Interventions for female drug-using offenders

What is the aim?

To assess the effectiveness of interventions to reduce drug use, criminal activity, or both, in women involved in the criminal justice system.

What is the key message?

We are uncertain whether the treatments reduce subsequent drug use, criminal activity, or both. We identified too few studies to evaluate whether the treatment
setting (for example, court or community) had an impact on the success of such programmes. The study sample sizes were small and the certainty of this evidence was very low. High quality research is required to evaluate the effectiveness of different treatment options.

What was studied?

We studied any intervention aimed at reducing drug use, criminal activity, or both. Many more people involved in the criminal justice system experience drug use compared to people who have no contact with the criminal justice system. Most of the interventions that are used to support the rehabilitation of drug use in the criminal justice system are aimed at men and not women. Women have different needs to men and existing schemes need to be evaluated and adapted to deal with the complexity of the kinds of problems that women experience in order to reduce female drug use, criminal activity, or both

What are the main results?

We found 13 trials including 2560 participants. The 13 trials included people who were assigned at random to one of two interventions, conducted mainly in the USA. Studies were conducted in prison and the community. Study participants received a range of different interventions in comparison to nothing, another intervention or treatment as usual.
The review shows that:

- when women engage with collaborative case management, it may make little or no difference to reducing drug use, reincarceration or rearrest in comparison to treatment as usual (low-certainty evidence);

- when women take buprenorphine, we are uncertain whether it reduces drug use in comparison to a placebo (very low-certainty evidence);

- when women take buprenorphine pre-release from prison, it may make little or no difference to reducing drug use or criminal activity in comparison to taking buprenorphine post-release from prison (low-certainty evidence);

- when women engage with interpersonal psychotherapy, it may make little or no difference to reducing a relapse into drug use in comparison to a psychoeducational intervention (low-certainty evidence);

- when women engage in acceptance and commitment therapy, it may make little or no difference to reducing drug use/ abstinence from drug use in comparison to a waiting list control (low-certainty evidence);

- when women engage with cognitive skills in comparison to a therapeutic community intervention, we are uncertain whether it produces a reduction in subsequent drug use, being rearrested, committing criminal activity or drug-related crimes (very low-certainty evidence);

- when women engage with cognitive skills in comparison to a therapeutic community intervention, it may reduce subsequent arrest (not parole violations) (very low-certainty evidence);

- when women engage with cognitive skills in comparison to standard therapy, we are uncertain whether it reduces subsequent drug use (very low-certainty evidence);

- when women engage with a single session of a computerised intervention, it may make little or no difference to reducing subsequent drug use (low-certainty evidence) in comparison to face-to-face case management;

- when women engage with dialectic behavioural therapy and case management, we are uncertain whether it produces a reduction in subsequent drug use in comparison to a health promotion scheme (very low-certainty evidence);

- when women engage in a therapeutic community programme, we are uncertain whether it reduces subsequent drug use and criminal activity in comparison to a work release programme (very low- to low-certainty evidence);

- when women engage with intensive discharge planning upon release, it probably does not reduce subsequent drug use and criminal activity in comparison to prison only (moderate-certainty evidence).

Funding sources were reported by all studies and included government and research/charitable foundations.

How up-to-date is this review?

February 2019.

Authors' conclusions: 

The studies showed a high degree of heterogeneity for types of comparisons, outcome measures and small samples. Descriptions of treatment modalities are required. On one outcome of arrest (no parole violations), we identified a significant reduction when cognitive behavioural therapy (CBT) was compared to a therapeutic community programme. But for all other outcomes, none of the interventions were effective. Larger trials are required to increase the precision of confidence about the certainty of evidence.

Read the full abstract...
Background: 

This review represents one in a family of three reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders.

Objectives: 

To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both.

Search strategy: 

We searched 12 electronic bibliographic databases up to February 2019.

Selection criteria: 

We included randomised controlled trials (RCTs).

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane.

Main results: 

We included 13 trials with 2560 participants. Interventions were delivered in prison (7/13 studies, 53%) and community (6/13 studies, 47%) settings. The rating of bias was affected by the lack of clear reporting by authors, and we rated many items as 'unclear'.

In two studies (190 participants) collaborative case management in comparison to treatment as usual did not reduce drug use (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.20 to 2.12; 1 study, 77 participants; low-certainty evidence), reincarceration at nine months (RR 0.71, 95% CI 0.32 to 1.57; 1 study, 77 participants; low-certainty evidence), and number of subsequent arrests at 12 months (RR 1.11, 95% CI 0.83 to 1.49; 1 study, 113 participants; low-certainty evidence).

One study (36 participants) comparing buprenorphine to placebo showed no significant reduction in self-reported drug use at end of treatment (RR 0.57, 95% CI 0.27 to 1.20) and three months (RR 0.58, 95% CI 0.25 to 1.35); very low-certainty evidence. No adverse events were reported.

One study (38 participants) comparing interpersonal psychotherapy to a psychoeducational intervention did not find reduction in drug use at three months (RR 0.67, 95% CI 0.30 to 1.50; low-certainty evidence).

One study (31 participants) comparing acceptance and commitment therapy (ACT) to a waiting list showed no significant reduction in self-reported drug use using the Addiction Severity Index (mean difference (MD) -0.04, 95% CI -0.37 to 0.29) and abstinence from drug use at six months (RR 2.89, 95% CI 0.73 to 11.43); low-certainty evidence.

One study (314 participants) comparing cognitive behavioural skills to a therapeutic community programme and aftercare showed no significant reduction in self-reported drug use (RR 0.86, 95% CI 0.58 to 1.27), re-arrest for any type of crime (RR 0.73, 95% CI 0.52 to 1.03); criminal activity (RR 0.80, 95% CI 0.63 to 1.03), or drug-related crime (RR 0.95, 95% CI 0.68 to 1.32). A significant reduction for arrested (not for parole) violations at six months follow-up was significantly in favour of cognitive behavioural skills (RR 0.43, 95% CI 0.25 to 0.77; very low-certainty evidence). A second study with 115 participants comparing cognitive behavioural skills to an alternative substance abuse treatment showed no significant reduction in reincarceration at 12 months (RR 0.70, 95% CI 0.43 to 1.12; low certainty-evidence.

One study (44 participants) comparing cognitive behavioural skills and standard therapy versus treatment as usual showed no significant reduction in Addiction Severity Index (ASI) drug score at three months (MD 0.02, 95% CI -0.05 to 0.09) and six months (MD -0.02, 95% CI -0.09 to 0.05), and incarceration at three months (RR 0.46, 95% CI 0.04 to 4.68) and six months (RR 0.51, 95% CI 0.20 to 1.27); very low-certainty evidence.

One study (171 participants) comparing a single computerised intervention versus case management showed no significant reduction in the number of days not using drugs at three months (MD -0.89, 95% CI -4.83 to 3.05; low certainty-evidence).

One study (116 participants) comparing dialectic behavioural therapy and case management (DBT-CM) versus a health promotion intervention showed no significant reduction at six months follow-up in positive drug testing (RR 0.67, 95% CI 0.43 to 1.03), number of people not using marijuana (RR 1.23, 95% CI 0.95 to 1.59), crack (RR 1.00, 95% CI 0.87 to 1.14), cocaine (RR 1.02, 95% CI 0.93 to 1.12), heroin (RR 1.05, 95% CI 0.98 to 1.13), methamphetamine (RR 1.02, 95% CI 0.87 to 1.20), and self-reported drug use for any drug (RR 1.20, 95% CI 0.92 to 1.56); very low-certainty evidence.

One study (211 participants) comparing a therapeutic community programme versus work release showed no significant reduction in marijuana use at six months (RR 1.03, 95% CI 0.19 to 5.65), nor 18 months (RR 1.00, 95% CI 0.07 to 14.45), heroin use at six months (RR 1.59, 95% CI 0.49 to 5.14), nor 18 months (RR 1.92, 95% CI 0.24 to 15.37), crack use at six months (RR 2.07, 95% CI 0.41 to 10.41), nor 18 months (RR 1.64, 95% CI 0.19 to 14.06), cocaine use at six months (RR 1.09, 95% CI 0.79 to 1.50), nor 18 months (RR 0.93, 95% CI 0.64 to 1.35). It also showed no significant reduction in incarceration for drug offences at 18 months (RR 1.45, 95% CI 0.87 to 2.42); with overall very low- to low-certainty evidence.

One study (511 participants) comparing intensive discharge planning and case management versus prison only showed no significant reduction in use of marijuana (RR 0.79, 95% CI 0.53 to 1.16), hard drugs (RR 1.12, 95% CI 0.88 to 1.43), crack cocaine (RR 1.08, 95% CI 0.75 to 1.54), nor positive hair testing for marijuana (RR 0.75, 95% CI 0.55 to 1.03); it found a significant reduction in arrests (RR 0.19, 95% CI 0.04 to 0.87), but no significant reduction in drug charges (RR 1.07, 95% CI 0.75 to 1.53) nor incarceration (RR 1.09, 95% CI 0.86 to 1.39); moderate-certainty evidence.

One narrative study summary (211 participants) comparing buprenorphine pre- and post-release from prison showed no significant reduction in drug use at 12 months post-release; low certainty-evidence. No adverse effects were reported.

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