METHAMPHETAMINE (MAP) ABUSE has been a social problem in Japan ever since the end of World War II. Very few medical institutions in Japan have specialized treatments for drug dependency until now, and many MAP-dependent individuals have little opportunity to receive medical treatment before being incarcerated for drug abuse. Furthermore, they do not receive adequate drug dependency treatment in prison, and often relapse after being released. To improve this situation, the ‘Act on Penal Detention Facilities and Treatment of Inmates and Detainees’, which codified an educational and therapeutic approach for imprisoned criminals to promote their social remediation and rehabilitation, came into force in 2007. Prisons operated by the Private Finance Initiative (PFI), which uses private capital and expertise in the construction, maintenance, and operation of public institutions, are expected to provide drug-dependent inmates with multidisciplinary treatment by obtaining the cooperation of extramural experts.
The Harima Rehabilitation Program Center (HRPC) is one of the four PFI prisons in Japan. Since its establishment, the HRPC has provided a relapse-prevention program (the Program) specifically designed for inmates who are dependent on MAP, cannabis, or other drugs. In 2009, the HRPC started to use the Serigaya Methamphetamine Relapse Prevention Program (SMARPP)-Jr, a self-teaching workbook developed to promote recovery from drug dependence. This was used in conjunction with group therapy as it was in the SMARPP, to assist the recovery of addicts from drug dependence. Although the intervention effect of such a progressive effort naturally needs to be verified, conducting a randomized controlled trial (RCT) at penal detention facilities has various problems from a legal and human rights standpoint. Moreover, little evidence is available regarding the effectiveness of treatment programs for drug dependence in Japan. To the best of our knowledge, no RCT have been conducted in Japan and there is only one case–control study of a small population, and one study that used a group in a report in the literature as a control group.
In this context, we previously attempted to evaluate the effect of an intervention by evaluating the changes in the participant's score on scales before and after intervention, using the score changes in a pre-intervention period as a control, confirming desirable changes in the attitudes toward one's drug-related problems and the motivation for receiving therapy. However, our previous studies have three serious shortcomings: (i) the drugs abused in the participants diverged in terms of their pharmacological actions; (ii) the sample size was relatively small; and (iii) the severities of drug-related problems were not considered. Thus, no conclusions regarding the effect of the intervention on MAP abusers could be directly drawn from the results. In the present study, therefore, we only included MAP abusers and assessed the effect of the intervention in the same manner as in our preliminary study, overcoming such shortcomings.
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The mean (SD) DAST-20 score of the 251 participants was 9.08 (3.57) points. Based on their scores, we divided participants into three groups: low-dependence (n = 43, 17.1%), moderate-dependence (n = 128, 51.0%), and high-dependence (n = 80, 31.9%). No significant differences were found in the mean ages (SD) among these groups (low, 39.40 [9.47]; moderate, 37.74 [7.14]; high, 37.78 [7.75]: anova).
Table 1 shows the changes in SSDD and SOCRATES-8D scores of participants as a whole. As shown in the table, the change in SOCRATES-8D scores during the pre-intervention period was not significant, although SSDD scores significantly increased (P < 0.001). During the self-teaching workbook phase, SSDD scores did not significantly change, although SOCRATES-8D scores showed a significant increase (P < 0.001). Both SSDD scores (P = 0.001) and SOCRATES-8D scores (P < 0.001) significantly increased during group therapy.
Table 1. Changes of the SSDD and SOCRATES-8D scores by interventions of a self-teaching workbook and group work
|Self-teaching workbook phase||SSDD||77.44||18.89||78.90||19.46||1.390||0.164|
|Group work phase||SSDD||78.90||19.46||81.02||17.16||3.182||0.001|
Table 2 shows the changes in SSDD and SOCRATES-8D scores according to severity. There was no significant change in SSDD scores in the low-dependence group, although there was a significant increase in SOCRATES-8D scores (P = 0.018) during the pre-intervention period. Although no significant changes in scores on either scale occurred during the self-teaching workbook phase, we observed significant increases in both SSDD scores (P = 0.011) and SOCRATES-8D scores (P = 0.004) during group therapy.
Table 2. Changes of the SSDD and SOCRATES-8D scores by classification of severity of drug-related problems
|Mild type (n = 43)||Waiting phase||SSDD||83.02||17.05||84.56||17.21||1.217||0.224|
|Self-teaching workbook phase||SSDD||84.56||17.21||83.19||15.91||1.164||0.244|
|Group work phase||SSDD||83.19||15.91||88.93||12.91||2.548||0.011|
|Moderate type (n = 128)||Waiting phase||SSDD||78.55||15.69||81.62||16.36||2.778||0.005|
|Self-teaching workbook phase||SSDD||81.62||16.36||78.07||16.78||3.933||<0.001|
|Group work phase||SSDD||78.07||16.78||86.95||13.83||6.703||<0.001|
|Severe type (n = 80)||Waiting phase||SSDD||76.79||19.37||77.83||17.65||1.648||0.099|
|Self-teaching workbook phase||SSDD||77.83||17.65||76.87||17.96||2.375||0.018|
|Group work phase||SSDD||76.87||17.96||84.81||15.17||4.671||<0.001|
In the moderate-dependence group, by contrast, there were no significant changes in SOCRATES-8D scores during the pre-intervention period, but there was a significant increase in SSDD scores (P = 0.005). In the self-teaching workbook phase, however, SSDD scores significantly decreased (P < 0.001), and SOCRATES-8D scores significantly increased (P < 0.001). During group therapy, SSDD scores again significantly increased (P < 0.001), and SOCRATES-8D scores also significantly increased (P < 0.001). The pattern of score changes in the high-dependence group was similar to the pattern in the moderate-dependence group. More specifically, we observed an increasing trend (P = 0.099) in SSDD scores during the pre-intervention period, whereas we observed a significant decrease in SSDD scores (P = 0.018) and significant increase in SOCRATES-8D scores (P = 0.010) in the self-teaching workbook phase; both scores significantly increased during group therapy (P < 0.001).
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During the pre-intervention period and for each part of the intervention (i.e. the self-teaching workbook and group therapy), scores on the scales revealed a distinctive profile of changes. Results for participants as a whole revealed that only SSDD scores increased during the pre-intervention period, when no intervention was being provided, whereas only SOCRATES-8D scores increased after the start of the intervention using the self-teaching workbook. When group therapy was implemented, both SSDD and SOCRATES-8D scores increased.
The profile of changes in scores of participants as a whole suggests that participants might have experienced a three-stage mental transformation during the course of the Program. The first stage occurred during the pre-intervention period, the second stage during the self-teaching workbook phase, and the third stage during group therapy. The first stage of the mental transformation occurred during the period between the time the inmates were sent to prison and when the Program started. Confidence in their ability to cope with drug cravings increased during this stage, even though their insights into their drug-related problems failed to deepen. The second stage began when they started using the self-teaching workbook. During this stage their insights into their drug-related problems deepened and their degree of motivation for treatment increased, even though confidence in their ability to cope with cravings did not increase. The third stage occurred during their participation in the group therapy, when their insights into their drug-related problems and their degree of motivation for treatment improved further, and their confidence in their ability to cope with drug cravings also increased. These findings are consistent with our preliminary study.
The present study also demonstrated that the changes in scores on the scales varied with the severity of participants' drug-related problems. The changes in the low-dependence group were different from the changes for participants as a whole: their SSDD scores did not increase during the pre-intervention period but their SOCRATES-8D scores did. Furthermore, while their scores on neither scale changed significantly during the self-teaching workbook phase, their scores on both the SSDD and SOCRATES-8D increased during group therapy. By contrast, results for changes in the scores in the moderate- and high-dependence groups were considerably different from the results in the low-dependence group during both the pre-intervention period and the self-teaching workbook phase. However, changes in the scores of all three groups were similar during group therapy. In other words, results for the moderate- and high-dependence groups showed that SSDD scores increased during the pre-intervention period, but dropped when participants used the self-teaching workbook, whereas SOCRATES-8D scores did not change during the pre-intervention period, but increased during use of the self-teaching workbook.
The study's results have two clinically relevant implications. First, if the problems of drug addicts are moderate or severe, merely incarcerating them might not stimulate them to deepen their insights into their drug-related problems or increase their motivation for treatment. Furthermore, their confidence that they can cope with drug cravings may increase, despite not being provided with any treatment program. These changes in their insights, motivation, and confidence might lead such inmates to be less likely to access support resources in the community after their release from prison. They may also be more prone to contact their former drug-related peers, and approach situations that could trigger drug use – all based on their ‘groundless’ confidence. In that sense, these results support the need for relapse-prevention programs for inmates with drug-related problems of a certain degree of severity.
The second clinically relevant implication of the results of this study is that using the Program as an intervention to treat inmates with moderate or high dependence on drugs temporarily decreased their confidence in their ability to cope with drug cravings in the early part of intervention. However their confidence increased as the intervention proceeded. Such changes in their confidence, reflected in their SSDD scores, were in marked contrast to the changes in participants' insights into their drug-related problems and motivation for treatment, which steadily improved during the course of the intervention. Similar patterns were observed in the results of an intervention study on drug dependence by Morita et al. They reported that participants' insights into their own drug-related problems deepened while their self-efficacy scale scores temporarily decreased in the early phase of the intervention, with the self-efficacy scale score subsequently increasing. This demonstrated the eventual effectiveness of the intervention.
It should be noted that many clinicians specializing in the treatment of substance dependence have been empirically aware of the mental transformation observed in drug abusers during the course of the type of treatment described above. In fact, it is only natural that confidence in coping with drug cravings decreases when a drug abuser's awareness and insight into their problems related to drug use increase and they start to consider that ‘I may be an addict’ or ‘I may not be able to handle my drug use problem’. Such a decrease in confidence itself has a therapeutic effect, because it prepares the abusers to actively access support resources or gives them motivation to continue treatment. Moreover, it can decrease the risk of relapse. This is because it can lead drug abusers to avoid situations that stimulate drug cravings or involve higher risk of drug use in their daily lives. Nevertheless, if confidence in their ability to cope with drug cravings is not adequately built up despite being provided with a certain amount of treatment, their lives and activities will be restricted for a long time. As Prochaska and DiClemente pointed out, for drug abusers to persist in their effort to refrain from using drugs for long periods, they must have the self-confidence that tells themselves: ‘I can stay off drugs’. Thus, the fact that the Program temporarily decreased drug abusers' ability to resist cravings for drugs and later increased it could imply that the Program is ideal as an intervention for the treatment of drug dependence.
The characteristics of the changes in the effect of the intervention on drug abusers with moderate or high dependence on drugs can also be explained from the point of view of the difference between the methods used for the intervention (self-teaching workbook vs group therapy), which could produce different effects. The self-teaching workbook is an independent unidirectional learning method, whereas during group therapy participants directly interact with facilitators. Furthermore, during group therapy, the participants were provided specific descriptions of cases of recovery by the DARC staff, and had opportunities to share their experience with other people with similar problems. These differences between methods might have contributed to the effects during group therapy that increased both participants' awareness of their problems and self-confidence regarding ability to resist drug cravings. However, even though the intervention that used the self-teaching workbook was less effective than group therapy, it does not mean that it is unnecessary. The ‘self-teaching’ method is still an efficient way of intervening with inmates for long periods with limited manpower. At the very least it increases a drug abuser's awareness of problems, their motivation for treatment and serves as preparation for group therapy.
There are several limitations of this study. First, this was not a randomized controlled trial. Second, we cannot rule out the possibility that participants' responses on the self-administered rating scales were affected by their being prison inmates. Third, psychosocial conditions of inmates (educational history, MAP use duration, term of imprisonment, and comorbid psychiatric disorders) were not considered in this evaluation. Fourth, the evaluation end-points we adopted were not ‘sustained discontinuation of drug use’ or ‘continuation of treatment in the community’. Instead the end-points were proxy variables in the form of before and after scores on rating scales, administered at a penal detention facility, as a result of the two parts of the intervention. Further outcome research is needed to determine how much the changes in scores predict participants' actual drug discontinuation behaviors and treatment continuation after their release from the HRPC.
Despite such limitations, this study of an intervention to treat MAP abusers was conducted on the largest sample size in Japan to date. It should contribute greatly to drug dependence treatment in Japan, a country where little evidence is available on therapeutic efficacy in this field.
We assessed the effect of an intervention that consisted of using a self-teaching workbook and group therapy to treat 251 adult male MAP abusers at a penal detention facility in which the changes in scores on scales before and after intervention were evaluated. The results revealed that inmates with moderate or high dependence on MAP might have increased their confidence in their ability to cope with drug cravings under incarceration without any interventions into their drug problems, even though their insight into their drug-related problems did not deepen. The results also showed that the part of the intervention in which the self-teaching workbook was used deepened inmates' awareness of drug-related problems but that there was a concurrent decrease in confidence in their ability to cope with drug cravings. Lastly, the results suggested that the group therapy phase of the intervention further deepened their awareness of their drug-related problems and simultaneously enhanced their self-efficacy in resisting drug cravings.