best practice

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

• HIV seroconversion in prison settings

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

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

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

• HCV transmission in prison settings

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

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

Naltrexone (NTX), an antagonist pharmacological treatment for relapse prevention, reversibly blocks reward associated with opioid use, without possessing any opioid-like properties of its own. Extended-release NTX is available and administered through intramuscular injections every 4 weeks, eliminating the need for daily oral dosing.

Naltrexone was found in a systematic review wit meta-analysis (Bahji et al., 2020, 11 studies, N= 1 045) to be effective in:

• improving retention in treatment (RR = 1.31; 95% confidence interval (CI) = 1.05, 1.63) - no difference between oral and extended release
• reducing rates of re-incarceration (RR = 0.70, 95% CI = 0.54–0.92) - significant reduction for oral NTX
• reducing opioid relapse (RR = 0.63, 95% CI = 0.53–0.76) - no difference between oral and extended release
• and improved opioid abstinence (RR = 1.38, 95% CI = 1.16–1.65) - significant reduction for extended release NTX

However, Naltrexone was associated with a greater burden of adverse events overall (RR = 1.49, 95% CI = 1.13–1.95). Mild to moderate adverse events were more frequently reported by participants receiving extended release -NTX (rather than oral NTX) compared to TAU conditions, and these included dry mouth, colic, fatigue, anxiety, blurred vision, abdominal pain, vomiting, nausea and insomnia. The most common reported side effects with extended release-NTX were immediate injection site reactions (such as redness and soreness) and fatigue.

Serious adverse events (i.e. requiring discontinuation or hospitalization) were not statistically significant higher among those who received Naltrexone.

Brief training and standardised naloxone supply for individuals at risk of opioid overdose in prison has been found to be effective in a pre-post evaluation of a national policy (Bird et al.,2016) in:

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

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

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

Cognitive behavioural therapy was found in a systematic review (Perry et al., 2019a) to be more effective than therapeutic communities (one study of low quality) in:

•     reducing criminal activity, i.e. arrested (not for parole) violations at six months follow-up (RR 0.43, 95 % CI 0.25 to 0.77, N=314)

There is evidence from a narrative review including results of one RCT (N=326) (Velleman 2009) that specific training given to young people in order to make them influence each other is not effective in:

• reducing alcohol and tobacco use;
• increasing knowledge and attitudes towards alcohol and tobacco

Knowledge focused programs were found in a systematic review (Faggiano et al, 2014) to have no different effect than usual school curricula or no intervention in:

• improvinge participants’ knowledge of illicit drugs (SMD 0.91, 95 % CI 0.42–1.39, 1 study, N=165);
• reducing illicit drug use

School-based brief interventions were found in a systematic review (Carney et al., 2016, 6 RCT, N=1 176) to have no different effect than information-only interventions (eg. general health promotion materials and harm reduction information) in:

• reducing alcohol and cannabis use
• reducing delinquent-type behaviours

There was very low-quality evidence that brief school-based interventions may be more effective in reducing alcohol and cannabis use than no-intervention (i.e when compared to assessment-only) and that these reductions were sustained at long-term follow-up, however it is premature to make a definitive statement.

School-based generic prevention programs (not including life/social skills approaches, see above in the Beneficial category) have not shown enough evidence to be effective in a systematic review (Foxcroft et al., 2011) of 53 RCTs in:

• reducing alcohol misuse in adolescents (no statistically significant outcomes in 24 out of 39 generic trials).