Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 8 May 2013

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


First entry asks what 'recovery' is and contrasts understandings in addiction with those in mental health. Whatever recovery is, extending remission in substance use via extended treatment is a key way to get there and the subject of the next two entries, both concerned with how to consolidate a break in substance use in to a life free of dependence. Last a study which confirms the reality of peer influence on which much drug prevention is based.

What is recovery? ...

Ways to extend cocaine treatment gains ...

Starting methadone in prison promotes treatment on release ...

Teenage peer influence on drinking is no illusion ...

The meanings of recovery from addiction: evolution and promises.

El-Guebaly N.
Journal of Addiction Medicine: 2012, 6(1), p 1–9.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr El-Guebaly at nady.el-guebaly@albertahealthservices.ca. You could also try this alternative source.

What is 'recovery' and what does it mean for the roles of treatment and of doctors? This analysis based on the last ten years' writings on the subject draws a parallel with mental health, where recovery in terms of a meaningful and self-directed life is reserved for persisting severe illness resistant to 'cure' via treatment.

Summary This literature review focuses on the history, definitions, and forms of 'recovery' from addiction, its nature and time course, and the implications for managing substance use disorders. The reviewer searched the English-language peer-reviewed literature of the past ten years using the key words "recovery from addiction" and followed up references in retrieved papers.

Main findings

Over the last 200 years terms for the resolution of severe substance use problems have been based on ideas about the causes of those problems. Such terms have included moral 'reformation', religious 'redemption', criminal 'rehabilitation', and medical 'recovery'.

Traditionally in medicine recovery has connoted a return to health after trauma or illness. In 1939, Alcoholics Anonymous (AA) published the book How more than one hundred men have recovered from alcoholism. For AA 'recovery' was a central concept underpinning the ongoing cognitive, emotional, behavioural, and spiritual reconstruction of the sobered alcoholic, shifting the emphasis from recovery initiation (how to stop drinking) to recovery maintenance (how not to start drinking) and from chemical sobriety to "emotional sobriety".

Though sobriety is central, 12-step movements acknowledge its limitations as the sole defining feature of recovery by recognising 'dry drunk' and 'white knuckling' forms of sobriety. In 1982, the American Society of Addiction Medicine differentiated between recovery ("a state of physical and psychological health, such as his/her abstinence from dependency-producing drug is complete and comfortable") and remission ("freedom from the active signs and symptoms of alcoholism, including the use of substitute drugs, during a period of independent living"), and conceptualised recovery as a "process".

More recent definitions have highlighted the experiential process involved: "recovery is the experience (a process and a sustained status) through which individuals, families, and communities impacted by severe alcohol and other drug (AOD) problems utilize internal and external resources to voluntarily resolve those problems, heal the wounds inflicted by AOD-related problems, actively manage their continued vulnerability to such problems, and develop a healthy, productive, and meaningful life".

A consensus panel convened by the US Betty Ford Institute defined recovery as a "voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship", where "sobriety" meant abstinence from alcohol and other non-prescribed drugs, considered "stable" after five years, "personal health" referred to improved quality of personal life, and "citizenship" to living with regard and respect for those around you.

In mental health and psychiatry, 'recovery' emerged as a reaction to the perceived shortcomings of an established system of care, and is defined somewhat differently. For the American Psychiatric Association, 'cure' through treatment is the resolution route for most mental health problems, while recovery is for the severe and persistently mentally ill. For them, it is seen as "emphasizing a person's capacity to have hope and lead a meaningful life ... It recognizes that patients often feel powerless or disenfranchised, that these feelings can interfere with initiation and maintenance of mental health and medical care and that the best results come when patients feel that treatment decisions are made in ways that suit their cultural, spiritual, and personal ideals. It focuses on wellness and resilience and encourages patients to participate actively in their care, particularly by enabling them to help define the goals of psychopharmacologic and psychotherapeutic treatments".

In both addiction and mental health fields, concepts of recovery have been shaped by service user experience described in firsthand accounts of recovery as individualised growth, emphasising the importance of family and peer support. In contrast, organised systems of care have been seen as focusing on cyclical episodes of symptom manifestation and clinical stabilisation and providing inadequate long-term services and supports. Of note, consumer advocacy in mental health thrived after the onset of deinstitutionalization without appropriately resourced community alternatives. The "learned helplessness" fostered in the asylums of old was replaced by the messages of hope and individual responsibility promoted in recovery.

Of the varieties of recovery, 'natural recovery' without treatment has been found the most common way out of alcohol use disorders, though in some studies for relatively low-risk drinkers to begin with, and usually followed by one or more relapses. Challenging recovery as a 'process' are accounts of sudden 'transformational' change, often an unplanned but permanent reaction to some event which involves profound religious, spiritual, or secular experiences that radically redefine personal identity, interpersonal relationships, and the prior pattern of substance use. 'Medication-assisted' recovery is increasingly recognised as a legitimate variant, exemplified by medically and socially stable patients on methadone. Of significance in defining this variant is whether the medication incites or quells compulsive drug-seeking, enhances or inhibits broader dimensions of global health, and increases or decreases the harm to individuals and their environment.

Management implications

From these considerations several implications emerge for the management of addiction, among which are:

Strategies for a chronic disorder Implied by seeing addiction recovery as a long-term and ongoing process which does not have an end point. The truism that 'there is no such thing as graduating'; is consistent with the prevalent view of addiction as a chronic condition and with findings that resolving addiction often takes multiple attempts and treatment episodes.

System implications of a recovery paradigm Constructing a continuum of care requires treatment providers to shift focus from acute biopsychosocial stabilisation to sustained recovery management, starting with pre-treatment services to strengthen engagement and motivation and remove obstacles to recovery, then in-treatment services to enhance retention and acquisition of skills transferable to one's community, and finally post-treatment recovery management involving extended monitoring, use of incentives and sanctions, recovery education and coaching, active linkages to communities of recovery, and early re-intervention. This continuum might be delivered via a cost-saving 'stepped care' process, whereby more intensive interventions are reserved for those who would not be or have not been well served by less intensive interventions, and intervention stepped down in intensity as recovery stabilises. To address the workforce needs of this new paradigm, recovery advocacy organisations and peer-based recovery support centres have expanded and new roles such as recovery coaches and personal recovery assistants have been created.

Monitoring and sustenance of recovery Managing addiction as a chronic condition requires more assiduous continuing care protocols such as regular check-ups, which have been found to facilitate early return to treatment when needed and more treatment. Recovery may also be sustained through various mutual help networks, randomised urine testing, journaling and daily readings (mostly based on relapse prevention strategies), the imposition of contingencies for behaviour, and e-health management programmes. Following the trend in other chronic disorders, technology-based initiatives have been developed and tested to improve outcomes and cost-effectiveness.

The authors' conclusions

Although the conceptualisation of recovery from addiction remains complex and a consensual theoretical framework is lacking, nevertheless it is also ushering in a transformation of treatment to a stepping-stone to recovery and to the range of long-term resources needed to sustain it. Major features of recovery include a healing and growth process spanning years rather than weeks or months, involving the initial stepping stones of treatment, such as biopsychosocial stabilisation, skills building, and relapse prevention, followed by a reconstructive journey ultimately aimed at discovering a meaning and purpose to one's life. While originally the goals of 'abstinence' and 'recovery' were used interchangeably, abstinence now emerges as significant means to an end, not the end itself.

This understanding of recovery allows for the inclusion of several pathways, including the use of medically monitored medications, whose recovery status is best evaluated in terms of the motivation for medication use and its effects. Harm reduction programmes not aimed at reducing drug use as such do not preclude, after an appropriate stabilisation period, renewed attempts to achieve a goal of recovery without the assistance of medication.

More so than recovery from other chronic health conditions, recovery in addiction is seen as entailing personal character change – a broader transformation of personal character or identity, enriching one's life with progress toward global health. 'Recovery' is not only about abstaining from drugs but also about becoming a better person.

All this means changes for the roles of doctors to span the recovery-oriented stages of care. They are involved in pre-treatment screening, brief intervention, and referral, acute biopsychosocial management, can provide appropriate medication and (along with other health providers) empirically proven interventions such as motivational interviewing and relapse prevention. At the post-treatment stage, primary care physicians or addiction specialists can provide systematic medical/recovery check-ups, facilitate the provision of health care resources based on a stepped care model, and the provision of laboratory monitoring of substance use associated with rewards and sanctions. The premiere models for such a medical programme are US physician health programmes.

However, this literature and these conceptions overwhelmingly arise from a North American culture shaped by 12-step philosophy. Although the need for mutual help is universally recognised, traditions elsewhere vary in terms of autonomy from professional treatment, tradition of anonymity, and relative role of religion.

Last revised 17 April 2013. First uploaded 17 April 2013

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MATRIX CELL 2014 Drug Matrix cell A2: Interventions; Generic and cross-cutting issues

HOT TOPIC 2016 ‘Recovery’: meaning and implications for treatment

HOT TOPIC 2016 What is addiction treatment for?

HOT TOPIC 2015 Promoting recovery through employment

MATRIX CELL 2014 Drug Matrix cell C2: Management/supervision; Generic and cross-cutting issues

STUDY 2013 The assessment of recovery capital: properties and psychometrics of a measure of addiction recovery strengths

REVIEW 2009 Peer-based addiction recovery support: history, theory, practice, and scientific evaluation

STUDY 2011 A good quality of life under the influence of methadone: a qualitative study among opiate-dependent individuals

DOCUMENT 2013 Delivering recovery. Independent expert review of opioid replacement therapies in Scotland

REVIEW 2012 Social reintegration and employment: evidence and interventions for drug users in treatment

Randomized trial of continuing care enhancements for cocaine-dependent patients following initial engagement.

McKay J.R., Lynch K.G., Coviello D. et al.
Journal of Consulting and Clinical Psychology: 2010, 78(1), p. 111–120.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr McKay at mckay_j@mail.trc.upenn.edu. You could also try this alternative source.

Unusually this US study took a set of patients who had generally already initiated abstinence from cocaine use and then used abstinence incentives and/or cognitive-behavioural therapy to extend and consolidate these gains. There was some evidence that offering the therapy and improving attendance via incentives prolonged the impact of those incentives.

Summary This US study of treatment for cocaine dependence aimed to test whether the remission of patients who had initially done well in intensive outpatient treatment could be preserved and extended by financially rewarding cocaine non-use ('contingency management') and/or by extra individual counselling sessions based on cognitive-behavioural principles intended to help the patients avoid relapse. Unusually it tested contingency management not as way to initiate abstinence, but to sustain it. Essentially the study found that the combination of both approaches helped the greatest proportions of patients to remain free of cocaine use, most notably in the middle of the 18-month follow-up.

The study recruited 100 adult patients who had attended regularly during their initial fortnight at one of two 12-step group-based programmes. For up to four months, these programmes scheduled sessions three days a week totalling nine to 10 hours per week, before stepping down to a session a week. Of the 573 patients approached to see if they were suitable for and wanted to join the study, 200 did not join because they did not complete the initial fortnight or the following baseline research assessments. Among other criteria, the patients had to have not injected heroin for at least a year. Typically participants were unmarried black women (nearly 6 in 10 were female) and were in the their late 30s and early 40s. By the time they entered the study, 70% had not used cocaine for at least a month.

They were randomly allocated to carry on with treatment as usual or to one of three additional therapies. For 12 weeks one set (the contingency management set) were rewarded Patients would receive vouchers worth $1150 if all urines were submitted and tested cocaine-free. In the event the contingency management patients averaged $740 and the combination patients (explained below) $856. with shopping vouchers if urine tests taken three days a week were clear of indications of cocaine use, a regimen implemented by non-clinical study staff. Another set (relapse-prevention patients) were instead offered 20 weekly individual relapse-prevention counselling sessions aimed at identifying situations which for them had precipitated substance use and learning to anticipate and cope with these in future. The final set (combination patients) were offered both types of additional intervention, with the rider that the voucher incentives required not just cocaine-free urine tests, but also attendance at the relapse-prevention sessions. This seems to have had the desired impact, as on average they attended 13 sessions compared to just three for the relapse-prevention patients who had been offered the same sessions but with no inducements to attend. By the final follow-up 18 months after the study started, three quarters of the patients could be reassessed by being interviewed and the same proportion by urine tests.

Main findings

Generally at each quarterly assessment from three months to 18 months after study start and on both the urine test and interview indicators, a smaller proportion of combination than of the other patients were found or assumed Interviews or urine tests missed before the patient had left treatment were assumed to be indicative of cocaine use; after they had left, missed tests/interviews were simply ignored. to have used cocaine. Only at the six-month and nine-month points were these differences large and consistent enough to be statistically significant, in comparison specifically to the treatment-as-usual and relapse-prevention patients. At no point did the non-combination patients allocated only to contingency management or only to relapse prevention sessions do significantly better than treatment-as-usual patients. This picture remained similar when all missed urine tests were assumed to be indicative of cocaine use rather than just those missed before the patient had entirely dropped out of treatment.

The authors' conclusions

The findings show that cocaine-dependent patients who have achieved initial engagement in an intensive outpatient programme and significant reductions in cocaine use can still benefit from incentives for cocaine-free urines. Reduced cocaine use was sustained for six months after incentives ended and was particularly strong when incentives were combined with individual cognitive-behavioural relapse-prevention sessions, as long as the incentives were also tied to consistent participation in the sessions. Without this 'carrot', the patients apparently had little interest in adding the sessions to the required core programme. Since so few were attended, it is no surprise that offering these sessions did not improve on treatment as usual. When attendance was improved via incentives, the sessions did seem to make a positive difference, and the combination's benefits outlasted provision of both incentives and the sessions.

These persisting effects may have been due to the incentives helping to open up 'windows of abstinence' (known to have happened from in-treatment urine tests) during which patients were exposed to 'natural' incentives for abstinence such as being able to take up a new hobby, reconnect with non-drug-related friends, or other rewarding activities incompatible with a return to cocaine use. However, such windows were also opened by contingency management alone yet did not persist as well without relapse prevention sessions, suggesting that attending these sessions was the active ingredient in persisting cocaine use reductions. As intended, they may have equipped patients with better coping skills or greater self-efficacy and commitment to abstinence, and did provide the patients' sole opportunity to develop an individual relationship with a helpful and concerned therapist.

A puzzling finding was that offering relapse-prevention sessions without incentives actually seemed at most time points to make abstinence slightly (and non-significantly) less likely than not offering these sessions. Possibly relevant is that these patients attended significantly fewer of the core programme's therapy groups than the other patients (25 v. 38). Relapse prevention session were not fully integrated in to this core programme and were provided by different counsellors; perhaps offering them in some way confused the patients or undermined their motivation to continue in the core programme.

Findings logo commentary As the authors comment, a more usual strategy is to use incentives to initiate abstinence, paired with cognitive-behavioural therapy or therapies based on harnessing social networks to help sustain abstinence by teaching enduring skills, changing thought patterns, and altering how the user's social circle responds to them. In this guise there is research support for the combination. The featured study instead took a set of patients who had generally already initiated abstinence from cocaine use and sustained it for several weeks, and then used incentives and/or cognitive-behavioural therapy to extend and consolidate these gains. There was some evidence that this worked, specifically for the proposition that offering relapse prevention sessions and making attendance at these a requirement for incentives prolonged the impact of those incentives.

For methodological reasons (see below) these findings are suggestive only, but assuming they represent a real effect, forming a relationship with an experienced therapist may have been influential, though the average of 13 weekly sessions attended by the combination patients was just over the 12 weeks it would have taken to qualify for all the incentives. If these periods were concurrent, it seems possible that once attending the sessions was no longer incentivised, many contingency management patients stopped attending, not indicative of a strong relationship. However, some also continued, perhaps enough to make a small difference, and before leaving others may have absorbed the skills they later used to stay clear of cocaine.

Had (as is often the case) only the patient's own accounts of their cocaine use been available, except for nine-month follow-up it would not have been possible to suggest that the relapse prevention sessions had helped preserve life changes patients made during abstinence windows opened up by incentives; the proportions abstinent were virtually identical whether or not incentives had been supplemented by the sessions. On this measure too, at the longest terms investigated by the study (15 and 18 months) it seems virtually nothing had been gained from adding any of the three options to usual treatment.

In respect of urine tests the gap between incentives plus sessions and incentives alone was also apparent at the six-month follow-up but had slipped back to near zero by a year and then remained under 10%. At this degree of difference the impact of missed interviews and tests becomes potentially important (by the end a quarter were missing), and generally more urines tests were missed than interviews.

Another factor to consider is the possible demoralisation of patients who volunteered for the study perhaps on the 50-50 chance that they would stand to gain hundreds of dollars from doing what they hoped to do in any event, avoid using cocaine. Those who missed out will have seen their fellow patients (possibly in the same therapy groups) being rewarded for abstinence while they got nothing material out of their achievements.

Thanks for their comments on this entry in draft to James R. McKay of the University of Pennsylvania in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 07 May 2013. First uploaded 03 May 2013

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STUDY 2008 Toward cost-effective initial care for substance-abusing homeless

STUDY 2011 Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses

REVIEW 2009 Efficacy of opiate maintenance therapy and adjunctive interventions for opioid dependence with comorbid cocaine use disorders: a systematic review and meta-analysis of controlled clinical trials

REVIEW 2015 Psychological and psychosocial interventions for cannabis cessation in adults: a systematic review short report

MATRIX CELL 2014 Drug Matrix cell E4 Treatment systems: Psychosocial therapies

STUDY 2005 Aftercare calls suit less relapse-prone patients

STUDY 2010 Review of treatment for cocaine dependence

REVIEW 2009 Continuing care research: what we have learned and where we are going

ABSTRACT 2008 Coping skills training and contingency management treatments for marijuana dependence: exploring mechanisms of behavior change

REVIEW 2014 Prize-based contingency management for the treatment of substance abusers: a meta-analysis

A randomized trial of methadone initiation prior to release from incarceration.

McKenzie M., Zaller N., Dickman S.L. et al.
Substance Abuse: 2012, 33(1), p. 19–29.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Rich at jrich@lifespan.org. You could also try this alternative source.

This US randomised trial in Rhode Island among formerly opiate dependent prisoners found that starting methadone treatment in prison radically improved treatment uptake on release and reduced heroin and cocaine use over the following six months, confirming results from Baltimore.

Summary Just over half of US prison systems offer any methadone treatment to opioid-addicted prisoners and those which do, offer it to very few, while the patients face financial and other barriers to continuing treatment on release. The featured study sought to determine whether initiating methadone in prison and/or funding it on release would help opioid-addicted prisoners continue in treatment and reduce their drug use and associated risks after leaving prison. It was conducted across the US state of Rhode Island's prison/jail system, a system centralised at a single site. For prisoners on methadone at entry, generally the system maintains them for a further week and then tapers the dose, meaning that (depending on the sentence) their dose at release could be very low or zero.

Instead the study aimed to randomly allocate prisoners To join the study prisoners also had (among other criteria) to have between 28 days and two years left of their sentence, previously been on and tolerated methadone and previously imprisoned for drug-related reasons, willing to be randomised and to conduct follow-up interviews for up to 24 months, and able to name at least two verifiable people who could help locate them for follow up. who were injecting drugs just before their imprisonment, and were on methadone or dependent on heroin, to one of three approaches to arranging methadone treatment on release (to enter the study this had to be their aim). Before their release all the prisoners in the study were counselled about the risks of HIV and overdose and helped to link up to their chosen post-release methadone programme. The first clinic appointment was arranged and help given with required documentation and arranging transport. For one set of randomly allocated prisoners (referral-only) this was the sole assistance. For another set (referral-plus-funding) their post-release methadone treatment was funded in full for 12 weeks and half-funded for another 12. Finally, another set (referral-plus-funding-plus-methadone) received all this assistance, and could also begin their methadone treatment (all on the basis of supervised consumption) whilst still in prison, which could be continued after release at their chosen programme.

Approaches to over 1500 inmates (the researchers could not know in advance who might qualify) netted 90 who could and did join the study and were randomised to one of the three release planning options. Two inmates were later found not to meet the study's criteria, and 19 transferred to the referral-plus-funding group. Four did so after being unable to start treatment in prison. Another 15 allocated to referral-only took advantage of a new federal scheme funding post-release treatment for six months, effectively making them referral-plus-funding patients. The result was that 25 patients were actually offered methadone in prison (of whom 21 could be assessed six months later), 48 were referred and had their treatment funded (of whom 32 were reassessed), and just 15 were left to be referred with no funding (of whom nine could be reassessed). Typically they were white men who had not completed high school, never been married, were not working before their imprisonment, and had no health insurance cover on their release.

The 22 patients who were not only offered but started methadone in prison averaged about a fortnight on the drug ranging up to a month. On release they averaged a dose of 33mg and at the most 38mg.

Main findings

The researchers analysed their results in two ways: firstly, on the basis of the post-release arrangements intended by the study; secondly, on the basis of the actual arrangements. Given that 19 of 88 patients did not receive their intended allocation, the researchers placed greatest weight on the results as per the arrangements actually implemented. Unless indicated otherwise, these are the results reported below, based on the 62 patients followed up six months after their release.

First issue was whether starting methadone before release promoted continuing treatment after release. This was clearly the case: within a month of release 86% of prisoners offered methadone in prison had (re)started methadone treatment, on average within two days. Without this and even if the treatment had been funded, under half as many (41%) started methadone treatment on release, and just two of the nine referral-only patients. These differences were statistically significant, as were the figures when analysed in terms of the arrangements the patients had been allocated to. By the end of the six-month follow-up 68% of the prisoners offered methadone in prison were in methadone treatment, 21% and 24% more than without this offer. There was no clear tendency for patients not offered methadone in prison to access other forms of addiction treatment more often on release to make up for their lower rate of access to methadone.

In the final month of the six-month follow-up only 14% of the referral-plus-funding-plus-methadone prisoners had used heroin compared to 56% and 44% of those not offered methadone in prison. There were similar differences in cocaine use and (but not to a statistically significant degree) in the prevalence of injecting and overall substance use.

Opiate overdose claimed the lives of two prisoners within days of their release; neither had been offered methadone in prison or started it on release. Over the six months another eight former prisoners experienced non-fatal overdoses; all but three had not engaged in methadone treatment. However, release arrangements made no clear difference to the chances that the prisoners would be re-arrested or re-imprisoned.

The authors' conclusions

The interval before released prisoners enrol in community-based methadone treatment is critical given the high risk of relapse, crime, disease transmission, and overdose. The featured study study showed that initiating methadone (even for a short period and on a low dose) in the weeks before release is feasible and improves access to pre-funded methadone treatment after release, as to a lesser degree does providing funding alone. Pre-funding plus methadone in prison also led to fewer patients using heroin.

The findings from this study complement those from a trial in Baltimore with similar results, but after initiating methadone three months before release rather than the 15-day average in the featured study. The results suggests that the benefits of pre-release methadone may not require several months of gradual dose escalation, or the attainment of a dose high enough to block the effects of opiate-type drugs.

Among other limitations of the study, only a small number of prisoners were recruited to the trial and it was affected by the new treatment funding scheme which led to prisoners being funded despite their allocation to referral-only. Unlike in Baltimore, entry to the study was restricted to prisoners who had previously been in methadone treatment, in hindsight an unnecessary caution.

Findings logo commentary Compared to just having a funded treatment slot arranged on release, starting methadone in prison meant that within the first month another 45% of offenders took up that slot; even by the end of the six month follow-up the difference was 21%. The result was reduced heroin and cocaine use, but over the first six months no documented impact on crime. There is also a strong indication that ensuring seamless transfer to methadone saved lives, one of its primary justifications in the UK. Besides post-release benefits, within prison itself methadone programmes improve the climate and reduce drug use, injecting and infection risk behaviour.

A key issue is whether starting methadone in prison perpetuated dependence among people who would have sustained abstinence on release. Both prisoners and staff commonly hope that an enforced break from drugs will provide an opportunity to reconstruct lives so the 'break' continues on release. In Rhode Island as in Baltimore there was some evidence that this was a realistic concern. Though funded and professing a desire for post-release methadone treatment, just 13 of 32 prisoners started it within a month and at the end of the six-month follow-up most (17) remained unprotected by methadone. That some did not need this protection, and that for some starting treatment in prison might have been superfluous, is also suggested by the fact that 44% of those who could be reassessed had not used heroin in the final month of the follow-up, though some may have used other opiates. Again as in Baltimore, the risk of perpetuating opioid dependence by facilitating methadone treatment must be set against the benefits of cutting heroin and cocaine use and injecting across the general run of patients in the studies, and thereby perhaps saving lives from overdose and infection. Given good access to housing, employment, psychosocial treatment, and other forms of good quality and attractive resettlement support, the balance of benefit may be tipped against initiating methadone in prison. Such supports are however in limited supply in Britain.

Conceivably the impact underpinning all the others was that more of the offenders started on methadone in prison continued treatment immediately after release. An optimistic interpretation is that having benefited from methadone in prison, offenders wanted to continue with their recovery on release; another is that leaving prison with a methadone habit, they faced an uncomfortable withdrawal unless they continued treatment. As the authors comment, this was less an issue in the featured study than in Baltimore, where the prisoners left prison on 60mg a day of methadone. Even if withdrawal avoidance was the motivation, it did lead (presumably via treatment) to more advanced recovery in the form of reduced heroin and cocaine use, and the prisoners voluntarily put themselves in this position.

Even for formerly heroin dependent injectors, prison methadone maintenance is clearly not a universally applicable treatment or one all would want. Relatively long sentences in the USA allow for therapeutic communities. Together with aftercare (especially if this is required as part of the sentence) these reduce drug use and crime. Such facilities are rare in British prisons, but there are a number of other less intensive and/or shorter term programmes which have yet to be adequately evaluated. According to a UN/WHO guide on opiate maintenance in prisons, none of the alternative treatments are yet as reliably effective due to their limited attraction to prisoners and high drop-out and relapse rates.

See the Findings analysis of the Baltimore study for policy and practice in the UK shortly before the change of government in May 2010. Since then there have been structural and policy changes which may have altered the situation, but these are unlikely to have made the initiation of methadone maintenance in prison any less rare than it was.

Low recruitment to the featured study was attributed partly to the (even in a relatively favourable environment) substantial logistical and attitudinal barriers to mounting methadone maintenance programmes in US and other prisons. It cannot be assumed that results based on the 80 who were recruited and the 62 on whom the follow-up results were largely based would also apply to the greater number of prisoners who would be recruited in a routinised programme.

Last revised 22 April 2013. First uploaded 22 April 2013

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DOCUMENT 2013 Community loses from failure to offer maintenance prescribing in prisons

REVIEW 2012 The effectiveness of opioid maintenance treatment in prison settings: a systematic review

STUDY 2009 A randomized clinical trial of methadone maintenance for prisoners: results at 12 months postrelease

STUDY 2009 The Drug Treatment Outcomes Research Study (DTORS): final outcomes report

STUDY 2005 Continuity vital after prison treatment

STUDY 2010 Naltrexone implants compared to methadone: outcomes six months after prison release

DOCUMENT 2014 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations

DOCUMENT 2009 Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence

STUDY 2012 The first 90 days following release from jail: Findings from the Recovery Management Checkups for Women Offenders (RMCWO) experiment

STUDY 2013 Criminal justice responses to drug related crime in Scotland

Social network effects in alcohol consumption among adolescents.

Ali M.M., Dwyer D.S.
Addictive Behaviors: 2010, 35, p. 337–342.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Ali at mir.ali3@utoledo.edu. You could also try this alternative source.

Is the peer influence on which many substance use prevention programmes are based an illusion due to other factors like pupils sharing similar environments or choosing like-minded friends? Not entirely, finds this unusually rigorous US analysis; the chances of a given child drinking rise by 4% for every 10% more of their school year-mates who drink.

Summary Presumptions about the influence of friends and peers on the substance use of young people lie at the heart of important approaches to preventing substance use. However, estimating the strength of this influence is complicated by the tendency for youngsters to choose like-minded friends, meaning that the causal relation is reversed – young drinkers choosing for example to befriend other young drinkers rather than being influenced to take up drinking by their friends. Another type of complicating factor are shared influences which might affect both the focal child's drinking and that of their friends, creating the illusion that one is causally related to the other. An example might be the areas they live in and the schools they attend. Unless these confounding factors are controlled for, we risk basing prevention programmes on mistaken estimates about the influence of peers. The featured analysis sought to refine these estimates by as far as possible eliminating other influences.

Data for the analysis came from the 1994 wave of a national US study of adolescent health conducted in 132 schools between grades 7 and 12. The children were asked how often they had drunk in the past year, enabling the study to assess what proportion were drinkers and how frequently This was measured on a six-point scale as never drinks, once in the last year, once a month, 2–3 times last month, 1–2 times a week, and 3 or more times a week on average they drank. Just over 20,000 of the pupils (they averaged 15 years of age) were not just surveyed in schools but also interviewed in their homes where their parents too were interviewed, yielding information The method required finding variables which would affect the drinking of the focal child's peers but not directly the drinking of the focal child. In this analysis the variables selected were: the percentage of peers whose parents drink; the percentage of peers who have easy access to alcohol at home; the percentage of peers who live with both biological parents; and the percentage of peers whose parents are welfare recipients. which could help eliminate influences which might bias the estimate of the influence of peers.

Another major advantage of the survey was that it gathered information about two differently constructed sources of peer influence. The first came from asking the young people to name their five closest male and five closest female friends. Since these friends were usually also surveyed, it was possible to assess the extent of their drinking and in turn assess how this might have influenced the focal child. However, these estimates were vulnerable to reverse causality – similar peers gravitating towards each other. This was not the case for the second source of peer influence assessed by the analysis – the drinking of the other children in the same grade of the child's school, an influence particularly relevant to school-based prevention programmes which operate on whole classes and grades in a school. For both sources of influence the analysis assessed the possible impact on the focal child of the proportion of their peers who drank at all and of the average intensity of their drinking.

Main findings

Results not fully adjusted for confounding influences indicated that a 10% increase in the proportion of close friends who drink is associated with a just over 2% increase in the chance that the focal child too would drink. For grade-level peers the corresponding proportion was 4%. In both cases there were also strong and statistically significant relationships between how often peers drank and how often the focal child drank, and again this relationship was stronger for grade-level peers.

Once other influences had been accounted for, the results for grade-level peers remained roughly the same; a 4% increase in the chances that the child will drink for every 10% increase in the proportion of their peers who drink, and also a 4% increase in the frequency of their drinking for every 10% increase in the average frequency of drinking among other children in the same grade of the same school.

However, the results for friends did change, an expected consequence of taking in to account the formation of friendships between boys and girls from similar environments and of similar backgrounds and preferences. No longer was there a statistically significant relation between friends' drinking and the chances that the child would drink, and the relation between the frequency of the child's and their friends' drinking was diminished though still statistically significant.

Among the other possible influences, easy access to alcohol at home had strongest relationship with the child's drinking, one almost as great as peer effects.

The authors' conclusions

The findings indicate that peer effects are important determinants of drinking and could be used as a policy tool to reduce drinking among adolescents. Specifically, a 10% increase in the proportion of classmates who drink will increase the likelihood of drinking by about 4%. These findings suggest that public health interventions at the school level might be more cost-effective than previously estimated, since health-promoting behaviour in one pupil may spread to others. We also found evidence that the apparent influence of close friends is partly due to the clustering of similar youngsters together in friendship networks rather than an influence of network drinking on its members. Another significant finding was the importance of controlling for unobserved environmental confounders, confirming a correlation between those factors and the peer measures. Not controlling for such environmental factors resulted in larger estimated effects of peer influence even after the two-way nature of peer effects had been accounted for.

Last revised 24 April 2013. First uploaded 24 April 2013

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