Drug Treatment Matrix cell A5: Interventions; Safeguarding the community

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Interventions; Safeguarding the community

Seminal and key studies shedding light on treatment’s contribution to safeguarding the community and preventing crime. Commentary addresses two highly controversial issues, asking, “Can it ever be safe to leave children with seriously problematic drug users?”, and examining the ethical considerations and evidence on pressuring opioid-dependent offenders to take the opiate-blocker naltrexone.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text

S Lessons of forced treatment in California Civil Addict Program (1977). Study of treatment enforced by the California Civil Addict Program found drug testing and sanctions suppressed crime, but despite a less strict regimen and less resort to residential options, methadone maintenance had a greater and more lasting impact. For discussion click and scroll down to highlighted heading.

S Reassurance of naltrexone blockade opens up reintegration opportunity for heroin-dependent prisoners (1984). Describes what seems to have been the first documented use of naltrexone among offenders, a programme mounted in Nassau County Jail in New York from 1972 which qualified previously excluded prisoners to be let out of prison to work, earn and save money. See also other descriptions of the programme (1 2). For discussion click and scroll down to highlighted heading.

Cost per person entering treatment

K No crime reduction from mandatory drug testing and assessment of arrestees in England (2018). Schemes which force people arrested for certain offences to be tested for heroin or cocaine use, and if positive to be assessed for treatment, do not pay back in terms of treatment engagement or crime reduction. Evaluation of corresponding policy in Scotland led funding for mandatory testing schemes to be ended but continued for voluntary schemes. In some areas voluntary arrest referral schemes cost six to eight times less per drug user engaging with treatment chart.

K Flexible drug treatment and testing orders work best (Scottish Executive, 2004). Reconviction rates for drug using offenders in Scotland halved after they started court-ordered testing and treatment programmes; comparison with England suggests more flexible supervision by criminal justice caseworkers helps reduce recidivism.

K Anti-offending programme for drug users did not cut crime (2011). The main cognitive-behavioural group therapy programme (ASRO) for problem substance users on probation in the UK could not be shown to have affected reconviction rates.

K Drug recovery wings face uphill struggle in English prisons (2017). In 2010, drug recovery wings providing a therapeutic regimen for prisoners motivated to overcome drug dependence were an important element in the UK government’s turn towards abstinence-based recovery. Improvements in a followed-up minority of prisoners from these wings could not be benchmarked against a comparison group, and physical and mental health declined while on the wings. Patchy therapeutic and recovery-oriented inputs were countered by the anti-recovery effects of imprisonment and lack of support on release.

%s of prisoners at different risk of reoffending not reimprisoned after therapeutic community versus outpatient treatment

K No recidivism dividend from prison therapeutic community for high-risk offenders (2014). For the first time in a prison setting a randomised trial rigorously compared intensive residential therapeutic community treatment to outpatient counselling. Confounding expectations, the US prison for problem drug users which hosted the study gained nothing in terms of preventing recidivism by allocating to the more intensive treatment, even among prisoners most likely to reoffend chart.

K Therapeutic community for paroled dual diagnosis prisoners halves re-imprisonment (2012). From the USA, the first randomised trial of a post-prison residential therapeutic community designed for psychologically disturbed problem substance using offenders found it halved the numbers re-imprisoned and did even better when preceded by similar in-prison treatment, confirmation that what happens when people leave prison can be critical.

K Supervised naltrexone works for opiate-dependent offenders (1997). First randomised trial exemplified the conclusion that naltrexone has a role among closely monitored offenders who have much to lose (in this case, their freedom) from dropping out of treatment and returning to opiate use, especially when pill-taking is supervised – but also indicates that given the choice, few opt to have their freedom to use opiates pharmacologically curtailed. For discussion click and scroll down to highlighted heading.

K Randomised trial finds long-acting opiate-blocker reduces opioid use by offenders (2016). Long-acting naltrexone product injected into the body supplemented usual drug counselling for offenders with a history of opioid dependence living in the community under criminal justice supervision. The monthly injections were mainly renewed as intended and while active helped prevent relapse to opioid use but with no lasting effects. For discussion click and scroll down to highlighted heading.

K No demonstrable benefits from intensive support for “troubled families’ ([UK] Department for Education, 2011). Evaluation of national payment-by-results scheme to ’turn round’ troubled families in England found substantial remission in substance use problems, but could not attribute these to the interventions. Final evaluation report (2016) on the programme as implemented from 2012 to 2015 found that relative to comparison families, there were no significant impacts on substance use or outcomes related to employment, job-seeking, school attendance and anti-social behaviour. From 2015 the programme was revised to target families with a much broader range of disadvantages and to help younger children benefit. A series of evaluation reports have been published, but it seems none yet feature (2017) an adequate comparison group.

K Intensive support for substance-using parents enabled children to stay at home (Welsh Assembly Government, 2008). Found that a service which worked intensively over a few weeks with substance-using parents whose children faced imminent care proceedings forestalled their removal from the home. Later evaluation (2012) of the same service confirmed this was not at the expense of the children’s welfare. Initial evaluation of national rollout listed below. For discussion click and scroll down to highlighted heading.

K Lessons from Welsh pilot of integrated support for children affected by substance use in the family (Welsh Government, 2014). Evaluation of the first three local schemes in a nationwide rollout of services based on the evaluations listed above. Documents how the schemes changed in response to experience and strategic and operational contexts. For discussion click and scroll down to highlighted heading.

K Intensive English programme helped keep children at home (2009). Intensive short-term intervention by a specialist service for substance-dependent parents reduced the need to remove their children from the home. For discussion click and scroll down to highlighted heading.

K Therapeutic orientation improves outcomes of child care proceedings in London (2016). First UK family drug and alcohol court achieved sustainably improved parental and child outcomes at lower cost ([UK] Home Office, 2012) compared to ordinary care proceedings. The authors claimed “a sound basis for comparing outcomes”, but the families allocated to the family drug and alcohol court and comparison families were not randomly assigned and derived from different boroughs. For discussion click and scroll down to highlighted heading.

K Treating couples together further reduces domestic violence (2002; free source at the time of writing). Engaging potentially violent male drug users and their partners in therapy together needs great care (2007) but can reduce domestic violence more effectively than individual treatment. Similar results from a later study (2009) of the same approach from the same lead researcher.

K Support the relatives too (2011). Brief primary care counselling seemed to help relatives in England cope with living with a problem substance user, but without a control group against whom to benchmark the outcomes the study could not be sure the outcomes were due to the interventions.

K Maintain prisoners on methadone rather than imposing withdrawal (2018). From the USA, a rare randomised trial found in favour of continuing methadone maintenance when patients entered prison rather than compulsory withdrawal. The potential benefits were most apparent in the near-100% continuation of protective treatment during the highly overdose-prone weeks after leaving prison.

K Needle exchanges help keep area free of discarded syringes (2012). A major concern about needle exchanges is that after use the injecting equipment they supply will be left unsafely disfiguring public areas, but this US study strongly suggested the opposite.

R European studies find treatment cuts crime (2014). Amalgamated results from European studies which randomly allocated illegal drug users to treatment versus no or usual treatment indicate that treatment (especially opioid substitute prescribing using drugs such as methadone) substantially curbs the criminal activity of the patients. For discussion click and scroll down to highlighted heading.

R Treatment and supervision of drug-dependent offenders (2008). UK-focused review by the Institute for Criminal Policy Research in London: “the strongest evidence seems to favour the use of therapeutic communities, interventions modelled on the drug court approach and substitute treatments such as methadone maintenance.”

R Equivocal evidence for coerced treatment of drug using offenders (2013). Notes that “to justify the disempowering nature of coerced treatment, practitioners, policy-makers, and researchers are obliged to demonstrate [its] effectiveness …” Maps the criminal justice process from pre-arrest to post-release, revealing lacking or equivocal evidence for coerced treatment at most stages, and that the strongest record is for offending reductions generated by drug courts – though these have been criticised (2010) for bringing more drug users into the criminal justice system and ultimately punishing the many who do not respond as intended.

R Integrate community-based treatment with criminal justice supervision (2003). Leading US expert makes sense of the literature, extracting the principles underlying effective treatment in the criminal justice system and identifying effective interventions.

R Opioid maintenance treatment works in prisons too (2011). Continuity of methadone maintenance from before to during and after prison is the key to gaining benefits similar to those in seen in community settings.

R Is therapy undermined by a punishment context? (2005). Asks whether in criminal justice settings, the contradictions of helping and punishing at the same time (‘motivational arm-twisting’) undermine interventions which might work elsewhere – in particular, the client-centred motivational interviewing style of counselling.

R Preventing drug-related disease spread in prisons (2009; free source at time of writing). Findings likely to be applicable to any blood-borne disease are that needle and syringe programmes and opioid substitution treatment have proven effective at reducing HIV risk-behaviours in a wide range of prison environments, without negative consequences for the health of staff or prisoners – important findings because having been in prison has repeatedly been associated with increased risk of infection. See also review of HIV prevention specific to opioid substitution treatment in prison and (among other factors) study attributing the low incidence of hepatitis C infections in Scottish prisons to the widespread in-prison opioid substitution treatment.

R Treatment’s impact on the children (2009). Exhaustive search found just a handful of studies relevant to whether treating substance-using parents in the criminal justice system improves their children’s welfare.

R Routine substance use treatment can reduce domestic violence (2009; free source at the time of writing). When successful, treatment in general results in reduced violence between sexual partners; couples therapy has yet greater impacts, but is not always (2007) safe or feasible. For related discussion click and scroll down to highlighted heading.

R Family programmes can improve the prospects of children whose parents have substance use problems (2012) Of the reviewed programmes, most effective were those which involved both parents and children, particularly the Strengthening Families Programme (2004). For discussion click and scroll down to highlighted heading.

R Can opiate substitute patients drive safely? (2013). Methadone and buprenorphine certainly can make non-dependent drivers unsafe, but the jury is out on whether driving is impaired among dependent patients maintained on these drugs and who have therefore developed tolerance to their effects. Individual assessments are needed. UK guidance (2017) allows stabilised methadone and buprenorphine patients assessed as safe to drive to do so.

G Clinical management of drug dependence in the adult prison setting ([UK] Department of Health etc, 2006 and 2010 update).

G Treating prisoners in Scotland (Scottish Prison Service, 2011). Official guidance on the commissioning, management and delivery of interventions for substance-misusing offenders, dating from before the transfer of responsibility for treatment in Scottish prisons prison to the NHS.

G Health in prisons (World Health Organization [etc], 2007). Chapters on drug services in general and substitute prescribing in particular.

G US expert consensus on treatment in the criminal justice system ([US] Substance Abuse and Mental Health Services Administration, 2005). Guidance on interventions, matching to the offender, and planning programmes.

more Search for all relevant analyses or for subtopics go to the subject search page or hot topics on supporting families, drug testing and sanctions, naltrexone implants and injections, and protecting children.

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