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CORK Bibliography: Compulsory Treatment

50 citations. January 2003 to present

Prepared: September 2007

Barnett NP; Read JP. Mandatory alcohol intervention for alcohol-abusing college students: A systematic review. (review). Journal of Substance Abuse Treatment 29(2): 147-158, 2005. (71 refs.)

Most colleges and universities in the United States have programmatic responses for alcohol policy violators that commonly include some form of mandatory alcohol education or counseling. The purpose of this study was to conduct a review of intervention programs for college students who are required to attend alcohol education or counseling. MEDLINE, PsycINFO, and ERIC databases were searched for reports of college-based mandatory interventions offered on American campuses. When possible, within-group and between-group effect sizes were calculated. Sixteen reports were identified, including three randomized controlled trials. Most of the reviewed studies used qualitative or quasi-experimental designs, did not include comparison or control groups, had small or selective sample sizes, lacked behavioral measures of alcohol consumption, and/or had no follow-up, low follow-up rates, or short follow-up intervals. Recommendations for future research include testing different modes and types of interventions and sanctions, evaluating long-term efficacy, and establishing cost effectiveness.

Bean P; Nemitz T, eds. Drug Treatment: What Works?. London: Routledge, Taylor and Francis Group, 2004. (Chapter refs.)

This edited volume, with 13 chapters deals with the different approaches to treatment of drug abuse and treatment outcome. The chapters deal with the following topics: a historical review of opiate treatment; a review of treatment outcome data; treatment approaches in the criminal justice sytem; the role of drug testing; the use and outcome of compulsory treatment; responding to co-occurring disorders, both medical illness and psychiatric problems. In the book there is differing levels of detail. Thus some chapters provide clinical guidance, while others provide only very broad overviews.

Beynon CM; Bellis MA; McVeigh J. Trends in drop out, drug free discharge and rates of re-presentation: A retrospective cohort study of drug treatment clients in the North West of England. BMC Public Health 6(article 205), 2006. (37 refs.)

Background: Governments aim to increase treatment participation by problematic drug users. In the UK this has been achieved by fiscal investment, an expanded workforce, reduced waiting times and coercive measures (usually criminal justice) led). No assessment of these measures on treatment outcomes has been made. Using established monitoring systems we assessed trends in 'dropped out' and 'discharged drug free' (DDF), since the launch of the national drug strategy, and rates of treatment re-presentation for these cohorts. Methods: A longitudinal dataset of drug users (1997 to 2004/05, n = 26,415) was used to identify people who dropped out of, and were discharged drug free from, services for years 1998 to 2001/02, and representations of these people in years to 2004/05. Trends in drop out and discharged drug free, baseline comparisons of those discharged drug free and those who dropped out and outcome comparisons for those referred from the criminal justice system versus other routes of referral were examined using chi square. Logistic regression analyses identified variables predicting drop out versus discharged drug free' and subsequent representation versus no re-presentation. Results: The proportion of individuals dropping out has increased from 7.2% in 1998 to 9.6% in 2001/02 (P < 0.001). The proportion discharged drug free has fallen from 5.8% to 3.5% (P < 0.001). Drop out was more likely in later years, by those of younger age and by criminal justice referrals. The proportion re-presenting to treatment in the following year increased from 27.8% in 1998 to 44.5% in 2001/02 (P < 0.001) for those discharged drug free', and from 22.9% to 48.6% (P < 0.001) for those who dropped out. Older age and prior treatment experience predicted re-presentation. Outcome ( drop out or discharged drug free') did not predict re-presentation. Conclusion: Increasing numbers in treatment is associated with an increased proportion dropping out and an ever-smaller proportion discharged drug free. Rates of drop out are significantly higher for those coerced into treatment via the criminal justice system. Rates of re-presentation are similar for those dropping out and those discharged drug free'. Encouragingly, those who need to re-engage with treatment, particularly those who drop out, are doing so more quickly. The impact of coercion on treatment outcomes and the appropriateness of aftercare provision require further consideration.

Billinger K. A focus group investigation of care-provider perspectives in Swedish institutions for the coercive care of substance abusers. International Journal of Social Welfare 14(1): 55-64, 2005. (35 refs.)

Treatment processes, what is being done and why it is being done in treatment arrangements, is a field of substance abuse study in which relatively little research has been done. There are several methodological problems. The method used in this study of care providers' perspectives in Swedish LVM-institutions (institutions for the coercive care of substance abusers) is the focus group. In order to get a comprehensive approach, a strategic selection of four institutions was made, based on the institutions' therapeutic or pedagogical viewpoint. The analyses reveal that it is impossible to discern an explicit description of what constitutes motivational work at any of the LVM institutions, that the providers at the four LVM institutions gave completely different pictures of coercive care and that they used different tools to accomplish their central task - to motivate the clients. At three of the institutions the clients' abuse problems were only mentioned in passing in their treatment, and the staff spoke of the clients' resistance and negative attitudes against the coercion as obstacles they had to negotiate in order to continue the motivation work. The most radical strategy was to work as though the coercion did not exist.

Bonnie RJ. Judicially mandated naltrexone use by criminal offenders: A legal analysis. Journal of Substance Abuse Treatment 31(2): 121-127, 2006. (7 refs.)

The starting point for this article is the possibility of improving treatment adherence by making naltrexone therapy, particularly the recently developed depot preparation, a condition of probation or parole for nonviolent opiate-addicted offenders who voluntarily agree to these conditions. (I will characterize these arrangements as "leveraged agreements.") My assigned task is to reflect on the legal principles that would apply to these arrangements. Before addressing the legality of leveraged agreements, however, I want to consider two arrangements. First, I want to consider what I will call "no-agreement arrangements," in which a probationer or a parolee who does not want to receive naltrexone is required to do so under a threat of incarceration for noncompliance. Second, I want to consider a purely voluntary arrangement in which naltrexone treatment is not at all linked to criminal sentence. Finally, I will consider leveraged agreements.

Borsari B; Carey KB. Two brief alcohol interventions for mandated college students. Psychology of Addictive Behaviors 19(3): 296-302, 2005. (32 refs.)

Encouraging but limited research indicates that brief motivational interventions may be an effective way to reduce heavy episodic drinking in college students. At 2 campuses, students (83% male) mandated to a substance use prevention program were randomly assigned to I of 2 individually administered conditions: (a) a brief motivational interview (BMI; n = 34) or (b) an alcohol education session (AE; n = 30). Students in the BMI condition reported fewer alcohol-related problems than the AE students at 3- and 6-month assessments. Trends toward reductions in number of binge drinking episodes and typical blood alcohol levels were seen in both groups. Process measures confirmed the integrity of both interventions. The findings demonstrate that mandated BMIs can reduce alcohol problems in students referred for alcohol violations.

Boyum D; Reuter P. An Analytic Assessment of US Drug Policy. Washington DC: American Enterprise Press, 2005

In its efforts to control the use of cocaine, heroin, marijuana, and other illegal drugs, the United States spends about $35 billion per year in public funds. Almost half a million dealers and users are under incarceration. The goal of this book is to provide an assessment of how well these expenditutes are working. Three decades of drug war, with the billions of dollars spent and the millions arrested, have achieved only marginal results. Using a market framework, the book discusses the nature and effectiveness of efforts to tackle the nation's drug problems. Drug policy has become increasingly punitive, with the number of drug offenders in jail and prison growing tenfold between 1980 and 2003. Nevertheless, there is strikingly little evidence that tougher law enforcement can materially reduce drug use. By contrast, drug treatment services remain in short supply, even though research indicates that treatment expenditures easily pay for themselves in terms of reduced crime and improved productivity. The conclusion is that America's drug policy needs to be reoriented in several ways to become more effective. Enforcement should focus on reducing drug-related problems, such as violence associated with drug markets, rather than on locking up large numbers of low-level dealers. Treatment services for heavy users, particularly methadone and other opiate maintenance therapies, need more money and fewer regulations. In addition, programs that coerce convicted drug addicts to enter treatment and maintain abstinence as a condition of continued freedom should be expanded. the volume is organized into five chapters dealing with history of state and local drug policies; the dimenison of America's drug problmes in terms of pattterns of use and consequences of use; a review of currrent policies, in respect to enforcement, treatment, and prevention; a review of policy effectiveness, in terms of enforcement, source-country control, interdiction, domestic enforcement, user sanctions, treament effectiveness and prevention effectiveness; and recommendations for policy reforms, with attention to domestic enforcement, demand-side programs, targeting heavy users and harm reduction.

2006, Project Cork

Brecht ML; Anglin MD; Dylan M. Coerced treatment for methamphetamine abuse: Differential patient characteristics and outcomes. American Journal of Drug and Alcohol Abuse 31(2): 337-356, 2005. (66 refs.)

Policymakers have responded to the increase in the prevalence of methamphetamine (MA) use and the associated social costs (such as crime and child abuse and neglect) by mandating a growing number of MA users to substance abuse treatment via the criminal justice system (CJS) and/or child protective service (CPS) agencies. However, empirical evidence remains sparse about treatment outcomes specifically for MA users who report that their treatment admission occurred under such pressures. This analysis uses natural history interview data from 350 clients treated for MA use in Los Angeles County to examine clients' self-reported CJS/CPS pressure to enter treatment, comparing background and treatment characteristics and selected treatment outcomes across groups defined by existence of such perceived pressure and source of pressure. Approximately half the clients reported legal pressure to enter the index (used for sampling) treatment episode. Those reporting pressure were younger, less likely to have received residential treatment, and had longer treatment episodes than those not reporting pressure. Outcomes (treatment completion, relapse within 6 months, time to relapse, and percentage of days with MA use in 24 months following treatment) did not differ significantly in simple comparisons between the pressured and nonpressured groups; however, when client and treatment characteristics were controlled, the short term outcome of relapse within 6 months was worse for those reporting legal pressure. Outcomes did not differ by source of pressure.

Brecht ML; Greenwell L; Anglin MD. Methamphetamine treatment: Trends and predictors of retention and completion in a large state treatment system (1992-2002). Journal of Substance Abuse Treatment 29(4): 295-306, 2005. (70 refs.)

This report describes trends in treatment admissions for methamphetamine/amphetamine (MA) abuse from 1992 to 2002 in California and assesses predictors of treatment retention and completion. Results show such admissions increasing fivefold and representing a growing proportion of overall treatment admissions. Patients admitted for MA abuse were increasingly diverse in race/ethnicity, older in age, and more frequently under legal supervision status over time. There was a decrease in injection drug use. Several user characteristics played consistent roles as risk factors for noncompletion and shorter treatment retention for both residential and outpatient admissions: having lower than a high school education, being younger at treatment admission, having a disability, having greater severity of MA use, and using injection drugs. Consistently, those with legal supervision status at admission had higher completion rates and longer retention than those reporting no legal status. Overall, findings suggested that clients with greater socioeconomic disadvantage and more severe problems may require greater efforts (e.g., services) to be retained in treatment.

Brochu S; Cournoyer LG; Tremblay J; Bergeron J; Brunelle N; Landry M. Understanding treatment impact on drug-addicted offenders. Substance Use & Misuse 41(14): 1937-1949, 2006. (18 refs.)

This study examines variables that could predict treatment perseverance and impact for offenders (N = 124) admitted to one of five rehabilitation centers for alcoholics/drug addicts representing different regions of the province of Quebec. Information was collected on time spent in treatment, alcohol/drug use-related problems, motivation to change, criminal profile, subject's perception of judicial pressure, subjective assessment of importance/probability of judicial consequences tied to treatment dropout or substance use, quality of the therapeutic relationship, assessment of client commitment to treatment, and social support. Results indicate that judicial pressure only have impact on retention into treatment for those who are not already sentenced but this "forced" retention is not linked with positive results. The study's limitations are noted.

Broner N; Lattimore PK; Cowell AJ; Schlenger WE. Effects of diversion on adults with co-occurring mental illness and substance use: Outcomes from a national multi-site study. Behavioral Sciences and the Law 22(4): 519-541, 2004. (58 refs.)

This quasi-experimental non-equivalent comparison group study examines outcomes for participants in eight programs conducting criminal justice diversion for people with co-occurring serious mental illness and substance use disorders compared with jail detainees eligible for diversion, but who were processed through standard criminal justice methods without diversion. Nearly 2000 participants were interviewed at baseline, and 1500 at 3 month and 1300 at 12 month follow-up to baseline. In these interviews, outcome measures of re-arrest, mental health functioning, substance abuse, quality of life, and service utilization were obtained. Those diverted were more likely to have received mental health counseling, mental health medication, and mental health hospitalization than those not enrolled in a diversion program, but were equally likely to have received substance abuse counseling. Overall, the differences in proportions receiving services between the two groups were small, even when these differences were statistically significant. The effect associated with diversion differed somewhat across the individual sites. However, overall cross-site pooled analyses revealed no outcome differences between groups on measures of mental health symptoms, substance use, criminal justice recidivism, or quality of life. Although the immediate benefit of diversion as an access mechanism to community treatment is indicated in pooled cross-site results, such access was driven by more coercive (pre-booking and court) models and results suggest that effecting substantially greater access to services or services use did not occur. The findings also suggest that mental health, substance abuse, and criminal justice outcomes remain dependent on the treatment intervention received, perhaps moderated by type of diversion intervention, rather than on a generic and initial diversion event.

Caplan AL. Caplan AL. Ethical issues surrounding forced, mandated, or coerced treatment. Caplan AL. Ethical issues surrounding forced, mandated, or coerced treatment. Journal of Substance Abuse Treatment 31(2):117-120, 2006. (7 refs.) 31(2): 117-120, 2006. (7 refs.)

This is a special article on the ethics of complusory treatment. In brief, when someone argues in favor of mandatory treatment of drug-addicted individuals on the grounds that they will greatly benefit from a new drug or vaccine or that society will greatly benefit, these arguments are viwed as working up a very steep ethical hill. Regardless of the benefit, the notion of overriding a person's autonomy and forcing any type of treatment upon him or her is going to fall on the value of autonomy. A person has the fundamental right, well established in medical ethics and in American law, to refuse beneficial and helpful care even if such a refusal shortens his or her own life and has detrimental consequences for others. Although many proponents of mandatory treatments for drug-addicted prisoners are inclined to point to the benefits both for prisoners and for society, it is exceedingly unlikely that any form of treatment that is forced, coerced, or mandated upon a vulnerable population such as prisoners is going to find any traction in American ethics, law, or public policy. There is, however, a way in which self-determination may not conflict so strongly with the compulsory use of drugs for prisoners. The argument that is being made is that respect for self-determination sometimes requires mandatory treatment as a way to create or enable autonomy. It is not plausible to infringe on autonomy or force treatment in the name of public health or patient benefit when we rarely do so in other contexts. Nor are such arguments oriented toward the best interest of the person being forced to take treatment. However, if, for example, the research on naltrexone is sound, if it is possible to say that treatment can enhance, restore, build up, and add to the autonomy that drug-addicted individuals have by letting them be free from cravings, drives, and habits that inhibit their capacity to make choices, then doctors and prison officials can mandate treatment in the short run. The moral basis for this intervention is for the good of the patient and their autonomy. How long and whether someone ought to be able at some point say, �I've done this for six months, I'm finished, I want to get high again� are problems. But that is not the problem that has to be addressed first. The moral challenge is to open the door to mandatory treatment. Moreover, this argument can be put to an empirical test. If, at the end of a mandatory treatment period, prisoners or former prisoners feel that their autonomy and their self-determination are increased and enhanced following a run of naltrexone, then this justifies temporarily ignoring their autonomy. It may press current ethical thinking to the limit, but mandating treatment in the name of autonomy is not as immoral as many might otherwise deem forced treatment to be.

Chan KK; Neighbors C; Marlatt GA. Treating addictive behaviors in the employee assistance program: Implications for brief interventions. Addictive Behaviors 29(9): 1883-1887, 2004. (13 refs.)

Employee assistance programs (EAPs) are widely available to assist employees with a variety of problems. This research examined factors related to utilization and outcome by individuals with addictive behaviors (ABs) versus other problem areas. The specific aims of this study were to evaluate referral source and treatment outcome by gender and presenting problem. The sample included 3890 men and women who attended the EAP for a variety of concerns. Men were less likely than women to self-refer and more likely to be mandated to the EAP. Men were also much more likely to present with ABs. Relative to clients presenting with other issues, individuals with ABs were less likely to self-refer, have their problems resolved in the EAP, and were seen for fewer sessions. These results suggest that EAPs may be well suited for implementation of brief interventions (BIs) that have been empirically supported in other contexts.

Council of Europe; de Valbuena AR. Ethical Eye: Drug Addiction. Strasbourg: Council of Europe Publishing, 2005. (Chapter refs.)

Can a drug addict be forced to seek treatment? Should preventive screening be made systematic, particularly in the workplace? Do some information and education policies not have the effect of legitimising, or even trivialising, drug use? Is the financial cost of treatment justified in the light of society's other needs? These are some of the questions addressed. This book provides an European perspective on ethical issues, with a strong human rights focus. It encorporates a series of papers on a range of topics written by European authors from diverse disciplines (e.g. education, addiction treatment, ethics, social science, law, etc.) and national perspectives (British, French, Italian, Portuguese, Russian and Swedish). These papers analyze ethical quandaries that arise in in the addiction field -- data confidentiality in treatment, drug prevention programmes, compulsory treatment of addicts, drug testing in the work-place, access to treatment by adolescent substance users and the care of pregnant women and mothers using drugs. The chapters on compulsory treatment of addiction are of note as they are written by authors from countries with a long history of coerced treatment of addiction: Russia and Sweden. Both authors reveal some disillusionment with both the ethicality and efficacy of the coerced form of addiction treatment practised in their countries. The Portuguese contributor makes an important distinction between the ethical concerns raised by compulsory treatment against being offered a constrained choice of treatment as an alternative to imprisonment, suggesting that the latter form of coercion may be more justifiable than the former. Several topics are note addresed: a discussion of the ethics of opioid substitution treatment, including heroin maintenance; or consideration of potential outgrowths of neurobiological research such as drug vaccines, depot formulations of antagonist drugs and neurosurgery. (Adapted from review by Wayne Hall, "Addiction" 101(4): 458)

Day A; Tucker K; Howells K. Coerced offender rehabilitation - A defensible practice? Psychology, Crime & Law 10(3 (Special Issue)): 259-269, 2004. (38 refs.)

The use of the criminal justice system to force offenders to receive psychological treatment is one of the most controversial aspects of service provision for offenders. Coerced treatment needs to be distinguished from pressured treatment, both having objective and subjective dimensions. In this paper some arguments for and against coerced offender rehabilitation are discussed. We suggest that coercing offenders into attending rehabilitation programmes (or placing legal pressure on them to attend) is unlikely by itself to lead to poorer outcomes. Rather, the individual's perception of coercion will be more influential in determining how an offender approaches treatment. Even when offenders perceive they are being coerced, it is likely that pretreatment anti-therapeutic attitudes can change over the course of a programme, such that therapeutic gains (risk reduction) can occur. Coercion and its effects on treatment engagement and rehabilitation outcomes require further empirical research and conceptual analysis.

Dill PL; Wells-Parker E. Court-mandated treatment for convicted drinking drivers. Alcohol Research & Health 29(1): 41-48, 2006. (40 refs.)

Court-mandated treatment, which requires offenders convicted of alcohol or other drug-related crimes to participate in treatment for their substance abuse problems or face legal consequences, has long been a component of sanctioning for driving under the influence (DUI) and is a primary path of entry into alcoholism treatment for many people with problem drinking. Several issues are relevant to mandated treatment: screening, assessment and referral, effectiveness, DUI events as opportunities for intervention, brief interventions for offenders outside of mandated treatment, and cost-effectiveness of mandated treatment. Treatment effectiveness depends to some extent on offenders' motivation to participate, and offenders may resist treatment when their participation is coerced. Types of treatment such as motivational enhancement therapy may prove cost-effective with these involuntary participants. More research is needed into the changing DUI population, impaired driving and multidrug use, and new technologies for monitoring DUI offenders.

Public Domain

Evans E; Longshore D. Evaluation of the substance abuse and crime prevention act: Treatment clients and program types during the first year of implementation. Journal of Psychoactive Drugs Supplement 2: 165-174, 2004. (8 refs.)

The Substance Abuse and Crime Prevention Act (SACPA) represents a major shift in criminal justice policy. Eligible offenders can now be sentenced to drug treatment instead of either supervision without treatment or incarceration. UCLA is conducting an independent evaluation of SACPA that will continue over a 5 1/2 year period ending June 30, 2006. Analysis of data collected during the first year of implementation provides information on the flow of offenders through the SACPA "pipeline" from the initial decision to participate through treatment entry. Also available are characteristics of SACPA clients entering treatment and information on programs treating SACPA clients. Results show that most SACPA-eligible offenders chose to participate in SACPA and that almost two-thirds of those who chose SACPA went on to enter treatment. Also, compared to other treatment clients in California, SACPA treatment clients included fewer women, were older, were more likely to use methamphetamine, and had been using drugs for a longer period of time. Finally, most SACPA clients were referred to outpatient drug-free treatment, regardless of primary drug problem, and very few heroin users in SACPA were referred to methadone. Future reports will cover the possible cost-saving associated with SACPA, outcomes for SACPA clients, and overall lessons learned.

Farabee D. Naltrexone as negative reinforcement: Comments on "A behavioral analysis of coerced treatment for addicted offenders" (commentary). Journal of Substance Abuse Treatment 31(2): 141-142, 2006. (1 refs.)

Finch E; Brotchie J; Williams K; Ruben S; Felix L; Strang J. Sentenced to treatment: Early experience of drug treatment and testing orders in England. European Addiction Research 9(3): 131-137, 2003. (13 refs.)

Drug Treatment and Testing Orders (DTTOs) were introduced in the 1998 Crime and Disorder Bill and were piloted in three areas in England over the subsequent 18 months. The orders, funded by the Home Office, allow drug using offenders to be coerced into attending for treatment, to have regular urine tests and to be reviewed by the courts. In Croydon an equal partnership was set up between probation, a local statutory provider of drug services and a voluntary sector agency. Treatment plans were individualised and included a variety of treatment options. Forty-eight orders were imposed mainly for persistent shoplifting. Sixty-three percent of individuals had used heroin and 54% crack cocaine in the 30 days before the order was imposed. Ethical issues raised in coerced treatment were important for the individuals providing treatment although the clients all had to consent to treatment. The pilot programme raised issues about the nature of treatment, clinical responsibility, the selection of clients for orders and the objectives of treatment. Frequent urine testing was problematic but in the vast majority of cases clients were not breached just because of positive tests. The provision of DTTOs in an area created unacceptable inequalities in access to treatment. The paper concludes that partnership working and clear objectives are vital for treatment programmes to operate effectively. More research is needed to explore the most optimum way to deliver treatment in the context of a DTTO.

Gregoire TK; Burke AC. The relationship of legal coercion to readiness to change among adults with alcohol and other drug problems. Journal of Substance Abuse Treatment 26(1): 337-343, 2004. (38 refs.)

Prior research on legally coerced treatment for substance abuse tends to find no difference between coerced and non-coerced clients with respect to treatment retention and treatment outcomes. There is less known about the relationship between coercion and a client's motivation to change. We considered the relationship of legal coercion and readiness to change among 295 consecutive admissions to five publicly funded outpatient treatment programs. A logistic regression analysis indicated that legal coercion was associated with greater readiness to change after controlling for addiction severity, prior treatment history, and gender. Persons entering treatment due to legal coercion were over three times more likely to have engaged in recovery-oriented behavior in the month preceding admission. Entering treatment more prepared to benefit from the experience could contribute to outcomes that are more positive.

Hansen H; Alegria M; Caban CA; Pena M; Lai S; Shrout P. Drug treatment, health, and social service utilization by substance abusing women from a community-based sample. Medical Care 42(11): 1117-1124, 2004. (53 refs.)

Background: Substance abuse is an escalating problem among poor urban Latina women; little is known about their access to drug treatment and to needed social and health services. Objective: Our objectives were to (1) examine the need and use of substance abuse treatment, health services, government entitlement programs, and social service programs among cocaine and heroin using Puerto Rican women and (2) identify whether service use predicts their prospective entry into drug treatment. Research Design: This was a 3-wave longitudinal study of community substance abusing women evaluated on substance abuse and dependence using diagnostic measures, and hair and urine toxicological screens. Information was collected on self-reported need and receipt of substance abuse treatment, social services, general health services. and government entitlement programs. Subjects: A community sample of cocaine-, crack-, and/or heroin-using women from copping areas in low-income urban centers of Puerto Rico were interviewed in 1997-1998 with 2 follow-up periods. Results: Drug treatment, health, and social service utilization were low relative to need for services throughout all data waves. Social service utilization predicted prospective entry into drug treatment but not contacts with general health services or government entitlement programs. Conclusion: Drug-abusing women in low-income urban areas in Puerto Rico have substantial unmet substance abuse treatment, health, and social service needs. Mandated treatment by social service agencies may explain their clients' higher likelihood of entering drug treatment. Building linkages between service sectors to augment entry into drug treatment is essential for meeting the complex needs of this underserved population.

Harris J; Best D; Gossop M; Marshall J; Man L-H; Manning V et al. Prior Alcoholics Anonymous (AA) affiliation and the acceptability of the twelve steps to patients entering UK statutory addiction treatment. Journal of Studies on Alcohol 64(2): 257-261, 2003. (29 refs.)

Objective: The study investigates levels of affiliation with AA and beliefs about the organization and its philosophy among a cohort of alcoholics entering a UK (non-AA) alcohol treatment service. Method: A total of 150 consecutive admissions (75% men) were interviewed by an independent researcher within 5 days of their entry into a residential alcohol treatment unit. Results: Although about three quarters of these patients had previously attended AA meetings, levels of affiliation were low, with only 16% having worked any of the Twelve Steps. Previous AA attenders were more likely to be older, drinking greater daily quantities prior to treatment and to have first sought alcohol treatment at a younger age. Roughly equal groups expressed "positive," "neutral" and "negative" current attitudes towards AA (38%, 36% and 26%, respectively). Each of these three AA-attitude groups expressed greater endorsement of "Personal Responsibility" steps than of "Higher Power mediated" steps. Conclusions: Few participants were universally negative to AA or the Twelve Steps--most regarded some of the steps as positive, but many rejected those referring to a Higher Power. Most also regarded some aspects of the organization and its philosophy worth-while, with attitudes spread across the continuum.

Hepburn JR; Harvey AN. The effect of the threat of legal sanction on program retention and completion: Is that why they stay in drug court? Crime & Delinquency 53(2): 255-280, 2007. (82 refs.)

Drug courts routinely rely on the threat of legal sanction to motivate drug-using criminal offenders to enter and complete community-based treatment programs. In light of the high failure rates among drug court participants, what is the effect of the threat of legal sanction on program retention and completion? A quasiexperimental research design was used to study program retention and completion within two adult drug courts that employed the same staff to administer identical treatment and supervision programs in the same jurisdiction. One court relied on a 120-day suspended sentence to coerce program participation, whereas the other court was prohibited by law from imposing a jail sentence on its participants. Using alternative measures of program retention, a single measure of program completion, and controls for salient sociodemographic and criminal history factors, the analysis found no differences in program retention or completion between the two courts.

Hiller ML; Knight K; Saum CA; Simpson DD. Social functioning, treatment dropout, and recidivism of probationers mandated to a modified therapeutic community. Criminal Justice and Behavior 33(6): 738-759, 2006. (61 refs.)

Few studies have examined the impact of corrections-based drug abuse treatment programs on changes in social functioning. The current study, therefore, examines social functioning (i.e., hostility, risk taking, and social conformity) among 406 probationers in a modified therapeutic community. Data are collected prospectively and include intake, during treatment, and posttreatment information. Findings show that social functioning changes modestly during the first 90 days of treatment. Specifically, risk taking decreases with time, social conformity increases, and unexpectedly, hostility increases across time in treatment. Hostility is the only social functioning factor that predicts treatment dropout. Findings show there are no associations between social functioning indicators and recidivism both I and 2 years after treatment. However, recidivism within I year of treatment release is associated with criminal history, and recidivism within 2 years is associated with age.

Hills HA; Rugs D; Young MS. The impact of substance use disorders on women involved in dependency court. Washington University Journal of Law & Policy 14: 359+, 2004. (87 refs.)

Women are entering substance abuse treatment in increasing numbers and, often, come to treatment as the result of their involvement in dependency court. Part I of this Article reviews the literature and data discussing the relationship between child abuse and neglect and substance abuse. Florida's child abuse and neglect data is consistent with national data, as it indicates that child maltreatment is widespread, and may have fatal consequences. Given the relationship between parental substance abuse and child abuse and neglect, parental substance use disorder treatment appears crucial to the welfare of substance-abusing mothers and their children. The purpose of family drug (or drug treatment) court is to improve the way courts handle child abuse and neglect cases that involve a parent with a substance use disorder. Though limited, data indicates that it is beneficial to include children early on in the design and implementation of a mother's substance abuse treatment. Because there is a high rate of caseworker turnover, training poses a challenge. As substance abuse may be a contributing factor in 60% to 90% of all dependency court cases, it is recommended that whether or not a judge is operating in the context of a family drug court, the court should require that parents participate in substance abuse treatment. Part II identifies referral pathways through which women enter substance abuse treatment, focusing on the referral process in the Hillsborough County, Florida dependency courts. Part III describes the role of dependency courts in encouraging compliance with substance abuse treatment recommendations. Part IV identifies innovative substance abuse treatment models that address women and their children. Part V describes the methodology and findings of key informant interviews and file reviews, which were conducted to uncover the complex issues associated with women involved in substance abuse treatment as a result of abuse or neglect charges. Finally, Part VI provides recommendations to better address the substance use disorders of women involved in dependency court.

Horrocks C; Barker V; Kelly N; Robinson D. Coercive treatment for drug misuse: A dialogical juncture. Journal of Community and Applied Social Psychology 14(5): 345 -355, 2004. (27 refs.)

This article adopts a 'dialogical' relational perspective to explore the recently introduced initiative of coercive treatment for drug misuse in the UK. Conversational interviews were undertaken with 11 people who had been sentenced to the Drug Treatment and Testing Order. Receiving treatment for drug misuse is often storied within a motivational account that is expectant of a 'readiness to change'; such assumptions seem theoretically problematic when change is legally imposed. Therefore, moral and ethical concerns surround the introduction of this initiative, however the interview data illustrates the potential that participation might offer for the creation of 'counterstories' where a more moral self can be enacted. Our analysis suggests that this counterstory is co-constructed thus being an outcome of both self and other. Furthermore such stories appear fragile; constantly under assault from detrimental authoritative discourses that are not only part of wider social understandings around drug misuse but also permeate the policy and practice of coercive treatment.

Kaltiala-Heino R. Increase in involuntary psychiatric admissions of minors: A register study. Social Psychiatry and Psychiatric Epidemiology 39(1): 53-59, 2004. (40 refs.)

Objective The aim of this study was to assess the frequency and trend over time of involuntary psychiatric admissions of minors, and to examine the psychiatric diagnoses in involuntary admissions of minors as compared to those admitted on a voluntary basis. Method A retrospective register study was made during the period 1996-2000 of a nationally representative hospital discharge register in Finland. Results Involuntary admissions of children (aged < 12) and adolescents (aged 12-17) increased vastly over the study period, both in absolute figures and in proportion to all admissions in the age groups. Although some disorders were more likely to be linked to compulsory admission than others, a variety of individual diagnoses were represented under compulsory admission. Conclusion More comprehensive guidance for clinicians is needed regarding the involuntary admission of minors. More theoretical and empirical research is needed on minors' competence to consent to or refuse treatment.

Kelly JF; Finney JW; Moos R. Substance use disorder patients who are mandated to treatment: Characteristics, treatment process, and 1- and 5-year outcomes. Journal of Substance Abuse Treatment 28(3): 213-223, 2005. (39 refs.)

A substantial number of patients with substance use disorders (SUDs) are mandated to treatment by the justice system. However, little is known about their characteristics and how they fare during treatment and in the longer term compared with nonmandated, justice-system-involved patients and patients not involved in the justice system. This prospective study (n = 2,095) examined differences in pretreatment characteristics, treatment perceptions and satisfaction, during-treatment changes, and 1- and 5-year outcomes among these three types of patients and tested whether differences in pretreatment characteristics or during-treatment changes could help explain posttreatment outcome similarities or differences. Mandated patients had a less severe clinical profile at treatment intake, yet this did not account for their observed similar/better outcomes, which appeared because of the similar therapeutic gains made during treatment. Treatment perceptions and satisfaction were also comparable across groups. These findings appear to support the idea that judicial mandates can provide an opportunity for offenders with SUDs to access and benefit from needed treatment.

Klag S; Creed P; O'Callaghan F. Development and initial validation of an instrument to measure perceived coercion to enter treatment for substance abuse. Psychology of Addictive Behaviors 20(4): 463-470, 2006. (48 refs.)

The present study involved 3 phases that led to the development and initial validation of the Perceived Coercion Questionnaire (PCQ), a scale that researchers use to measure perceptions of coercion of drug and alcohol users to enter drug and alcohol treatment. In Phase 1, the authors used focus groups to generate 48 pilot items. In Phase 2, the items were administered to a sample of 158 drug and alcohol users who were in residential treatment within a therapeutic community setting. Item and exploratory factor analyses reduced the number of items to 32, which represented 6 homogeneous and internally reliable subscales. In Phase 3, the PCQ was administered to a second sample of 362 drug and alcohol users. Confirmatory factor analysis led to a final scale of 30 items across 6 subscales that demonstrated sound consistency and validity. Implications for research and practice are highlighted.

Klag S; O'Callaghan F; Creed P. The use of legal coercion in the treatment of substance abusers: (a) An overview and critical analysis of thirty years of research. (review). Substance Use & Misuse 40(12): 1777-1795, 2005. (117 refs.)

Drug and alcohol use presents a serious social problem for most countries in the world. Of particular concern is the well-documented relationship between substance use and crime, which has contributed to an increased popularity and willingness to utilize more forceful means to pressure substance users into treatment. Although compulsory/legally mandated treatment is appealing, it has been one of the most fiercely debated topics in the addiction field, raising a number of issues including ethical concerns and motivational considerations. In this context, the most important question to be answered is whether or not compulsory treatment is effective in the rehabilitation of addicted offenders. Regrettably, three decades of research into the effectiveness of compulsory treatment have yielded a mixed, inconsistent, and inconclusive pattern of results, calling into question the evidence-based claims made by numerous researchers that compulsory treatment is effective in the rehabilitation of substance users. The present paper provides an overview of the key issues concerning the use and efficacy of legal coercion in the rehabilitation of substance users, including a critique of the research base and recommendations for future research.

Kleinig J. Ethical issues in substance use intervention. Substance Use & Misuse 39(3): 369-398, 2004. (42 refs.)

This essay offers an overview of some, of the ethical questions raised by governmental and medical interventions into drug use. With respect to the former, it begins with the liberal assumption that constraints on free action are to be justified by reference to its deleterious impact on others, but then qualifies that assumption by noting the social requisites of free action. With respect to medical interventions, it focuses on the codes that have been developed for treatment providers and their clients, and explores the ethical underpinnings of several of their central provisions-informed consent, privacy, confidentiality, nondiscrimination, professionalism, and accountability.

London M; Canitrot J; Dzialdowski A; Bates R; Gwynn A. Contact with treatment services among arrested drug users. Psychiatric Bulletin 27(6): 214-216, 2003. (4 refs.)

To identify the proportion of arrested drug misusers with prior contact with treatment services, police surgeons' records were examined over a 12-month period and compared with the records of the local drug misuse services. The investigated sample consisted of 124 cases, 92 of whom were drug-related and 32 alcohol-related. Both referrals and those who attended with face-to-face contact were noted. Sixty-seven per cent of drug-related cases had been referred to services prior to arrest and 58% had attended with face-to-face contact on at least one occasion. Homeless and male drug users were more likely to have had no past contact. Police surgeons treated three-quarters of the cases for opiate dependence. Drug misusers were much more likely to have had past contact with services than arrested alcohol misusers, and were more likely to reoffend. The evidence base for motivational enhancement in the transient coercive setting of police custody is not established, and arrest referral schemes might not be cost-effective in areas where most cases have had previous contact with services. Local research may contribute to more informed decisions about these treatment-related criminal justice initiatives.

Longshore D; Teruya C. Treatment motivation in drug users: A theory-based analysis. Drug and Alcohol Dependence 81(2): 179-188, 2006. (56 refs.)

Motivation for drug use treatment is widely regarded as crucial to a client's engagement in treatment and success in quitting drug use. Motivation is typically measured with items reflecting high treatment readiness (e.g., perceived need for treatment and commitment to participate) and low treatment resistance (e.g., skepticism regarding benefits of treatment). Building upon reactance theory and the psychotherapeutic construct of resistance, we conceptualized these two aspects of treatment motivation - readiness and resistance - as distinct constructs and examined their predictive power in a sample of 1295 drug-using offenders referred to treatment while on probation. The sample was 60.7% African Americans, 33.5% non-Hispanic Whites, and 21.2% women; their ages ranged from 16 to 63 years old. Interviews occurred at treatment entry and 6 months later. Readiness (but not resistance) predicted treatment retention during the 6-month period. Resistance (but not readiness) predicted drug use, especially among offenders for whom the treatment referral was coercive. These findings suggest that readiness and resistance should both be assessed among clients entering treatment, especially when the referral is coercive. Intake and counseling protocols should address readiness and resistance separately.

Marlowe DB. Depot naltrexone in lieu of incarceration: A behavioral analysis of coerced treatment for addicted offenders. Journal of Substance Abuse Treatment 31(2): 131-139, 2006. (72 refs.)

This article is part of a series of articles examining a proposal to offer depot naltrexone to certain nonviolent opiate-addicted criminal offenders in exchange for release from incarceration or diversion from prosecution. This "negative-reinforcement" behavioral paradigm could have a better chance of success than what has heretofore been attempted with drug-abusing offenders. Traditional correctional efforts have been largely unsuccessful due to the complexities of implementation and the side effects of punishment. Although positive reinforcement can be more efficacious, it has often been strenuously resisted on the ground that it is inequitable to reward antisocial individuals for doing what is minimally expected of most citizens. Negative reinforcement steers between these hurdles by avoiding the iatrogenic effects of punishment, while also being palatable to stakeholders. More research is needed to identify the effects, costs, and side effects of negative-reinforcement arrangements for drug offenders. The current proposal provides an excellent platform for conducting this research because the target intervention (depot naltrexone) is demonstrably efficacious, nonpsychoactive, and has few, if any, side effects. Therefore, use of this medication would be unlikely to invoke the same types of legal and ethical objections that have traditionally been levied against the use of psychoactive medications with vulnerable populations of institutionalized offenders. Specific recommendations are offered for questions that must be addressed in future research studies.

Mihanovic M; Restek-Petrovic B; Babic G; Sain I; Telarovic S; Zilic-Dzeba J. Involuntary hospitalizations in the psychiatric hospital (Jankomir) before and following the alterations and amendments made to ZZODS. Collegium Antropologicum 28(1): 385-391, 2004. (30 refs.)

Schizophrenia and other psychotic disorders as well as the delirium caused by abstinence from alcohol and acute state of drunkenness appear at the very top of the list of factors, which are positively correlated with involuntary hospitalization of patients. This is at the same time a confirmation of the data found in literature considering psychosis an essential factor of involuntary hospitalization; the same referring to the male sex was not, however, confirmed by the results obtained in the first and second research period. Regarding the positive correlation between schizophrenia and other psychotic disturbances, dementia, delirium and other cognitive impairments including the delirium caused by abstinence from alcohol and an accute state of drunkenness on the one side and the high rate of involuntary hospitalization on the other, there is no statistically significant difference between the period preceding and the period following the alterations and amendments to the Law on the protection of patients with mental disorders.

Moretti SA; Tracy BS; O'leary-Tevyaw TA; Monti PM; Colby SM. Alcohol expectancies of mandated college students. (meeting abstract). Alcoholism: Clinical and Experimental Research 28(5 Supplement): 143A-143A, 2004. (0 refs.)

Mullins SA; Suarez M; Ondersma SJ; Page MC. The impact of motivational interviewing on substance abuse treatment retention: A randomized control trial of women involved with child welfare. Journal of Substance Abuse Treatment 27(1): 51-58, 2004. (38 refs.)

Previous studies have supported the efficacy of Motivational Interviewing (MI) in increasing treatment engagement and retention among people with substance abuse disorders. However, few studies have assessed the impact of MI with coerced populations, particularly women referred to drug abuse treatment by child welfare due to prenatal drug use. Seventy-one such women who used drugs during pregnancy were randomly assigned to either receive three MI sessions or to watch two educational videos and participate in a home visit. Treatment retention group attendance and random urine analysis results were evaluated in these women during the first 8 weeks of treatment. No differences were found between the two conditions on these variables. Possible reasons for these negative findings are discussed, as are ideas for future research with coerced populations.

Polcin DL; Beattie M. Relationship and institutional pressure to enter treatment: Differences by demographics, problem severity, and motivation. Journal of Studies on Alcohol 68(3): 428-436, 2007. (48 refs.)

Objective: Studies have shown that individuals with substance-use problems frequently receive pressure to enter treatment. Pressure can come from institutions (e.g., criminal justice or welfare) or relationships (e.g., family or friends). Research has also shown that pressure can facilitate treatment entry. However, few studies have assessed how pressure from different sources varies. Method: Six hundred ninety-eight individuals entering residential or outpatient treatment for alcohol or drug problems completed face-to-face interviews soon after admission. Pressure was assessed by asking participants if others had suggested they enter treatment, including family, friends, and professionals within institutions. Additional assessments included the Addiction Severity Index and readiness to change. Results: Most of the participants (73%) reported some type of pressure: 29% from personal relationships, 30% from institutions, and 14% from both. The remaining 27% reported no pressure to enter treatment. Multinomial logistic regression of baseline data showed being on parole or probation, not being employed full time, and having more severe legal problems predicted pressure from institutions. In contrast, relationship pressure at baseline was predicted by severity of alcohol problems. Compared with participants receiving only relationship pressure, those receiving only institutional pressure had lower alcohol, drug, family, psychiatric, and medical severity In addition, institutional pressure was associated with lower motivation at baseline, whereas relationship pressure was not related to motivation at all. When controlling for problem severity, baseline pressure was not associated with 12-month outcome. Conclusions: Correlates of pressure from institutions for individuals to enter treatment differ from those associated with pressure from personal relationships to enter treatment. Implications of these findings for public policy, treatment, and further research are discussed.

Polcin DL; Greenfield TK. Factors associated with probation officers' use of criminal justice coercion to mandate alcohol treatment. American Journal of Drug and Alcohol Abuse 29(3): 647-670, 2003. (28 refs.)

Alcohol problems are widespread among individuals in county criminal justice probation systems. However, it is unclear why only a small fraction of these problem drinkers receive treatment. In this Study, self-administered questionnaires were mailed to 145 probation officers in nine California counties to identify factors that predicted probation officers' use of coercion to mandate alcohol treatment. The questionnaire measured characteristics of probation officers, characteristics of their caseloads, and perceptions about their departments. Principle components analysis combined some of the items into six factor-based scales. Multiple regression analyses identified two significant predictors of use of coercion into treatment: a belief that treatment was effective and a belief that one's peers in the department were using coercion frequently. Implications for increasing treatment entry of probationers with drinking problems include educating probation officers about the effectiveness of substance abuse treatment in general and about coerced treatment in particular. Probation departments are encouraged to develop management styles that facilitate shared normative beliefs about assessing and managing alcohol problems among probationers.

Presenza LJ. Naltrexone as a "mandate" or as a choice: Comments on "Judicially mandated naltrexone use by criminal offenders: A legal analysis" (editorial). Journal of Substance Abuse Treatment 31(2): 129-130, 2006. (0 refs.)

Ridgely MS; Iguchi MY. Coercive use of vaccines against drug addiction: Is it permissible and is it good public policy? Virginia Journal of Social Policy & the Law 12(2): 260-329, 2005. (310 refs.)

Vaccines against drug addiction may represent the hope of the future for many addicted individuals who are eager to access state-of-the-art treatment. They may also be a promising solution for a society seeking to lower the social and economic costs of addiction among populations such as recidivist drug offenders. Given the medical and socio-economic benefits, this Article explores the legal and public policy aspects of a potential use of vaccines to fight drug addiction. The following is the core question: Will current law support the coercive use of vaccines against drug addiction? Following a brief introduction, Section II provides a context for the discussion by briefly describing the problem of addiction, the relationship of addiction to social problems such as crime and homelessness, the current approaches to treatment for addiction, and new immunotherapies under development. Although immunotherapies are still under development, the analysis in the remainder of the paper assumes, arguendo, the production of a vaccine against addiction that is approved by the FDA as safe and effective and has no significant adverse side effect profile. Section III summarizes the law on an individual's right to self-determination and asks whether addicted individuals can give voluntary consent to receive/refuse addiction treatment. This section also outlines the law on the "right to refuse" treatment and addresses the role courts have accorded to parents in medical decision-making for their children. Section IV discusses the circumstances under which the government has the right to compel treatment against the wishes of a competent individual by asserting its parens patriae and police powers to act in the best interest of society. Section IV also identifies when compulsory treatment is available for specific vulnerable populations under current law and discusses the limits of the state's power to impose treatment on such populations. Courts have generally allowed mandated addiction treatments in a variety of contexts, civil and criminal, and there is little to suggest that immunotherapies would be treated differently than other forms of pharmacological intervention. Finally, Section V considers whether the coercive use of vaccines is legally permissible and whether it is consistent with good public policy. The conclusion is that there are situations where coercion is arguably necessary, and likely to be effective, in reducing recidivism and the negative impacts of addiction on both the individual and society. In terms of the negative effects of coercion, legal due process protections may be particularly important in facilitating the ethical use of immunotherapies, especially in the first few years after FDA approval. Furthermore, research on the experience of coercion in the mental health context suggests that the clinicians could go a long way toward minimizing the negative effects of coercion if they are committed to acting in good faith, treating patients with respect, taking what patients say seriously, and giving their patients a voice in the process. Authority to coerce treatment is derived from the state's parens patriae and police powers, but is constrained by the countervailing right to self-determination in medical treatment. That right typically assumes the competence of the individuals making the self-determination. Even given competence, however, the interests of the state may prevail over the rights of individuals within certain classes in society. This Article reviews pertinent statutes and case law bearing on the state's ability to justify the use of coercion. Assuming a situation in which immunotherapy may be legally coerced, this Article concludes by offering some reflections for policy makers and clinicians on fairness in implementing a policy of coercion.

Rootman DB; Mann RE; Ferris LE; Chalin C; Adlaf E; Shuggi R. Predictors of completion status in a remedial program for male convicted drinking drivers. Journal of Studies on Alcohol 66(3): 423-427, 2005. (27 refs.)

Objective: Rates of attrition in alcohol and drug treatment programs are often greater than 50%, and completion of treatment has been shown to be a potent predictor of posttreatment outcome. The current study examined both rates and predictors of completion among male participants in a remedial measures program for convicted drinking drivers. Method: Male individuals (n = 5,409) convicted of a drinking driving offense in Ontario between October 2000 and December 2002 who did and did not complete a mandatory rehabilitation program were described in terms of demographic, drug use and legal variables collected at time of assessment. Results: The program completion rate was extremely high (97.3%). In multivariate analyses, noncompleters- relative to completers-were younger; drank more frequently; were less likely to own a home; and were more likely to live in urban centers, have two or more lifetime impaired driving convictions and have experienced more than one adverse consequence of substance use. Conclusions: Ontario's remedial measures program for convicted drinking drivers, in which the return of a suspended license after the period of mandatory suspension is contingent on the completion of the program, demonstrates a very low level of client attrition. Individuals who do not complete the program bear many similarities to those at high risk for persistent drink-drive behavior and its associated negative health consequences.

Rush BR; Wild TC. Substance abuse treatment and pressures from the criminal justice system: data from a provincial client monitoring system. Addiction 98(8): 1119-1128, 2003. (19 refs.)

Aims; Compulsory treatment is discussed increasingly as a way to reduce the population burden of addictive behaviours. This study explores the extent to which social control strategies exercised through the criminal justice system are used to bring people into substance abuse treatment at a system level. We also assessed whether particular subgroups may be more or less likely to be brought into treatment in this manner. Design: We employed a secondary analysis of data from a client-based information system which captured demographic, referral and substance use characteristics from people seeking treatment for substance abuse. Participants A census of clients (n=45123) entering specialized Ontario addiction treatment programmes between 1 April 1999 and 31 March 2000. Some 28.90% of clients reported legal problems at treatment intake, and 13.9% had an explicit corrections-related condition of treatment contact. Logistic regression analyses indicated that legal problems and corrections-related conditions of treatment were more prevalent among younger, unmarried and unemployed males, who had not completed high school. A number of important interactions were identified between these factors and substance of abuse. Conclusions: Implications for equity, accessibility and effectiveness of substance abuse treatment are discussed in relation to the tendency of treatment mandates from criminal justice system to disproportionately affect the entry of this segment of substance-abusing clients.

Sansoy P; Ambroselli C; Padieu R; Ives R; Masar O; Anokhina IP, eds. Ethical Eye: Drug Addiction. Strasbourg France: Council of Europe Publishing, 2005

This edited volume with twelve chapters and sixteen contributors deals with ethical issues related to substance abuse, drawing upon the experiences in a variety of European countries and the Russian Federation. Following an introduction and opening chapter which outline ethical issues in respect to durg and use and the societal concerns drug use presents, the following chapters focus upon specific issues. Chapters consider information processing and data confidentiality; drug prevention and education; intensive treatment in countries with weak economics; compulsory treatment from three perspectives, the approach in the Russian Federation, the Swedish approach, and the treatment as an alternative to imprisonment. Other areas addressed are drug testing in the workplace, care for pregnant women or mothers, and treatment access for young people. The concluding chapter deals with the role of the Council of Europe in addressing drug addiction.

Stevens A; Berto D; Frick U; Hunt N; Kerschl V; McSweeney T et al. The relationship between legal status, perceived pressure and motivation in treatment for drug dependence: Results from a European study of quasi-compulsory treatment. European Addiction Research 12(4): 197-209, 2006. (48 refs.)

This paper reports on intake data from Quasi-Compulsory Treatment in Europe, a study of quasi-compulsory treatment (QCT)for drug dependent offenders. It explores the link between formal legal coercion, perceived pressure to be in treatment and motivation amongst a sample of 845 people who entered treatment for drug dependence in five European countries, half of them in quasi-compulsory treatment and half 'voluntarily'. Using both quantitative and qualitative data, it suggests that those who enter treatment under QCT do perceive greater pressure to be in treatment, but that this does not necessarily lead to higher or lower motivation than 'volunteers'. Many drug-dependent offenders value QCT as an opportunity to get treatment. Motivation is mutable and can be developed or diminished by the quality of support and services offered to drug-dependent offenders.

Stevens A; Berto D; Heckmann W; Kerschl V; Oeuvray K; Van Ooyen M. Quasi-compulsory treatment of drug dependent offenders: An international literature review. Substance Use & Misuse 40(3): 269-283, 2005. (87 refs.)

This paper reports on a review of the literature on the quasi-compulsory treatment (QCT) of drug dependent offenders in five languages; English, German, French, Italian and Dutch. The findings of this review on previous reviews and on the availability, process, and outcomes of QCT are summarized. The review found that previous, anglophone reviews have tended to present positive outcomes front QCT, but that there are some problems with this research. QCT is increasingly available internationally, but may be applied at different stages of the criminal justice process, and to different types of offender. Research on the process of QCT is comparatively rare. The available research does suggest problems of system integration between criminal justice and treatment agencies in implementing QCT. The research in languages other than English shows a wider range of outcomes (including negative affects) for QCT than was found in the English literature. We conclude that the international literature shows that QCT does not inevitably produce worse outcome than voluntary treatment, but that we need more multimethod, multisite studies of QCT in order to inform policy and practice, which is currently being made in the absence of reliable evidence in many countries.

Van Dorn RA; Elbogen EB; Redlich AD; Swanson JW; Swartz MS; Mustillo S. The relationship between mandated community treatment and perceived barriers to care in persons with severe mental illness. International Journal of Law and Psychiatry 29(6): 495-506, 2006. (47 refs.)

Objective: In recent decades debate has intensified over both the ethics and effectiveness of mandated mental health treatment for persons residing in the community. Perceived barriers to care among persons subjected to mandated community treatment, and the possibility that fear of involuntary treatment may actually create or strengthen such barriers rather than dissolve them, are key issues relevant to this debate but have been little studied. This article explores the link between receipt of mandated (or "leveraged") community treatment and reasons for avoiding or delaying treatment reported by persons with severe mental illness. It also examines the potential moderating effect of social support on the association between mandated treatment experiences and barriers attributable to fear of involuntary commitment or forced treatment. Method: Data are presented from a survey of 1011 persons with psychiatric disorders being treated in public-sector mental health service systems in five U.S. cities. Logistic and negative binomial regression analyses were used to examine the association between mandated community treatment and perceptions of barriers to care, controlling for demographic and clinical characteristics. Results: Across sites, 32.4% to 46.3% of respondents reported barriers attributed to fear of forced treatment. Whereas 63.7% to 76.1% reported at least one non-mandate-related barrier to care; the mean number of non-mandated barriers to care ranged from 1.6 to 2.3 (range 0-7). Between 44.1% and 59.0% of participants had experienced at least one type of leveraged treatment. Persons experiencing multiple forms of mandated treatment were more likely to report barriers to care in comparison to those not reporting mandated treatment. Findings also indicated that social support moderates the relationship between multiple leverages (three or four forms) and mandate-related barriers to care. Conclusions: Perceived barriers to care associated with mandated treatment experience have the potential to adversely affect both treatment adherence and therapeutic alliance. Awareness of potential barriers to care and how they interact with patients' perceived social support may lead to improved outcomes associated with mandated treatment.

Wallace B. Making Mandated Addiction Treatment Work. Lanhan: Jason Aronson, 2005

A dramatic rise in the number of "multi-problem" clients have forced community-based addiction treatment centers to answer some tough questions: How do you effectively treat record numbers of diverse and difficult clients? How do you tailor evidence-based interventions to a client's individual background involving possible incarceration, ongoing supervision, a history of trauma and a high risk of relapse? Moreover, how do practitioners work effectively within a society that stigmatizes drug users? Because the largest and fastest growing segment of the community-based addiction treatment population includes those who are mandated, this book addresses the task of making mandated addiction treatment work. It serves as a guide to adapting and integrating evidence-based addiction treatments to create a unified treatment model. The book is organized into 9 chapters that consider the phenomenon of mandated treatment, client characteristics of mandataed clients, timing of treatment interventions, the initial psychological assessment and psychiatric screening, long-term treatment outcome.

Wallander L; Blomqvist. Who "needs" compulsory care? A factorial suvery of Swedish social workers' assessments of clients in relation to the Care of Abusers (Special Provisions) Act. Nordic Studies on Alcohol and Drugs 22(English Supplement): 63-86, 2005. (41 refs.)

Background: Due to its wide scope and the way in which it is applied, the Swedish compulsory care legislation for problem substance users is rather unique, both from an international and a Nordic perspective. Accordingly, form the time of its introduction about 25 years ago, the current legislation has repeatedly been criticized on ethical and scientific grounds. Methods: This study employs the factorial survey approach to disentangle predictors relation to assessments of eligibility for compulsory care among a sample of 205 social workers from 36 social service units. The data, which comprise social workers' ideal assessments of randomly constructed hypothetical clients, have been analyzed using multi-level logistic regression. The results show that overall, the social workers' assessment of client eligibility for compulsory care correspond well with the legislation. However, the results also reveal that several factors not specified in the legislation have an effect on these assessments. These include elements from the popular discourse on drugs in Sweden, the social workers' ideological convictions and the organizational structure of and experiences of handling compulsory applications at, the respondents' workplaces.

Wild TC. Social control and coercion in addiction treatment: Towards evidence-based policy and practice. (review). Addiction 101(1): 40-49, 2006. (75 refs.)

Background: Social pressures are often an integral part of the process of seeking addiction treatment. However, scientists have not developed conclusive evidence on the processes, benefits and limitations of using legal, formal and informal social control tactics to inform policy makers, service providers and the public. This paper characterizes barriers to a robust interdisciplinary analysis of social control and coercion in addiction treatment and provides directions for future research. Approach: Conceptual analysis and review of key studies and trends in the area are used to describe eight implicit assumptions underlying policy, practice and scholarship on this topic. Findings: Many policies, programmes and researchers are guided by a simplistic behaviourist and health-service perspective on social controls that (a) overemphasizes the use of criminal justice systems to compel individuals into treatment and (b) fails to take into account provider, patient and public views. Conclusions: Policies and programmes that expand addiction treatment options deserve support. However, drawing a firm distinction between social controls (objective use of social pressure) and coercion (client perceptions and decision-making processes) supports a parallel position that rejects treatment policies, programmes, and associated practices that create client perceptions of coercion.

Wild TC; Cunningham JA; Ryan RM. Social pressure, coercion, and client engagement at treatment entry: A self-determination theory perspective. Addictive Behaviors 31(10): 1858-1872, 2006. (41 refs.)

Research on coercion in addiction treatment typically investigates objective sources of social pressure among legally mandated clients. Little research has examined the impact of clients' perceptions of social pressures in generalist addiction services. Clients seeking substance abuse treatment (N=300; 221 males and 79 females; M age=36.6 years) rated the extent to which treatment was being sought because of coercive social pressures (external motivation; alpha=.89), guilt about continued substance abuse (introjected motivation; alpha=.84), or a personal choice and commitment to the goals of the program (identified motivation; alpha=.85). External treatment motivation was positively correlated with legal referral, social network pressures to enter treatment, and was inversely related to problem severity. In contrast, identified treatment motivation was positively correlated with self-referral and problem severity, and was inversely related to perceived coercion (ps <.05). Hierarchical multiple regression analyses showed that referral source (i.e., mandated treatment status), legal history, and social network pressures did not predict any of 6 measures of client engagement at the time treatment was sought. However, treatment motivation variables accounted for unique variance in these outcomes when added to each model (Delta R(2)s=.06-.23, ps <.05). Specifically, identified treatment motivation predicted perceived benefits of reducing substance use, attempts to reduce drinking and drug use, as well as self (and therapist) ratings of interest in the upcoming treatment episode (beta s=.18-.31, ps <.05). Results suggest that the presence of legal referral and/or social network pressures to quit, cut down, and/or enter treatment does not affect client engagement at treatment entry.

Wilde ML. The liability of Alaska mental health providers for mandated treatment. Alaska Law Review 20: 271-303, 2003. (278 refs.)

Court-ordered treatment programs for substance abuse and mental illness have become a popular tool to achieve the goals of the criminal justice system: to punish, rehabilitate, and deter criminal behavior. ... The Seibel court held in favor of the mental health provider, recognizing that unless insulated from liability, providers would be less likely to accept judicial appointments for mental health evaluations. ... Continuing Treatment: Duties Owed to the Patient by the Mental Health Provider ... The current version of Alaska Rule of Evidence 504 contains a general privilege for physician-patient communications, a stronger privilege for psychotherapist-patient communications, and several exceptions. ... There are relatively few Alaska cases involving tort liability for breach of confidentiality by a mental health provider. ... " Expanding upon this view, the Alaska Supreme Court held in Korman v. Mallin that, unlike in a medical malpractice case, expert testimony regarding standards of disclosure is not required in an informed consent case. ... Thus, while the issue remains open in Alaska, it appears that the agents of a mental health provider may be subject to the same standard of care required of the provider when acting under her supervision. ... When one asks a layman what duties a mental health provider owes to a mandated patient, common responses are "none" and "exactly the same as any other patient." ... This Article analyzes the liability of mental health professionals for services rendered to patients who are ordered by a court to undergo mental health treatment. After a brief review of relevant legal authority, this Article examines mandated treatment under the framework of quasi-judicial immunity and continues by discussing the specific duties of mental health professionals to patients undergoing mandated treatment. The Article also comments on the unique issues that arise from treatment of patients under federal benefit programs. It concludes by arguing that mental health professionals do not enjoy a blanket exemption from malpractice liability and by suggesting a cautious course of action for such professionals.

Wiley D; Beattie M; Nguyen H; Puckett K; Banerjee K; Poon W. When you assume...the reality of implementing a legally mandated substance abuse treatment program. Journal of Psychoactive Drugs Supplement 2: 175-180, 2004. (9 refs.)

In 2000, the voters of California approved the Substance Abuse and Crime Prevention Act (SACPA), mandating that substance-abusing offenders who met the eligibility criteria receive treatment and not jail time. In preparation for implementation, the Santa Clara County Department of Alcohol and Drug Services Research Institute worked to identify the number and type of clients who would be eligible to receive treatment. The purpose of this article is to analyze the differences between a profile of SACPA-eligible clients that was based on pre-SACPA implementation clients and assumptions that were made concerning eligibility for the program and the reality of post-SACPA implementation clients. This article examines causes and consequences of the discrepancies between policy and implementation in the area of substance abuse treatment.

Yates R; McIvor G; Eley S; Malloch M; Barnsdale L. Coercion in drug treatment: The impact on motivation, aspiraton and outcome. IN: Pederson MU; Segraeus V; Hellman M, eds. Evidence Based Practice? Challenges in Substance Abuse Treatment. NAD Monograph No. 47. Helsinki Finland: Nordic Council for Alcohol and Drug Research, 2005. pp. 159-169. (19 refs.)

Treatment programs have long worked alongside the criminal justice system. Early research has shown little difference in prognosis between involuntary and voluntary admissions, although the latter tend to drop out at somewhat higher rates. This paper draws upon the findings of an evaluation of two Scotland pilot project of referrals from a dedicated drug court. The authors review the drug use history of participants, motivation for entering into treatment (predominantly to "get off drugs" rather than to avoid prison, prior treatment experience, views of drug testing and mandated periodic reviews. The conclusion is that treatment is cost-effective in reducing drug use and associated offending. It was also found that there was little resentment toward the coercive element.

Young D; Fluellen R; Belenko S. Criminal recidivism in three models of mandatory drug treatment. Journal of Substance Abuse Treatment 27(4): 313-323, 2004. (55 refs.)

Although research has generally been supportive of compulsory treatment programs for drug abusers. findings remain mixed. and few studies have assessed the impacts of different coercive program elements. This study compared criminal recidivism outcomes of 350 clients mandated to the same long-term residential treatment facilities from three different legal sources. On several measures of recidivism, including long-term re-arrest rates that controlled for time at risk. Clients mandated from two highly structured programs were found to recidivate at less than half the rate of comparison group clients. This group effect was upheld in multivariate models that controlled for pre-treatment differences and other factors related to recidivism. Combined with results of a previous retention study involving these clients, the findings provide support for the use of structured protocols for informing clients in mandatory programs about legal contingencies of participation. and enforcing contingencies through frequent contact between legal agents and treatment staff.