The The Alcohol and Offenders Criminal Justice

Research Programme

Dr Lesley GrahamDr Lesley GrahamAssociate Specialist, Public HealthAssociate Specialist, Public Health

ISD, NHS National Services ScotlandISD, NHS National Services Scotland

Andrew McAuleyAndrew McAuleyPublic Health Advisor (Substance Misuse/Alcohol)Public Health Advisor (Substance Misuse/Alcohol)

NHS Health ScotlandNHS Health Scotland

AcknowledgementsAdvisory Group MembersIain MacAllister, Scottish GovernmentSharon Grant, Scottish Government George Howie, NHS Health ScotlandRuth Parker, Scottish Prison Service (SPS)Jim Carnie, SPSStephen Heller-Murphy, Health Improvement Scotland

(formerly SPS)Research TeamsTessa Parkes, Susan MacAskill and team, Stirling UniversityKate Skellington Orr, Shirley McCoard and team, MVA

Consultancy

Describes nature and scale of alcohol problems in Describes nature and scale of alcohol problems in offendersoffendersExamines and contributes to the evidence base of Examines and contributes to the evidence base of what workswhat worksMaps current activity highlighting best practiceMaps current activity highlighting best practice

The Alcohol and Offenders Criminal Justice The Alcohol and Offenders Criminal Justice Research ProgrammeResearch Programme

Alcohol in ScotlandAlcohol in Scotland Enough alcohol is sold in Scotland for every

adult to exceed male weekly limits [Health Scotland 2011]

Excess consumption is across all age and socio-economic groups [Scottish Health Survey 2010]

1 in 20 deaths attributable to alcohol [Grant, Springbett and Graham 2009]

Those from the most deprived areas in Scotland are 6 times more likely to die an alcohol related death [Alcohol Statistics Scotland 2011]

Alcohol-related mortality by Alcohol-related mortality by deprivation, Scotlanddeprivation, Scotland

Alcohol-related deaths (underlying cause, deprivation category, 2001/02, 2005/06, 2009/10)

Source: ISD Scotland (NRS)

0

10

20

30

40

50

60

70

5 4 3 2 1

SIMD quintile

EASR

per

100

,000

pop

ulat

ion

2001

2005

2009

Alcohol and Crime in ScotlandAlcohol and Crime in Scotland Half (50%) of prisoners in Scotland reported

being drunk at the time of their offence, rising to three quarters (77%) of young offenders [Scottish Prison Survey 2009]

The problem is getting worseThe problem is getting worse

There has been a rise in proportion of young Scottish offenders who consider alcohol has contributed to their offending (from 48% in 1979 to 80% in 2007) [McKinlay et al 2009]

Alcohol related crime is estimated to cost Scotland over £700 million per year [Societal Cost for Alcohol Misuse in Scotland in 2007 Scottish Government 2010]

Alcohol and Violent Crime in Alcohol and Violent Crime in ScotlandScotland

Where known, alcohol is a factor in more than two thirds (69%) of those accused of homicide [Homicide in Scotland 2008/9]

70% of assaults in A&E may be alcohol related 70% of assaults in A&E may be alcohol related [QIS 2006]

In 62% of violent crime, victims said the In 62% of violent crime, victims said the offenders were under the influence of alcohol offenders were under the influence of alcohol [Scottish Crime and Justice Survey 2010]

Alcohol Problems in OffendersAlcohol Problems in OffendersThe prevalence of alcohol problems in offenders The prevalence of alcohol problems in offenders is highis high

46% of Scottish prisoners may have harmful 46% of Scottish prisoners may have harmful use/dependency (as defined by CAGE) compared use/dependency (as defined by CAGE) compared to 14% of the adult male general populationto 14% of the adult male general population [Alcohol Statistics Scotland 2011][Scottish Health Survey 2010]

Important to note that not all alcohol problems in Important to note that not all alcohol problems in offenders are directly linked to their offenceoffenders are directly linked to their offence

The offender pathway: an opportunity for intervention

Population with a high prevalence of alcohol problems

Easier to reach the ‘hard to reach’-over a third of prisoners said if they were offered help for their alcohol problems they would take it [Scottish Prison Survey 2009]

Potential to reduce re-offending Positive effect on others (many young

offenders have family members who have served a custodial sentence)

Reduce health inequalities

A Prison Health Needs Assessment A Prison Health Needs Assessment for Alcohol Problemsfor Alcohol Problems

MethodsMethods Epidemiology of alcohol problems in prisoners in Epidemiology of alcohol problems in prisoners in

ScotlandScotland Rapid review of international literature on screening Rapid review of international literature on screening

tools and effective interventionstools and effective interventions Mapping of alcohol services across all Scottish Mapping of alcohol services across all Scottish

prisons prisons Case study of one prisonCase study of one prison

-screening of prisoners using AUDIT-screening of prisoners using AUDIT-interviews with key informants (including prisoners)-interviews with key informants (including prisoners)

Gap analysisGap analysis A model of careA model of care

Rapid review: findingsRapid review: findings ScreeningScreening

- AUDIT most promising but no single screening AUDIT most promising but no single screening tool superior tool superior

- Timing of screening may be importantTiming of screening may be important InterventionsInterventions

- Evidence limited for most interventions Evidence limited for most interventions (though therapeutic communities may be (though therapeutic communities may be effective)effective)

- Alcohol Brief Interventions have highest Alcohol Brief Interventions have highest evidence base in general populationevidence base in general population

ThroughcareThroughcare- little research available- little research available

Screening: findings in one prisonScreening: findings in one prison

0102030405060708090

100

18-24 Years 25-29 30-39 40-64

AUDIT Score by Age (n = 259)

0-7 Low risk

8-15 Hazardous16-19 Harmful

20- 40 Possibly Dependent

Mapping: findings across Mapping: findings across prisonsprisons

Recognition that prison provides an opportunity to detect and Recognition that prison provides an opportunity to detect and intervene with alcohol problemsintervene with alcohol problems

No use of validated screening toolNo use of validated screening tool Timing of asking can be importantTiming of asking can be important

Range of interventions to address alcohol problemsRange of interventions to address alcohol problems Not all interventions available to those on short Not all interventions available to those on short

sentences/remandsentences/remand Low numbersLow numbers of prisoners accessing interventionsof prisoners accessing interventions Variation in capacity of staff due to other demands Variation in capacity of staff due to other demands

Problems establishing continuity of careProblems establishing continuity of care Limited in-reachLimited in-reach though this is developing though this is developing

Case study: Case study: findings from interviews with prisoners & findings from interviews with prisoners & staffstaff

Broadly convergent understanding of many alcohol Broadly convergent understanding of many alcohol aspects among prisoners and staffaspects among prisoners and staff

Perception that alcohol issues are not as well resourced Perception that alcohol issues are not as well resourced or as prominent as drug interventionsor as prominent as drug interventions

Prisoners view alcohol problem assessment on admission Prisoners view alcohol problem assessment on admission as an ‘yes or no’ question, asked at a time of competing as an ‘yes or no’ question, asked at a time of competing concernsconcerns

Recognition that not all prisoners will acknowledge Recognition that not all prisoners will acknowledge alcohol problems or want to deal with themalcohol problems or want to deal with them

Recognition that differing patterns of alcohol misuse exist Recognition that differing patterns of alcohol misuse exist across age groupsacross age groups

Prisoners want more involvement of ‘outsiders’ and those Prisoners want more involvement of ‘outsiders’ and those with experience of alcohol problemswith experience of alcohol problems

Four tiers of intervention Four tiers of intervention (MoCAM)(MoCAM)

Tier 1 InterventionsTier 1 Interventionsalcohol-related information and advice; screening; alcohol-related information and advice; screening; simple brief interventions; and referralsimple brief interventions; and referralTier 2 InterventionsTier 2 Interventionsopen access, non-care-planned, alcohol-specific open access, non-care-planned, alcohol-specific interventionsinterventionsTier 3 InterventionsTier 3 Interventionscommunity-based, structured, care-planned alcohol community-based, structured, care-planned alcohol treatment treatment Tier 4 InterventionsTier 4 Interventionsalcohol specialist inpatient treatment and residential alcohol specialist inpatient treatment and residential rehabilitationrehabilitation

Model of CareModel of Care

Scoping of Interventions for Offenders with Alcohol Problems in Community Justice Settings

MethodsMethods Literature review and desk top analysisLiterature review and desk top analysis

Primary data collectionPrimary data collection-interviews with Community Justice Authority -interviews with Community Justice Authority

Chief OfficersChief Officers-interviews with CJA local partners-interviews with CJA local partners

Rapid review: findingsRapid review: findings Limited data on prevalence of alcohol problems Limited data on prevalence of alcohol problems

in offendersin offenders Limited routine data on alcohol-related offendingLimited routine data on alcohol-related offending

- 11% of probation orders had alcohol treatment as a 11% of probation orders had alcohol treatment as a requirementrequirement

ScreeningScreening- again, AUDIT most promisingagain, AUDIT most promising

InterventionsInterventions- Evidence limited for most interventions Evidence limited for most interventions - Alcohol Brief Interventions have highest evidence base Alcohol Brief Interventions have highest evidence base

in general populationin general population- Arrest Referral effective in identifying those with Arrest Referral effective in identifying those with

alcohol problemsalcohol problems

Local Practice: findings Alcohol rising up the agenda Mainstream services being accessed but no

formal care/offender pathways Limited interventions specifically for offenders

(e.g. alcohol and violence) Most interventions post sentence Some local examples of good practice

Good practice examples Alcohol Diversion Scheme (Fife)

- early intervention addressing binge drinking and associated anti-social behaviour - opportunity to participate in an alcohol education session instead of FPN - especially popular with the 18 to 30 age group

Opportunity to Reduce Criminal Activity (ORCA) service (Grampian)- builds on multi agency working practices in its service delivery - observed reduction in crime locally

Tayside Short Term Prisoner Protocol- pre-release ‘surgeries’ facilitate integration back into community- short term prisoners referred to alcohol services on release

Alcohol Brief Interventions is the Alcohol Brief Interventions is the Community Justice Setting: a Community Justice Setting: a feasibility pilot feasibility pilot

MethodsMethods Three pilot sites Three pilot sites Offenders on probation orders or community

service orders Single blind randomisation to either:

-Screening (using AUDIT) and leaflet-Screening and ABI

Follow up at three/six months Online staff survey Analysis of training (pre and post) In depth interviews with key staff Cost analysis

ABI pilot: findings 419 assessed; of whom 295 (70%)

eligible; of whom 207 consented (70%) 85% male; mean age 31 years 59% (n=116) had an Alcohol Use

Disorder of whom 42% (n=82) eligible for an ABI

32 (39%) lost to follow up; 34 other outcome known, 16 individuals followed-up

ABI pilot: findings Training generally thought useful, relevant and

improved confidence AUDIT easy to use and ABI easy to deliver Timing thought to be more beneficial earlier in

process Mixed views as to appropriateness and client

engagement Some lack of understanding by frontline staff

about study design, purpose and effectiveness £67 per person (majority overheads)

Next Steps £0.75 million funding for ADPs in

2011/12 for alcohol in prisons Dissemination of research

including event in February 2011 Briefing of ADP chairs ADP/CJA event in December Guidance statement Report for WHO HIPP on alcohol

Contact/Further InformationContact/Further Information

Dr Lesley GrahamDr Lesley Grahamlesley.graham@nhs.net

Alcohol and Offender Criminal Justice Alcohol and Offender Criminal Justice Programme Programme

http://www.healthscotland.com/topics/health/alcohol/offenders.aspx