice involvement among men with substance abuse histories is associated with increased HIV risk behaviors. Findings underscore the need for targeted HIV prevention efforts for men on methadone with a recent history of arrest or incarceration. An erratum to this article can be found at     

Predictors of prison-based treatment outcomes: a comparison of men and women participants

The purpose of this study was to examine differences between men and women entering prison-based therapeutic community (TC) treatment and to explore the relationship of those differences to posttreatment outcomes (i.e., aftercare participation and reincarceration rates). Extensive treatment-intake interview data for 4,386 women and 4,164 men from 16 prison-based TCs in California were compared using chi-square analyses and t-tests. Logistic regression analyses were then conducted separately for men and women to identify gender-specific factors associated with post-treatment outcomes. Prison intake data and treatment participation data come from a 5-year process and outcome evaluation of the California Department of Corrections' (CDC) Prison Treatment Expansion Initiative. The return-to-custody data came from the CDC's Offender Based Information System. Bivariate results showed that women were at a substantial disadvantage compared with their male counterparts with regard to histories of employment, substance abuse, psychological functioning, and sexual and physical abuse prior to incarceration. In contrast, men had more serious criminal justice involvement than women prior to incarceration. After controlling for these and other factors related to outcomes, regression findings showed that there were both similarities and differences with regard to gender-specific predictors of posttreatment outcomes. Time in treatment and motivation for treatment were similar predictors of aftercare participation for men and women. Psychological impairment was the strongest predictor of recidivism for both men and women. Substantial differences in background characteristics and the limited number of predictors related to posttreatment outcomes for women suggests the plausibility of gender-specific paths in the recovery process.     

Comparison of Health Realization and 12-Step Treatment in Women's Residential Substance Abuse Treatment Programs

The purpose of this study was to compare a relatively new therapeutic option for substance abuse treatment, Health Realization, and 12-Step approaches offered in women's residential programs. The study was sponsored by a large California county's Department of Alcohol and Drug Services, which had offered Health Realization treatment for a number of years. This study constitutes the first systematic evaluation of Health Realization as a substance abuse treatment program for adult women in a residential treatment setting. This was a randomized study with two observations-admission and 9 months post-admission. The results showed that clients in both Health Realization and 12-Step treatment exhibited comparable outcomes on domains such as substance use, criminal justice involvement, employment, housing, adverse effects of substance use and psychological well being. Substance use declined significantly between admission and follow-up in both treatment groups, irrespective of duration of treatment. Similarly, adverse effects of substance use declined between admission and 9-month follow-up. Health Realization and 12-Step treatment offered comparable benefits for women in residential substance abuse treatment programs.     

Comparison of Health Realization and 12-Step treatment in women's residential substance abuse treatment programs

The purpose of this study was to compare a relatively new therapeutic option for substance abuse treatment, Health Realization, and 12-Step approaches offered in women's residential programs. The study was sponsored by a large California county's Department of Alcohol and Drug Services, which had offered Health Realization treatment for a number of years. This study constitutes the first systematic evaluation of Health Realization as a substance abuse treatment program for adult women in a residential treatment setting. This was a randomized study with two observations-admission and 9 months post-admission. The results showed that clients in both Health Realization and 12-Step treatment exhibited comparable outcomes on domains such as substance use, criminal justice involvement, employment, housing, adverse effects of substance use and psychological well being. Substance use declined significantly between admission and follow-up in both treatment groups, irrespective of duration of treatment. Similarly, adverse effects of substance use declined between admission and 9-month follow-up. Health Realization and 12-Step treatment offered comparable benefits for women in residential substance abuse treatment programs.     

Diversion from jail of detainees with substance abuse: the interaction with dual diagnosis.

The objective of this retrospective study was to determine if a jail diversion program reduced days of incarceration over the year following arrest in a sample of detainees with substance abuse disorders who had been arrested for a minor (misdemeanor) crime (n = 252) compared to a group (n = 95) who were not diverted. Particular attention was paid to comparing those singly diagnosed to those dually diagnosed. Analyses indicated that 1) detainees with substance abuse alone were less likely to be diverted than those with a dual diagnosis; 2) jail diversion reduced incarceration time during the next year; and 3) the effect of diversion differed depending upon the level of criminal charge. Diversion significantly reduced jail time only among those who were arrested for the more serious of the minor offenses that are associated with longer jail sentences.     

Criminal behavior in antisocial substance abusers between five and fifteen years follow-up

Antisocial personality disorder (ASPD) is one of the most common co-occurring disorders in substance abusers, characterized among other things by a high propensity for criminal actions. A cohort of 125 substance abusers were followed in a longitudinal design. Patients were diagnosed with ASPD at an index treatment episode, interviewed at five-year follow-up, and followed-up through the Swedish criminal justice register by 2005 for the years 1995-2003. ASPD and non-ASPD subjects were compared using Mann Whitney U test for ordinal variables (number of offenses and months in prison) and chi-square tests for categorical variables. A total of 107 were alive by 1995, when the period of observation began. ASPD diagnosed at baseline was related to criminal offenses and incarceration during the follow-up from 5 to 15 years. For most categories, ASPD diagnosis was associated with higher frequency of offense. An ASPD diagnosis based on SCID-II interview made at five-year follow-up was related to the number of offenses but unrelated to incarceration. In a sample of drug abusers, ASPD was associated with high levels of criminal behavior, even years after the diagnosis was given. A diagnosis based on clinical observation during treatment was at least as predictive of criminal behavior as a diagnosis based on a SCID-II interview.