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Interventions in prison

This page refers to the current evidence on the effectiveness of the available interventions in prison. Information on the methodology used and the definition of terms can be found on the methodology page.

Date of last update: 05.2017     Next update: 10.2017

Interventions for drug users in prison

Beneficial

Psychosocial interventions vs treatment as usual to reduce criminal activity (re-incarceration) in female drug-using offenders

Psychosocial interventions were found in a systematic review (Perry et al., 2015a) to be effective more than treatment as usual in:

  • reducing criminal activity, i.e. re-incarceration rates (RR 0.46, 95 % CI 0.34 to 0.64, N=630)

Opioid substitution therapy to reduce deaths in prison

One cohort study (Larney et al., 2014) enrolling N=16 715 opioid dependent people who were in prison between 2000 and 2012 showed that:

  • being in OST was associated with a 74% lower hazard of dying in prison (adjusted HR (AHR) 0.26; 95% CI 0.13 to 0.50), compared to time not in OST
  • being in OST was associated with a 87% lower hazard of unnatural death (adjusted HR (AHR) 0.13; 95% CI 0.05 to 0.35), compared to time not in OST
  • being in OST was associated with a 94% lower all-cause mortality hazard during the first 4 weeks of incarceration (adjusted HR (AHR) 0.06; 95% CI 0.01 to 0.48), compared to time not in OST
  • being in OST was associated with a 93% lower hazard of unnatural death during the first 4 weeks of incarceration (adjusted HR (AHR)  0.07; 95% CI 0.01 to 0.59), compared to time not in OST

Likely to be beneficial

Continuity of treatment from prison to community to reduce post-release mortality

One cohort study (Degenhardt et al., 2014) enrolling N=16453 people released from prison 60161 times (all opioid dependent people who entered OST between 1985 and 2010 and were released from prison at least once between 2000 and 2012 in Australia) showed that those continuously  retained in OST after being released from prison (continuity of care):

  • had a reduced risk of mortality by 75% (adjusted hazard ration=0.25, 95 % CI 0.12 to 0.53)

One RCT (Dolan et al., 2005, cited in EMCDDA, 2010) suggests that retention in MMT in prison settings is associated with:

  • reduced mortality from all causes (OR 0.54, 95 % CI 0.20 to 1.43);
  • reduced mortality for overdose

Naloxone training and prescription to reduce opioid overdose mortality after release from prison

Brief training and standardised naloxone supply for individuals at risk of opioid overdose in prison has been found to be effective in a pre-post evaluation of a national policy (Bird et al.,2015) in:

  • reducing by 36 % the proportion of opioid-related deaths that occurred in the 4 weeks following release from prison (from 9.8 % of ORDs (193/1970) in 2006–10 to 6.3 % of ORDs (76/1212) in 2011–13).

Naltrexone vs non-pharmacological treatment to reduce criminal activity (re-incarceration) in drug-using offenders

Naltrexone (antagonist pharmacological treatment for relapse prevention) was found in a systematic review (Perry et al., 2015a) to be effective in: :

  • reducing criminal activity, i.e re-incarceration rates (RR 0.40, 95 % CI 0.21 to 0.74, 2 studies, N=114)

Opioid substitution treatment (OST) to reduce injecting risk behaviour in prison

A systematic review without meta-analysis (Hedrich et al, 2012) concluded that there is:

  • there is consistent evidence that OST in prison reduces injecting risk behaviour

Therapeutic communities in prison to reduce re-incarceration rates and drug misuse relapse

Therapeutic communities in prison (including aftercare or transitional programs and drug-free wings) were found in a systematic review without meta-analysis (Galassi et al., 2015, 14 studies, N =8245) to be more effective than control conditions in:

  • reducing re-incarceration rates (5 studies out of 7 found significant results)
  • reducing or preventing drug misuses relapse (7 studies out of 9 found positive results)

Therapeutic communities in prison and aftercare to reduce re-incarceration rates drug-using offenders with co-occurring mental illness

Therapeutic communities and aftercare were found in a narrative systematic review (Perry et al., 2015b; 8 RTCs, N = 2 058) to have a moderate effect in:

  • reducing re-incarceration rates of drug-using offenders with co-occurring mental illness

Trade-off between benefits and harms

No interventions met these criteria.

Unknown effectiveness

Interventions for drug-using offenders with co-occurring mental illness to reduce drug use and re-arrest

Different interventions targeting drug-using offenders with co-occurring mental illness (including therapeutic communities in prison, mental health drug court, motivational interviewing and cognitive skills and interpersonal psychotherapy) were found in a narrative systematic review (Perry et al., 2015b, 8 studies, N =2 058) to have no effect in:

  • reducing drug use
  • reducing re-arrest rates

Needle and syringe programmes to reduce HIV, HCV and injecting risk behaviour in prison

Two narrative reviews (Dolan et al., 2003; Stöver, 2003 cited in EMCDDA, 2010) enclosed in the EMCDDA HR monograph, concluded that there is insufficient evidence to either support or discount the effectiveness of prison NSPs in:

  • reducing HIV transmission among IDUs
  • reducing HCV transmission among IDUs.
  • reducing injecting risk behaviour among IDUs

Opioid substitution treatment (OST) to reduce HIV and HCV 

One systematic review (Gowing et al., 2008 cited in EMCDDA, 2010) without meta-anlysis, did not find sufficient evidence to draw conclusions about the effect of OST on:

  • HIV seroconversion in prison settings

Data from one RCT (Dolan et al., 2003) in a jurisdiction with low HIV prevalence found no difference in:

  • HIV incidence between those receiving methadone maintenance treatment (MMT) and controls (RR 1.09, 95 % CI 0.30 to 4.01, N=382)

One narrative review (Stallwitz et al., 2007 cited in EMCDDA, 2010) found no evidence to either support or discount the effectiveness of OST with respect to:

  • HCV transmission in prison settings

Pharmacological vs non-pharmacological treatment to reduce use and criminal activity in drug-using offenders

Agonist pharmacological treatments for drug-using offenders were found in a systematic review (Perry et al., 2015a) to have no different effect than non-pharmacological interventions in:

  • reducing drug use
    • measured (RR 0.72, 95 % CI 0.51 to 1.00, 2 studies, N=237)
    • self-reported (RR 0.61, 95 % CI 0.31 to1.18, 3 studies, N=317)
  • reducing criminal activity
    • arrests (RR 0.60, 95 % CI 0.32 to 1.14, 1 study, N=62)
    • re-incarceration (RR 0.77, 95 % CI 0.36 to 1.64, 3 studies, N=472)

Antagonist pharmacological treatments (Naltrexone) were found in the same review (Perry et al., 2015a) to also have no different effect than non-pharmacological interventions in:

  • reducing drug use (measured) (RR 0.69, 95 % CI 0.28 to 1.70, 1 study, N=63)

When comparing the drugs no significant differences between comparisons (methadone versus buprenorphine, diamorphine and naltrexone) on any of the outcome measures.

Pharmacological treatment vs placebo treatment to reduce use in female drug-using offenders

Pharmacological treatment (Buprenorphine) for female drug-using offenders was found in a systematic review (Perry et al., 2015a) to have no different effect than placebo in:

  • reducing drug use - self-reported  (RR 0.58, 95 % CI 0.25 to 1.35, 1 study, N=36)

Psychosocial interventions vs treatment as usual to reduce use in female drug-using offenders

Psychosocial interventions for female drug-using offenders were found in a systematic review (Perry et al., 2015a) to have no different effect than treatment as usual in:

  • reducing drug use (RR 0.65, 95 % CI 0.20 to 2.12, 1 study, N=77)

Therapeutic communities in prison to reduce re-arrests rates

Therapeutic communities in prison (including aftercare or transitional programs and drug-free wings) were found in a systematic review without meta-analysis (Galassi et al., 2015, 14 studies, N =8245) to have no effect in:

  • reducing re-arrest rates (5 studies out of 9 found positive results, yet those studies had much shorter follow-up periods)

Evidence of ineffectiveness

No interventions met these criteria.

References and definitions

References

Explanation of terms used

Below you can find definitions and further explanation for some of the terms used in this section of the Best practice portal. A more general glossary for the best practice portal is also available.

Affective-focused prevention intervention

A type of prevention intervention which aims to they aim to modify inner qualities (personality traits such as self-esteem and self-efficacy, and motivational aspects such as the intention to use drugs).

BA

Before-after (BA) study design

BAL

Blood alcohol level (BAL)

Beneficial

Interventions for which precise measures of the effects in favour of the type of intervention were found in systematic reviews of relevant studies. An intervention ranked as ‘beneficial’ is suitable for most patients/contexts. See the relevant module methodology page for further information.

CBA

Controlled before-after (CBA) study design. UCBA stands for Uncontrolled before-after study design.

CBT

Cognitive behavioral therapy is an individual based intervention occurring in three stages. Phase 1 is aimed at determining and prioritizing the patient’s problems and constructing the treatment contract. Phase 2 is aimed at increasing coping competence and reducing risky behaviors. Phase 3 focuses on relapse prevention. Each session is administered once per week over a period of 4-6 months with 60- to 90-minute sessions (Beck AT, Wright FW, Newman CF, Liese B. Cognitive Therapy of substance abuse. New York: Guilford Press, 1993).

CCT

Controlled clinical trials (CCT)

Cohort study

A cohort study is a type of observational study that follows a group of people (i.e. a cohort) over time. In a prospective cohort study, the cohort is formed and then followed over time. In a retrospective cohort study, data is gathered for a cohort that was formed sometime in the past.

Confidence Interval (CI)

The Confidence Interval (CI) is a measure of the precision (or uncertainty) of study results. It is the interval that most likely includes the true value of the parameter we are calculating, where 'most likely' is taken by common usage to be a 95% probability. Thus the current expression of '95 % CI'. A wide CI indicates less precise estimates of effect and vice versa.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
CPS

Current population survey (CPS)

Cross-sectional study

A cross-sectional study is a study employing a single point of data collection for each participant or system being studied.They are usually conducted to estimate the prevalence of the outcome of interest for a given population at a given point in time.

Evidence of ineffectiveness

Interventions that gave negative results if compared with a standard intervention or no intervention, for example. See the relevant module methodology page for further information.

Additional information for prevention
For ethical reasons this category in prevention should be considered as interventions with negative and undesired (iatrogenic) effect.

IP

Individual psychotherapy is a standard individual treatment based on counseling and motivational interviewing and focused on substance use triggers and strategies for relapse prevention. It includes elements of cognitive-behavioral therapy (CBT).

IQR

Interquartile range (IQR) - also called the midspread or middle fifty - is a measure of statistical dispersion. It is a trimmed estimator, defined as the 25% trimmed mid-range, and is the most significant basic robust measure of scale.

ITS

Intermittent time series design (ITS)

Knowledge-focused prevention intervention

A type of prevention intervention which aims to to enhance knowledge of drugs, and drug effects, and consequences.

Likely to be beneficial

Interventions that were shown to have limited measures of effect, that are likely to be effective but for which evidence is limited. An intervention ranked as ‘likely to be beneficial’ is suitable for most contexts/patients, with some discretion. See the relevant module methodology page for further information.

Number Needed to Treat (NNT)

The Number Needed to Treat (NNT)indicates the number of patients that needs to be treated to obtain one respondent patient. Numerically the NNT is the reciprocal of the difference between the proportion of events in the experimental and the comparison group (absolute risk reduction). Taking into consideration that the ideal NNT would be 1 (the unreal situation in which every single patient succeeded) it is easily understood that a NNT value close to 3 or 4 would be very good.

Adjusted Odds Ratio (AOR)

The Adjusted Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups, yet they are calculated adjusting for or controlling for other possible contributions from other variables (tipically demographic variables) in the model. An AOR equal to 1 implies that the the event is equally probable in both groups. An AOR greater than 1 implies that the event is more likely in the first group. An AOR less than 1 implies that the event is less likely in the first group.

Odds Ratio (OR)

The Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups. Like the Relative Risk, an OR equal to 1 implies that the the event is equally probable in both groups. A OR greater than 1 implies that the event is more likely in the first group. A OR less than 1 implies that the event is less likely in the first group. In medical research, the odds ratio is commonly used for case-control studies, as odds, but not probabilities, are usually estimated. Relative risk is used in randomized controlled trials and cohort studies.

p value

A p-value is a measure of how much evidence we have against the null hypothesis. The null hypothesis represents the hypothesis of no change or no effect. The smaller the p-value, the more evidence we have against the null hypothesis thus it is more likely that our sample result is true. Traditionally, researchers will reject a null hypothesis if the p-value is less than 0.05.

RBS

Responsible beverage service (RBS)

RCT

Randomised controlled trial (RCT)

Relative Risk (RR)

The Relative Risk (RR) is used to compare the risk in the two different groups of people, i.e. treated and control groups to see if belonging to one group or another increases or decreases the risk of developing certain outcomes. This measure of effect will tell us the number of times an outcome is more likely (RR > 1) or less likely (RR < 1) to happen in the treatment group compared with the control group.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
Trade-off between benefits and harms

Interventions that obtained measures of effects in favour of the intervention, but that showed some limitations or unintended effects that need to be assessed before providing them. See the relevant module methodology page for further information.

 
Unknown effectiveness

Interventions for which there are not enough studies or where available studies are of low quality (with few patients or with uncertain methodological rigour), making it difficult to assess if they are effective or not. Interventions for which more research should be undertaken are also grouped in this category.

Additional information for prevention
For prevention interventions,  this  is also known as 'zero effect'.

Skill-focused prevention intervention

A type of prevention intervention which aims to enhance students’ abilities in generic skills, refusal skills and safety skills.

Standardised Mean Difference (SMD)

The Standardised Mean Difference (SMD) is the difference in means divided by a standard deviation. Note that it is not the standard error of the difference in means (a common confusion). The standardized mean difference has the important property that its value does not depend on the measurement scale. It may be useful if there are several trials assessing the same outcome, but using different scales.

z score (Standard Score)

The z-score (aka, a standard score) indicates how many standard deviations an element is from the mean of the population.

 

 

 

 

 

 

 

About drug use in prison

Definition

Prisoners report higher lifetime rates of drug use than the general population and more harmful patterns of use, with injection rates reported between 6 % and 31 %. High rates of hepatitis C and other infectious diseases have also been observed among prisoner populations.

Interventions

Treatment, both pharmacological and psychosocial, and harm reduction measures are the most important interventions implemented in the prison settings for drug-using offenders. The WHO recommends that a package of prevention responses, including free and voluntary testing for infectious diseases, distribution of condoms and sterile injecting equipment, infectious diseases treatment and treatment of drug dependence is made available to all prisoners.

Outcomes

  • Retention in treatment
  • Relapse to use
  • Mortality
  • Criminal activity

 

About the EMCDDA

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the reference point on drugs and drug addiction information in Europe. Inaugurated in Lisbon in 1995, it is one of the EU's decentralised agencies. Read more >>

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Page last updated: Thursday, 18 May 2017