1. www.phrn.nhs.uk Systematic Review of the Effectiveness of Alcohol Treatments in Offender Populations Amanda Roberts

2. 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)

3. 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.

4. 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)

5. 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

6. 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.

7. www.phrn.nhs.uk Search Sources  Nine databases (April 10 th -14 th 2007)  Comprehensive range of Criminological, Psychological and Social Science journals.

8. 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.

9. 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).

10. www.phrn.nhs.uk Search Results  28 journals met the final stage criteria.  4 further excluded after further inspection.  Final total 24 studies.

11. 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)

12. 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.

13. 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.

14. 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.

15. 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

16. www.phrn.nhs.uk Evaluated Interventions Type of InterventionNumber of Studies Psycho-Social-Behavioural12 VIPs6 Legal Sanctions (II)3 TCs2 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 VIP1 Other (Vipassana Meditation)1 Total Studies28

17. www.phrn.nhs.uk Examples of Interventions PSB  Alcohol education courses (AECs)  Self help manuals  AA  CBT  Psychological Interventions (individual or family)  Group dynamic interventions

18. www.phrn.nhs.uk Examples of Interventions PSB+Legal Sanctions  Jail term and PSB  Ignition Interlock and/or Licence suspensions and PSB

19. 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

20. 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.

21. 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

22. 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 alcohol- related driving offences

23. 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.

24. 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

25. 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.

26. 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)

27. 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.

28. 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?

29. 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

30. 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