Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 11 June 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.


Contents

Three of the these additions to the Effectiveness Bank concern treatment in prison: a widely implemented UK cognitive programme; opiate detoxification in an English prison; and a review of prison opioid maintenance programmes. Fourth offers proof that at least in the USA, college health clinics can implement widespread screening and brief alcohol advice.

UK prison programme associated with positive psychological change ...

In prison too, buprenorphine on average equivalent to methadone for withdrawal ...

Community loses from failure to offer maintenance prescribing in prisons ...

College health clinics can do mass alcohol screening and brief advice ...


The effectiveness of Prisoners Addressing Substance Related Offending (P-ASRO) programme: evaluating the pre and post treatment psychometric outcomes in an adult male category C prison.

Crane M.A.J., Blud L.
British Journal of Forensic Practice: 2012, 14(1), p.49–59.
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 Crane at mark.crane@hmps.gsi.gov.uk.

From the early 2000s cognitive-behavioural group therapy programmes have been relied on to improve the anti-offending record of UK prisons and probation services, but evidence has been scarce and generally negative. This prison study at least suggests that one such programme does promote the intended psychological changes.

Summary Many British prisons offer the Prisoners Addressing Substance Related Offending (P-ASRO) programme, a cognitive-behavioural intervention intended to reduce crime by helping prisoners for whom this is a risk factor overcome their dependence on substance use. During 20 two-hour group sessions to be delivered over six weeks, the programme aims to enhance motivation to change, strengthen self-control, develop strategies to avoid relapse to problem substance use, and encourage lifestyle change to reduce the risk of a return to substance use and offending. It is intended for prisoners with a low to medium severity of dependence on substance use.

The featured study set out to test the impact of the programme on some of the psychological processes it targets as a means of reducing substance use and crime. It used data collected anonymously from 81 male inmates in a prison in England who had completed Another nine had started the programme but not completed it, and for another six there was no record of their severity of dependence. the P-ASRO programme, the only one run by the prison to address substance use problems. They completed psychological assessment questionnaires before starting the programme and after completing it. Before the programme a standard questionnaire assessed their severity of dependence; 74 of the 81 prisoners scored as highly dependent and seven as low to medium, meaning that most would have been considered too highly dependent to be suitable for the programme.

Main findings

The study reported changes from before to after the P-ASRO programme in assessments of:
Locus of control The extent to which individuals believe that they can control events that affect them.
Impulsiveness The tendency to act without planning and on the spur of the moment and to be unable to sustain focus on the task in hand.
Social problem solving An individual's problem-solving strengths and weaknesses; whether they approach problems positively and rationally.
Stage of change An assessment of whether in relation to a particular issue (in this case, substance use) someone is not yet contemplating change, considering it, taking action, or maintaining the changes they have made.

On all four measures the prisoners had substantially improved. There were statistically significant improvements in the degree to which they felt in control of their lives and in their approaches to problem solving, and a reduction in the tendency to behave impulsively. Before the programme just 25% of the prisoners were taking steps to change their substance use habits, but afterwards 86% were doing so, generally having progressed from merely contemplating change. In no case was the degree of improvement related to how severely dependent the prisoner had been before the programme started.

The authors' conclusions

The findings of this study indicate that the P-ASRO programme may have a positive impact on key areas such as problem solving and self-control likely to affect pro-social behaviour change, and that it does so regardless of how severely dependent the prisoner was before the programme. After the programme, completers also were also more motivated to take action to change their substance patterns.

Improvement on the locus of control measure suggests the prisoners developed a greater sense of self-efficacy and belief in their ability to change, found in studies to be predictive of behaviour changes which minimise the risk of relapse. Impulsivity improvements suggests the offenders became more reflective in their thoughts and related actions, so possibly less likely to revert to drug use and more likely to consider the long-term consequences of their substance use. More positive problem-solving attitudes and better skills should enable offenders generate more pro-social solutions to problems and generally improve their problem-solving abilities. The stage of change assessments suggest that the P-ASRO programme may have motivated participants to take action towards achieving a lifestyle free of problem substance use.

However, the study could not assess whether these changes in the psychological processes presumed to generate substance use and crime actually did lead to longer term reduction in drug-related offending, nor whether users of different substances or polydrug users responded more or less well to the programme. Neither was there a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group of similar prisoners who did not go through the programme against which to benchmark the observed changes, and there was no way to adjust the results for factors which might have affected them such as the prisoner's age or risk of reconviction. Also, a few prisoners who did not complete the programme were excluded from the sample. Had they been included, average degrees of improvement might have been lower.


Findings logo commentary The results of this study at least suggest that the P-ASRO programme does not have counterproductive impacts; when like-minded people are brought together there is a risk that the group will reinforce the features they share, in this case, a tendency to criminogenic substance use. Regarding positive impacts, as the authors point out, it is impossible to say whether the changes they observed would have happened anyway, even without the programme, and whether they will translate in to less crime and substance use on release. On this score studies of similar programmes, and in Britain of the equivalent programme for offenders on probation, have not been promising ( below). However, the situation in prison is very different from that outside; in its favour, it seems many more prisoners than probationers complete the programmes, giving them a chance to have an impact, but motivation gained in prison is often of little consequence once the offender is released. It is then particularly disappointing that despite the thousands of prisoners who must have completed these programmes and the chance to match these to officially held reconviction records, it seems no such data has ever been collated and published.

P-ASRO is based on the ASRO programme for offenders serving community sentences outside prison, results from which have not been promising. In its 2008–2011 national drug strategy for offenders, the National Offender Management Service referred to research showing that re-offending rates fall by almost 7% for offenders placed on ASRO-type anti-offending programmes. This may refer to an unpublished Home Office evaluation Hollis V. Reconviction analysis of programme data using Interim Accredited Programmes Software (IAPS). London: RDS NOMS Research and Evaluation, 2007. not specific to the ASRO or P-ASRO programmes and which lacked a comparison group. Instead it compared predicted reconviction rates for offenders referred to programmes like ASRO with their actual convictions. The results appeared generally positive. Compared to a predicted rate of 61%, just 55% of all offenders were reconvicted within two years, while the reconviction rate for those completing a programme was 38% compared with a predicted rate of 51%. Though in the 'right' direction, the design of the research means its results cannot be relied on as indicating that the programmes reduced offending.

Set against this possibly positive finding are several studies which produced negative findings. Among these is British study which found that even the minority of offenders who completed an ASRO programme were no less likely to be reconvicted within the following year than similar comparison offenders. When from year 2000, ASRO-type cognitive programmes for offenders were being rolled out in Britain, an evaluation of their impact on offenders on probation found After other variables which might have influenced the findings had been taken in to account. no reduction in reconviction rates compared to offenders not placed on these programmes. There was, however, the familiar low level of reconviction among the minority who had completed the programmes, an effect which might have been due to factors which would have improved their prospects regardless of the programme, such as their motivation to change, ability to do so, and their stability. Among these programmes was the prototype ASRO, trialled on 62 offenders of whom 21% had completed it. Results from the ASRO paralleled those of the cognitive programmes in general.

Non drug-specific cognitive skills programmes also have a poor record in British prisons. A Home Office study including 2195 adult male offenders who had participated in one of two such programmes between 1998 and 2000 found they were no less likely than matched prisoners to be reconvicted over the next two years. A year after release prisoners who had completed one of the programmes (Enhanced Thinking Skills) were less likely to be reconvicted, possibly an artefact of their being more motivated or in a better position to avoid recidivism regardless of programme completion. But even this effect had disappeared by two years after release.

More generally, a review of studies which had randomly allocated offenders in or out of prison to anti-offending programmes found two which had evaluated ASRO-type cognitive skills approaches. These created no statistically significant gains on measures indicative of drug use or crime. Even when in a controlled study a cognitive programme has been found effective, this has not necessarily been maintained in a larger scale roll-out. In British prisons in the 1990s, early cognitive skills programmes aimed generally at tackling criminogenic attitudes and thought patterns at first evaluated positively but later the results were not replicated. Interventions for offenders are, it has been argued, highly context-specific; what works in one culture at one time may be ineffective in other settings and at other times.

P-ASRO and ASRO are among the programmes accredited by the Correctional Services Accreditation Panel for England and Wales. The panel's report for 2010–2011 notes that both will be replaced by a new programme, Building Skills for Recovery. By the last quarter of 2011–12, 21 prisons in England and Wales were running the new programme while 29 still offered P-ASRO. However, in 2010–2011 the dominant programme was neither of these but one intended for prisoners serving short sentences, on remand, or with just six months left to serve, also it seems to be replaced by Building Skills for Recovery.

In theory the panel required evaluation evidence before selecting programmes to accredit, but in practice this was rarely available within the time scale required to meet government implementation targets. Instead it usually accredited programmes on the basis that they embodied the general principles of 'what works', which (largely on the basis of North American evidence) meant cognitive-behavioural methods, of which ASRO is an example. Evidence on programmes as implemented in the UK derived largely from studies not capable of determining impacts on offending.

Thanks for their comments on this entry in draft to Mark Crane of HM Prison Service, Wolverhampton, England, one of the authors of the featured study. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 11 July 2013. First uploaded 03 June 2013

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STUDY 2011 Evaluation of the Addressing Substance-Related Offending (ASRO) program for substance-using offenders in the community: a reconviction analysis

STUDY 2009 Therapist behavior as a predictor of black and white caregiver responsiveness in multisystemic therapy

STUDY 2012 The effect on reconviction of an intervention for drink-driving offenders in the community

STUDY 2011 An experimental demonstration of training probation officers in evidence-based community supervision

STUDY 2009 Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD

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

STUDY 2011 Treatment of adolescents with a cannabis use disorder: Main findings of a randomized controlled trial comparing multidimensional family therapy and cognitive behavioral therapy in The Netherlands

STUDY 2010 A randomized experimental study of gender-responsive substance abuse treatment for women in prison

STUDY 2009 Multidimensional Family Therapy for young adolescent substance abuse: twelve-month outcomes of a randomized controlled trial

STUDY 2010 Long-term effect of community-based treatment: evidence from the adolescent outcomes project





Comparison of methadone and buprenorphine for opiate detoxification (LEEDS trial): a randomised controlled trial.

Wright N.M.J., Sheard L., Adams C.E. et al.
British Journal of General Practice: December 2011.
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 Wright at natwright@nhs.net. You could also try this alternative source.

Three English prisons hosted the first randomised trial of tapering doses of buprenorphine versus methadone to ease the withdrawal of opiate users entering prison. As outside prison, there was little difference in their effectiveness, and three months later just a fifth of the (former) prisoners were assessed as no longer using illegal opiates.

Summary Subject to clinician discretion, in English prisons sublingual Dissolved under the tongue. buprenorphine or oral methadone are recommended first-line medications to help ease the process when new prisoners ask to be withdrawn from the opiate-type drugs they had been taking before admission. Outside prison, these options have been found roughly equivalent in enabling patients to complete the process and achieve abstinence from opiate-type drugs. The featured study was the first to test whether this remained the case in prison.

Study treatments were offered between 2006 and 2008 at the healthcare departments of three remand prisons (two for men, one for women) in the north of England. In the medical reception areas researchers asked newly admitted prisoners aged 21–65 to join the study if urine tests had indicated use of illicit opiates, they said they wanted to detoxify and remain abstinent, and they were expected to stay in custody for at least another 28 days. Of the 439 who could have joined the study, 289 agreed and started one of the two treatments. Typically they were around 31 years of age and had used opiates for 10 years, just over half injecting and most of the rest smoking the drugs.

These 289 patients were randomly allocated either to a methadone or a buprenorphine detoxification programme overseen by general medical staff. No attempt was made to 'blind' patients or clinicians to the allocation. Detoxification was typically conducted over 20 days, tapering down from a five-day stabilisation dose of 30mg methadone or 8mg buprenorphine daily.

The primary outcome was whether patients were abstinent from illicit opiates eight days The time period required for the medications to be eliminated from urine. after completing detoxification, confirmed by urine test if they were still in the original prisons or by their own accounts or clinical notes if they had left. By these means it could be ascertained whether 213 of the 289 patients had used opiates after completing their detoxifications. Similar procedures were followed one, three and six months after detoxification, when 159, 94 and 60 patients (the latter considered too few for analysis) could be reassessed.

Main findings

At no point in the follow-up period were patients prescribed one of the medications significantly more likely to be opiate-free than those prescribed the other. This was the case whether all patients were included in the analyses (the assumption being that missing cases were not abstinent) or only those who could be reassessed. Eight days after the programmes ended, just over 50% of both sets of patients were assessed as abstinent (around 70% of those who could be reassessed), a figure which fell to 20% (62% of those who could be reassessed) three months after the programmes ended.

There remained no statistically significant differences between abstinence rates after other variables had been taken in to account, of which initially the most important was whether the prisoner was still in prison. If they were, abstinence was 18 times more likely at eight days and 13 times at one month. By three months when just 17% of patients could be urine tested [Editor's note; indicative that most had left their initial prisons], whether the patient had tested abstinent two months before was the dominant factor. In contrast, whether they had tested abstinent at the eight-day point was unrelated to abstinence at three months. Age and variables reflecting treatment and opiate use history were unrelated to abstinence.

The authors' conclusions

In a prison general practice setting, methadone and buprenorphine were equally effective in helping patients become abstinent eight days after their detoxifications ended. Being abstinent at this point was a strong predictor of being abstinent one month after the programmes ended; remaining in prison also strongly predicted abstinence. These findings suggest that on effectiveness grounds, either methadone or buprenorphine should be offered as a first-line treatment, taking into account patient preferences. However, sublingual buprenorphine is more vulnerable to being 'diverted' to the illicit market in drugs in prison, so where this is a problem, methadone is preferable.

Shortly after release there is a high risk of detoxified former prisoners relapsing and dying from drug-related causes. To minimise the risk of relapse, it would be prudent to offer detoxification only to patients who have made a planned decision to undergo it and whose care can be handed over to community primary care services on release.


Findings logo commentary In a prison setting this study confirms the rough equivalence of methadone and buprenorphine as detoxification medications. Along with other studies, the conclusion is that, as outside prison, these are the first-choice agents in terms of completing detoxification from illegal opiate use and the comfort of patients. The usual criterion of completion of detoxification is less relevant in prison where simply leaving the setting is not an option, non-completion is often for reasons (such as release or transfer) outside the control of both patients and medical staff, and patients who do opt to end the treatment may still be forced to complete detoxification unaided due to the difficulty of obtaining illegal drugs. However, 'difficulty' is not 'impossibility', as exemplified by urine test results from the 152 patients tested in prison eight days after the end of their detoxification programmes, of whom 33 tested positive for illegal opiates. It also seems from the study and from others that abstinence from illicit opiates achieved in the controlled environment of a prison is no indication of lasting abstinence. By three months after programme end, patients assessed as abstinent at eight days were non-significantly less likely still to be assessed as abstinent.

Other UK trials

Some of the same authors had previously conducted a similar trial in a remand prison in Leeds, but this time among men only and comparing buprenorphine with an alternative opioid drug, dihydrocodeine. Results favoured buprenorphine. Five days after completing the programmes, significantly more buprenorphine patients tested negative for opiates (57% v. 35%). However, this advantage did not translate in to longer-term gains from one to six months after programme end. At three months, 28% of all the patients were assessed as abstinent and 52% Table 4 says for buprenorphine and dihydrocodeine respectively, 2/8 and 1/4 urine tests indicated abstinence and 11/18 and 11/18 other indicators, a total of 25 abstinent from 48 cases or 52%. However, the paper says "At three months, follow up data were obtained on 55 participants". of those who could be assessed, similar to the featured study's tally of 20% and 62%.

Given that prison enforces an end to dependent use if not to use altogether, a more relevant criterion on which to judge detoxification methods may be the comfort of the patients. This was the one of main criteria in a randomised trial of detoxification from opiates in a prison in southern England, which pitted methadone against the non-opioid drug lofexidine. Lofexidine is an analogue of clonidine. Both are alpha2 adrenergic agonists which dampen withdrawal-induced hyperactivity in certain brain centres, relieving symptoms such as chills, cramps, and diarrhoea. It found the two medications offered equivalent amelioration of withdrawal symptoms, and that of those patients able to complete the process, 88% of methadone patients did so compared to 70% in the lofexidine group – not a statistically significant difference, but suggestive of an advantage for methadone of the kind seen outside prison.

Reviews and guidance

A review published in 2010 applied a new methodology to combine results from comparisons of the main medications used to help opiate-dependent patients complete withdrawal. It enabled the analysis to include indirect comparisons between two medications which, even though they may not have not been compared head-to-head, have been compared to the same third medication. The criterion of effectiveness was completing Typically defined as being retained to the final day of the planned duration, taking the final dose of the medication being tested in the study, or reaching a zero dose of the medication. the detoxification programme. Taking all the data in to account, it was estimated that for every 100 people who completed a methadone detoxification, 164 would complete if prescribed buprenorphine, but in the three head-to-head comparisons the medications seemed roughly equivalent. From 1.6 to nearly four times as many people completed procedures based on the two opiate-type medications (buprenorphine and methadone) than those based on either of the non-opioid medications (lofexidine and clonidine). It was concluded that both opiate-type medications were probably more effective than clonidine and lofexidine and that buprenorphine seemed the most effective of all at promoting completion. These were also the findings of another major review which used a different methodology to combine findings.

As the authors comment, the prison setting imposes special limitations on patient choice, for any individual patient there may be overriding contraindications, and everywhere cost is an issue, as is the extra time involved in supervising buprenorphine administration set against its greater safety in overdose. But on effectiveness grounds alone, in general choice of medication in can largely be based on the individual's informed preferences, based partly on the implications of the research cited above. British studies (1 2; details in background notes to an earlier Findings analysis) have found that patients who choose one of the least effective medications (lofexidine) do as well as those who choose the most effective (methadone or buprenorphine), possibly because the least dependent and perhaps most motivated patients opt to do without opiate-type drugs.

British guidance (1 2; details in background notes to an earlier Findings analysis) adds that patients already being prescribed methadone or buprenorphine on a maintenance basis or to stabilise them prior to detoxification should normally continue with the same medication. Though this should not override patient preference, guidance sees clonidine and lofexidine as most suitable for patients with low levels of dependence or who may not be dependent at all.

Completion is the main criterion for the success of detoxification, but it is a success which comes with risks. The guidance cited above warns that the loss of tolerance (the ability to tolerate higher doses after becoming used to regularly taking a drug) following detoxification heightens the risk of overdose and death if patients return to opiate-type drugs, especially if at the same time they drink or take benzodiazepines. This risk is greatest among patients who complete the detoxification phase of the programme (1 2 3), highlighting the need to carefully select and prepare detoxification candidates and to invest in aftercare. Patients who complete withdrawal in protected environments without having chosen to stop using opiates may be particularly ill-equipped to sustain an opiate-free life when they leave. Ironically, outpatient programmes which test the patient's resolve in real-world conditions may be safer because relapse is more likely to occur before tolerance is eliminated. See fuller discussion in background notes to an earlier Findings analysis.

Thanks for their comments on this entry in draft to Nat M.J. Wright of HMP Leeds in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 27 May 2013. First uploaded 22 May 2013

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STUDY 2010 Long-term outcomes of aftercare participation following various forms of drug abuse treatment in Scotland

STUDY 2015 Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England

HOT TOPIC 2016 Opiate-blocking implants: magic bullet or dangerous experiment?

STUDY 2011 Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence

DOCUMENT 2012 Medications in recovery: re-orientating drug dependence treatment

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 2010 The SUMMIT Trial: a field comparison of buprenorphine versus methadone maintenance treatment

STUDY 2010 Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK

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





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

Hedrich D., Alves P., Farrell M. et al.
Addiction: 2012, 107(3), p. 501–517.
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 Hedrich at dagmar.hedrich@emcdda.europa.eu. You could also try this alternative source.

Largely due to the treatment's health benefits, this review argues that failure to implement effective opioid maintenance programmes in prison represents an important missed opportunity to engage high-risk drug users in treatment, at possibly substantial costs both to individuals and to the community.

Summary Long-term or maintenance prescribing of substitute opiate-type drugs is the mainstay of treatment for heroin and other forms of opioid dependence, except in prisons, where implementation has been limited. Offering effective treatment in prisons is important because many prisoners have opioid-related problems but were not in treatment at the time of their imprisonment. While the frequency of drug use and injecting decreases after incarceration, some prisoners continue to use opioids (including by injection) and a few initiate injecting, and when drug use does occur it tends to be riskier than in the community. Having been imprisoned appears to increase one's risk of becoming infected with hepatitis C. On release, relapse is common, rates of treatment contact are low, and there is an elevated risk of overdose.

Given its potential importance, the featured review aimed to assess the evidence on opioid maintenance in prisons in terms of its impacts while patients are in prison, the difference is makes after release, and whether continuity of treatment from before to during and after imprisonment influences its effectiveness. Impacts reported in the literature include substance use, crime, and health. The review extended beyond formally published journal articles to 'grey literature' such as project reports.

In all 21 studies were found of which 15 simply observed the effects of programmes implemented in the normal way, while another six randomly allocated prisoners to a maintenance programme versus a comparison programme or none at all. Ten studies had been conducted in North America, five Australia, four Europe (but none in the UK), and two in Iran. Generally the medications were methadone or buprenorphine.

Main findings

In summary (details below) there is consistent evidence that while patients are in prison opioid maintenance programmes reduce opioid use, injecting, and sharing of injecting equipment. Such programmes consistently promote treatment entry and retention after release from prison, and generally too are associated with reduced opioid use. In respect of other desired impacts assessed by the studies, the evidence is inconsistent (reducing cocaine use, crime, and re-imprisonment rates) or weak (preventing deaths and hepatitis C infections).

During imprisonment

Eight of the 21 studies documented the possible benefits of opioid maintenance programmes while the patient is in prison. All six which included these assessments found significant reductions in illicit opioid use, primarily heroin. In the three studies which compared opioid maintenance programmes against no such programmes the differences were large: 21% using illicit opioids versus 94%, 25% versus 67%, and 6% versus 65%. In the two dose-comparison studies, illicit opiate use was significantly less common when methadone doses exceeded 50mg daily.

All five studies reporting on drug injecting found that opioid maintenance was associated with reduced heroin injecting in prison. All five reporting on syringe sharing also found significant reductions. Differences were large in the three studies which compared opioid maintenance programmes against no such programmes, for example, in the case of injecting, 11% versus 42%, 34% versus 70% and 15% versus 38%. Behaviours like these which risk infection diminished substantially among programme patients but remained unchanged or increased among comparison prisoners. One study found risk levels lower when patients were in high-dose (over 60mg daily) continuous methadone programmes than in low-dose, time-limited programmes. Another found significant reductions in syringe-sharing only after six months' treatment.

The one study to examine whether prisoners actually became infected with HIV or hepatitis C in prison found no difference between programme and comparison prisoners, while the single study which looked at prison infractions found that serious drug violations in prison fell among offenders in opioid maintenance programmes but increased in the non-treated group over the same period.

Impact of pre-release treatment on post-release outcomes

Post-release outcomes were documented by 13 studies over periods from one month to four years. All four relevant studies found that compared to no such programmes, opioid maintenance in prison was strongly associated with entering and staying in treatment on release. Across these studies, about 85% of maintenance patients continued treatment compared to just 15% of comparison prisoners, and six months after release over 50% versus less than 5% were in treatment.

Over up to a year, four of the five relevant studies found significant reductions in heroin use among programme patients versus comparison prisoners. The exception concerned a low-dose (30mg daily) methadone programme. In the two relevant studies cocaine use was also less among programme patients, but not as markedly as for heroin.

Of the four relevant studies, one found that programme patients reported significantly less criminal activity than comparison prisoners (but only up to six months after release), two non-significantly less, and one no difference. In four of nine studies patients who had received opioid maintenance in prison were less likely than comparison prisoners to return to prison over generally the following year; the remaining five found no such advantage, including one which found programme patients were more likely to later be re-convicted.

Of the two dose-comparison studies, one found high-dose (over 60mg daily) methadone reduced re-imprisonment rates significantly more than low-dose (under 30mg) methadone; the other found dose made no difference. No differences were found also in a randomised trial of buprenorphine versus methadone.

Two studies reported on whether after release programme patients were more or less likely to die than comparison prisoners. One found prisoners offered either maintenance in prison and continuation on release, or guaranteed, seamless transfer to a methadone programme on release, were far less likely to die over the following year than prisoners offered neither.

Impact of continuity with community-based treatment

Four observational studies reported results relevant to the impact of continuity or disruption of opioid maintenance as a result of transitions in and out of prison. They variously found more continuous and/or longer treatment was associated with reduced risk of infection, re-imprisonment and death and a greater likelihood of continued treatment. However, one Australian study found that injectors in a prison methadone programme were more likely to have become infected with hepatitis C over the past 12 months than those who were not in a programme, possibly because they were at greater risk.

The authors' conclusions

These studies show that opioid maintenance in prison reaps benefits similar to programmes outside prison. Prison-based programmes offer an opportunity to recruit problem opioid users in to treatment, reduce illicit opioid use and behaviours which risk infection in prison, and potentially also reduce overdoses on release. In liaison with community programmes, prison programmes can also facilitate continuity of treatment after release. Conversely, failure to implement effective opioid maintenance in prison represents an important missed opportunity to engage high-risk drug users in treatment, at possibly substantial costs both to individuals and to the community. As outside prison, dosages need to be adequate (over 60mg) and programmes long-term.

Prison discipline may also improve, consistent with accounts from prisoners or staff who believe the programmes help reduce tension and involvement in the prison drug trade.

After prisoners leave prison those who have been on opioid maintenance are less likely than comparison prisoners to use heroin, though the impact on cocaine use appears more limited. Evidence on post-release crime, arrests and re-incarceration is equivocal, just one study reported on deaths (fewer among former patients), and no study has yet investigated whether prison programmes reduce the numbers who after release become infected with blood-borne viruses.

Despite this being under-investigated, continuity with pre-arrest treatment may be critical, in particular in the prevention of hepatitis C infections.

The variety of countries and prison systems covered in this review suggests that the broad conclusions may apply to quite a wide range of settings. However, most studies had important methodological shortcomings.


Findings logo commentary The featured review documents a consistent picture of potential health benefits in prison from methadone and buprenorphine programmes and similar and other benefits after release, largely contingent on the treatment being seamlessly continued. However, post-release continuity often proves difficult to secure. In Britain prisoners released on licence can be required to attend certain treatment services, but currently this applies only to sentences of over a year, and methadone-maintained offenders leaving prison have no automatic and immediate access to similar treatment in the community.

For prisons, UK policy espouses an equality principle, meaning that prisoners should expect the same standard of health care inside as outside prison in the same circumstances, but in the case of addiction treatment, the circumstances are clearly not the same because of impeded access to illegal drugs and discipline and control requirements. This meant that long-term opioid substitute prescribing in prisons was relegated to an exception and detoxification was the norm, a pattern which seems to have reversed in the early 2010s. In the future the policy emphasis on ‘recovery’, interpreted as entailing an end to treatment rather than long-term maintenance, could mean that the equality principle reduces access to maintenance prescribing in prison. This could happen partly to mirror trends outside, and partly because it might become more difficult to secure continued maintenance prescribing on release, seen in some policy documents as a prerequisite to offering the treatment in prison. More on policy considerations below.

In 2006 Department of Health clinical guidelines on prison treatment in England suggested that pre-prison opioid maintenance programmes should normally be continued in prison, and that the treatment should be offered to dependent opiate users on short sentences. They also advised considering raising pre-release doses to previous maintenance levels as a form of post-release overdose protection for offenders prone to relapse. An 'update' published in 2010 was concerned that "some prescribing may be clinically inappropriate" and in particular to "ensure that prisoners do not remain on open-ended maintenance regimes when detoxification or a gradual reduction tailored to the individual's need would be the more appropriate option". In line with policy outside prison, it sought to tip the balance towards non-drug based treatment, most firmly for prisoners on sentences exceeding six months who "should be made aware [that] they will be expected to work towards becoming drug free".

From April 2013 the commissioning landscape changed in ways which may also erode the modest gains made in recent years in securing a place for methadone maintenance in English prisons. National expertise, specialist national services and advice and support are being provided by Public Health England, which has absorbed the National Treatment Agency for Substance Misuse. Locally the treatment budget formerly administered by that agency has been allocated to local authorities to help fund their new public health responsibilities, including the prevention and treatment of alcohol and drug problems. Criminal justice treatment-support funding is now under the control of the new police and crime commissioners, and prison health services (including drug and alcohol treatment) have become the responsibility of NHS England, formerly known as the NHS Commissioning Board.

This fragmentation of commissioning for treatment in prison, as part of community sentences, and in routine medical care, was in 2012 seen by the National Treatment Agency for Substance Misuse as a "potential threat to the gains made through integration" which might "jeopardise existing improvements to the continuity of care created through the local integration of commissioning". At the time of writing it is too soon to assess whether there has indeed been an impact on continuity of care in respect of opioid substitute prescribing of the kind which would undermine the benefits of prison programmes identified by the featured review.

Health care standards for Scottish prisons say that opioid substitute prescribing "should be offered where appropriate and where a community prescriber has been identified to continue treatment after release", interpreted Personal communication from Stephen Heller-Murphy of the Scottish Prison Service, September 2009. in practice as not offering the treatment unless it can be confirmed that a community prescriber will continue it on release. It was hoped that transfer from November 2011 of prison health care from the Scottish Prison Service to local NHS boards would improve continuity of treatment between prison and the community, identified as a priority by Scotland's National Forum on Drug-related Deaths.

Thanks for their comments on this entry in draft to Dagmar Hedrich of the European Monitoring Centre for Drugs and Drug Addiction in Lisbon, Portugal. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 24 March 2015. First uploaded 28 May 2013

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

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DOCUMENT 2014 Time limiting opioid substitution therapy

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Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics.

Fleming, M.F., Balousek S., Grossberg P.M. et al.
Journal of Studies on Alcohol and Drugs: 2010, 71, p. 23–31.
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 Fleming at mfflemin@wisc.edu. You could also try this alternative source.

Can college health clinics do widespread screening and brief alcohol advice? Yes they can, is one conclusion of this first large-scale test conducted at five North American universities. The other main conclusion – that by doing so they make worthwhile reductions in drinking and related harm – is weakened by the small size of the impacts.

Summary Brief advice from doctors in health care settings can reduce alcohol use, harm, mortality, and related costs among adult patients, but there is limited information on whether it is also effective for young patients, especially college students.

To address this issue the featured study was conducted at the health services of five diverse universities in the USA and Canada, where over a full-day interactive workshop plus booster sessions, 13 primary care physicians (in the event they conducted 91% of the interventions), three nurse practitioners, and one physician assistant were trained to deliver a brief intervention to heavy-drinking students. It was the first large alcohol screening and brief intervention trial conducted in a college health setting where primary care providers delivered the brief counselling protocol.

At the universities all students 18 and over were asked to complete a screening survey including questions on drinking as well as other health topics as they arrived for regularly scheduled appointments Except at one of the sites, where initial screening was conducted in a college health class. to see their primary care doctors. Over 85% were screened (12,900 students) of whom about a third screened positive Over 14 US standard drinks (each 1.75 UK units) a week for men, 11 for women; over five drinks more than four times in the previous 28 days; and/or two or more positive answers to the CAGE questions about feeling the need to drink less, being annoyed by criticism of one's drinking, feeling guilty, or needing a drink first thing. for at-risk drinking. Of these 4512 positive-screen students, 46% or 2090 agreed to join the study and were interviewed face-to-face by researchers to determine whether they met the trial's criteria. Over a 1000 were eliminated because over the past four weeks they had not drunk heavily according to the study's criteria, For men over 50 US standard drinks (each 1.75 UK units) or eight or more heavy drinking episodes (five or more drinks); for women, over 40 drinks or six or more heavy drinking episodes (four or more drinks). leaving (after other exclusions) 986 enrolled in the trial.

The researchers gave all enrolled students a booklet on general health issues. For a randomly selected half (the control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group) this was the sole 'intervention', and rather than focusing on drinking, they were told the trial included drinking along with other health-related behaviours, questions about which were included in all the assessments. They saw the same doctors as the other patients allocated to the brief intervention, but medical staff were not told they were part of the trial.

The other half of the students were allocated to the brief intervention. Appointments were made for them to see their doctors for two 15-minute consultations (the second to reinforce the first) a month apart, and each was phoned between the sessions and a month later to check progress and offer encouragement. The sessions were guided by a manual which instructed the clinician to offer or discuss with the student: how their drinking compared to other young adults; a list of alcohol's adverse consequences relevant to college students; lists of personal likes and dislikes about drinking; worksheets on drinking cues; a blood alcohol level calculator; the impact of their drinking on achieving their goals; agreement to reduce alcohol-related risks in the form of a prescription signed by the student; and drinking diary cards.

Students were paid a total of $200 if they completed the required procedures. Editor's note: which for the intervention students appeared to include attending the brief intervention sessions; the manual says students should be invited to ask about health issues other than alcohol for which another visit would be scheduled, but students should be warned "You would not be paid for that visit, however." All but 12% of the intervention students completed all four intervention phases. Of the total sample, 96% were interviewed over the phone six and 12 months later by a researcher unaware of to which group they had been allocated. Drinking patterns and other data What the relatively few students who did not complete the follow-ups might have said was estimated from their earlier responses. gathered by these interviews were compared with the pre-intervention data to assess whether intervention students had reduced their drinking and related risks more than the control students.

Main findings

From each drinking about 70 US standard drinks (about 123 UK units) over four weeks before the intervention, a year later both sets of students had cut down to around 53 drinks (about 93 UK units). However, the reduction (by 27% v. 21%) was greater among students allocated to the brief intervention, and during the 12 months the extra reduction was statistically significant. Similarly, both sets of students reported substantial reductions in the number of days they drank heavily, Five or more US standard drinks for men and four for women. a reduction which was on average slightly greater among intervention students (26% v. 23%), but this time not to a statistically significant degree. This was also narrowly the case in respect of the extra reduction (15.4% v. 12.6%) among intervention students in the number of days they drank at all.

Another set of questions asked students about the number of times they had undesirable alcohol-related experiences over the past year, such as causing shame or embarrassment, passing out, having a bad time, or an altercation with a friend. For both sets of students these experiences had become substantially less frequent, but the reduction was significantly steeper among students allocated to the brief intervention.

There were no statistically significant differences in trends in respect of other measures including health care utilisation, injuries, drink driving, depression, or smoking.

The authors' conclusions

This trial provides some of the best evidence to date that spending time talking with students about their alcohol use is worth the time, effort, and resources required to do so, evidenced by the high proportion of students who on health grounds needed to cut down on their drinking, and the extra reductions seen after the brief alcohol advice sessions. The diversity of sites in the study offer reassurance that similar results would be found elsewhere.

One practical implication is that systematic alcohol screening of college students attending health clinics for routine care is feasible using a paper-and-pencil questionnaire; receptionists can distribute the questionnaires, and students are willing to provide information on health habits such as exercise, smoking, weight concerns, and drinking, contradicting concerns that clinic or student resistance means college health clinics have a minimal role to play in campus-wide efforts to identify high-risk students. The study also showed that primary care providers can be trained to conduct and successfully implement brief alcohol interventions; as commonly happens, such work does not have to be diverted to counselling centres and non-clinical settings.

The extra reductions in drinking and harm were less than those seen in similar studies of non-student adult populations, possibly because young people often feel invincible and have limited experience of the serious consequences of drinking, and/or peer pressure and perceived social norms. Though these were greater among students allocated to the brief intervention, the study also found large reductions in drinking and related harms in the control group, perhaps due to natural transitions due to aging or the abating of an atypically high level of drinking, or the impact of being asked about one's drinking and related harms. Of the 4512 students screened positive for risky drinking by the health screening survey, just 22% participated in the trial. It is possible that they differed in salient ways from the students who did not in the end meet the trial's criteria and agree to join it.


Findings logo commentary The authors make the case for their study justifying resource allocation to alcohol screening and brief advice for college students. One half of the argument – the prevalence of heavy drinking – seems persuasive. But the other half – that the intervention reduced drinking to a degree worth the investment – can be questioned. For example, a year after the intervention the students allocated to it were drinking on average about 23 UK units a week, the other students about one unit more. The difference may seem insufficient to be clinically significant or to warrant the investment. Though this was how they ended up, because the intervention students started at a slightly higher level, they reduced their drinking by about two UK units more a week, a figure which may still seem unconvincing, especially since part may have been due to them knowing the study was really about their drinking and not their general health, a fact hidden from the control group students. This 'social desirability' bias is one of several possible reasons why control groups in brief alcohol intervention studies on average substantially reduce their drinking or at least say they have.

An alternative perspective is that simply asking about drinking and its adverse consequences had an impact which the intervention reinforced, meaning the whole package led to substantial drinking reductions. This can happen, but if it did, the research assessments which may have promoted those reductions would have to be costed in to the package, and also the financial inducement to complete those assessments and to complete (if this also was rewarded) the intervention itself.

Overall offering some alcohol intervention has led to greater reductions in drinking and drink-related problems in college students than simply assessment (with or without a control intervention not intended to reduce drinking). Effects are small, but of the order to be expected from a broad public health measure as opposed to targeted treatment for people actually seeking to curb their drinking.

As well as counselling individual heavy drinkers, an alternative and, it has been argued, the primary strategy, is to change the college environment and culture to make regular and heavy drinking less possible and less attractive. Where these levers are available, college administrators concerned to reduce drinking and its adverse consequences among their students may consider tightening campus rules, more vigorous enforcement of those rules and of general alcohol laws, alcohol-free bars and entertainments, and generally fostering an environment which makes sobriety easier and the opposite harder. Such initiatives are limited by the fact that much drinking occurs off-campus, but have effectively been extended to the local area.

Last revised 31 May 2013. First uploaded 24 May 2013

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2013 Alcohol assessment and feedback by email for university students: main findings from a randomised controlled trial

STUDY 2014 The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

REVIEW 2012 Efficacy of brief alcohol screening intervention for college students (BASICS): a meta-analysis of randomized controlled trials

STUDY 2012 Text-message-based drinking assessments and brief interventions for young adults discharged from the emergency department

REVIEW 2015 Electronic interventions for alcohol misuse and alcohol use disorders: a systematic review

STUDY 2012 Personalised normative feedback for preventing alcohol misuse in university students: Solomon three-group randomised controlled trial

STUDY 2012 Alcohol screening and brief intervention in primary health care

STUDY 2012 Alcohol screening and brief intervention in emergency departments

STUDY 2010 Providing web-based feedback and social norms information to reduce student alcohol intake: a multisite investigation

REVIEW 2010 Alcohol-use disorders: Preventing the development of hazardous and harmful drinking





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