The aim of this study was to evaluate the effect of a relapse-prevention program for methamphetamine (MAP)-dependent inmates in a prison.
The aim of this study was to evaluate the effect of a relapse-prevention program for methamphetamine (MAP)-dependent inmates in a prison.
Participants were 251 male inmates with MAP-abuse problems. We compared scores on the Self-efficacy Scale for Drug Dependence (SSDD) and the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) before and after intervention with a self-teaching workbook and group therapy.
For all participants, only SSDD scores increased during the pre-intervention period. SOCRATES-8D scores increased after the start of the intervention using the self-teaching workbook, and both SSDD and SOCRATES-8D scores increased when group therapy was implemented. Changes in scores in participants with moderate and high MAP dependence were considerably different from the scores of those with low dependence during the pre-intervention and the self-teaching workbook periods.
Intervention using a self-teaching workbook and group therapy in prisons might be effective for inmates with more than moderate severity of MAP abuse.
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.
Participants in the Program at the HRPC were male inmates who had been sent there between June 2009 and April 2012. Despite the reasons of the incarceration, they were determined by HRPC staff to meet either of the following two criteria: ‘the reason for detention is drug abuse’ or ‘the reason for detention is not drug abuse, but drug abuse may impede their social adjustment’. Of 328 inmates who met such criteria, 324 had completed the Program by April 2012, while four dropped out due to acting against the prison rules (e.g. prohibition against violent language or physical attack to others in prison life). Of the Program completers, 318 consented to measuring the effects of the intervention, but the final number of subjects to be evaluated was 317 (96.6%), excluding one inmate due to data-deficit (refusing final evaluation) (Fig. 1).
The types of substances the 317 inmates most frequently used immediately before their incarceration were MAP (251 participants), cannabis (33 participants), organic solvents (10 participants), magic mushrooms (five participants), heroin (one participant), 3,4-methylenedioxymethamphetamine (MDMA) (one participant), other drugs (two participants), and multiple drugs or unknown (14 participants). Of the 317 inmates, 251 (mean age [SD], 37.78 [7.75] years) who used MAP most frequently immediately before their incarceration were used for the analysis in this study.
The Program consisted of two parts: the use of a self-teaching workbook that the participants wrote in, and the attendance of group therapy in which the HRPC staff served as facilitators.
The self-teaching workbook used in this study was originally developed for use in juvenile classification homes and is called the ‘SMARPP-Jr’. It is a simplified version of the workbook used in the SMARPP, an integrated outpatient treatment program for drug dependence that we have been implementing based on the Matrix Model developed in the USA. In a previous study, we demonstrated that an intervention using the workbook at juvenile classification homes increased scores on scales that measured insight into drug-related problems and degree of motivation for treatment.
In the present study, the 251 participants were asked to use the self-teaching workbook for a month to prepare themselves for group therapy that would be introduced in the second part of the Program. Participants were divided into groups of 30 each and were introduced to the self-teaching workbook group by group.
After a month of using the self-teaching workbook, the 30 participants in each group were divided into three groups of 10 who then continued on to group therapy.
In cooperation with the Drug Addiction Rehabilitation Center (DARC), the HRPC developed a unique group therapy in which a workbook similar to the workbook used in the SMARPP was used to provide relapse-prevention skills training based on the principles of cognitive behavioral therapy. The group therapy was implemented once a week as a 90-min session. A single course originally consisted of eight sessions, but was later extended to 12 sessions. Irrespective of the number of sessions in the course, members of the DARC staff participated in three sessions, and participants were given an opportunity to meet with people who had recovered from drug abuse. Two members of the HRPC staff qualified for mental health support work (e.g., psychiatric social worker, social worker, or clinical psychologist) participated as a group facilitator and co-facilitator in every session.
At the four time-points described below, data were collected from participants using already available self-administered rating scales and our original self-administered questionnaire. These participants had been judged during the assessment after HRPC incarceration to require participation in the Program. They consented to participate in the measurement of its effect.
The four time-points were: (i) upon enrollment (the start of the pre-intervention period, that is, 1 month before starting the self-teaching workbook); (ii) at the beginning of the self-teaching workbook; (iii) after completion of the self-teaching workbook, that is, at the beginning of group therapy; and (iv) after completion of group therapy. Based on the data obtained at the above time-points, ‘Changes during the pre-intervention period’, ‘Changes during the self-teaching workbook’, and ‘Changes during group therapy’ were assessed on the basis of the changes in scores on the scales between (i) and (ii), between (ii) and (iii), and between (iii) and (iv), respectively. Participants had been inmates at the HRPC for at least 3 months before enrollment in this study, and therefore were assumed to have adapted to the prison environment to some extent.
The Drug Abuse Screening Test, 20 items (DAST-20) is a self-administered rating scale that was developed to screen for abuse of illicit and medicinal drugs. In the present study, the Japanese version of the DAST-20 developed by the Hizen Psychiatric Center was used to assess the baseline severity of participants' drug-related problems. The Japanese version of the DAST-20 has not yet been standardized, but the items are phrased to ask about the presence or absence of psychosocial issues related to drug use, and have face validity (i.e. the literal description of each item reflects the concept it measures). It has been widely used in Japan. Scores can range from 0 to 20 and are used to classify the severity of the problems into the following five levels: (i) None (0 points); (ii) Low (1–5 points); (iii) Intermediate (6–10 points); (iv) Substantial (11–15 points); and (v) Severe (16–20 points).
We administered the Japanese version of the DAST-20 at only the first time-point, ‘upon enrollment’, to divide participants according to the severity of their drug-related problems (i.e. based on their scores) into the following three groups: a low-dependence group (1–5 points), a moderate-dependence group (6–10 points), and a high-dependence group (11–20 points).
The Self-efficacy Scale for Drug Dependence (SSDD) consists of two parts and is an original self-administered rating scale that was developed and shown to be both valid and reliable by Morita and colleagues. It measures the degree of confidence (i.e. self-efficacy) participants have in their ability to cope with drug cravings. The first part consists of five questions regarding general self-efficacy that transcends specific situations, and responses are made on a 5-point scale from 1 (not true for me) to 5 (true for me). The second part consists of 11 questions that ask about a respondent's degree of confidence in their ability to refrain from abusing drugs in specific situations. It asks about such situations as ‘being tempted to use drugs’. Responses are made on a 7-point scale from 1 (not at all confident) to 7 (absolutely confident).
To investigate changes in total score on the SSDD, it was administered at the following four time-points in this study: (i) upon enrollment (1 month before the start of the self-teaching workbook phase); (ii) at the beginning of the self-teaching workbook phase; (iii) after the completion of the self-teaching workbook, that is, at the beginning of group therapy; and (iv) after the completion of group therapy.
The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) is a self-administered rating scale consisting of 19 items. It was developed by Miller and Tonigan to assess a person's awareness of problems caused by drug dependence and their degree of motivation for treatment. The questions in the English version have a three-factor structure composed of ‘Recognition’, ‘Ambivalence’, and ‘Taking Steps’. Participants with high Recognition scores are considered to acknowledge that they are having problems related to drug abuse and that they need to change their behavior because various harmful effects will occur if they continue to abuse drugs. Participants with high Ambivalence scores indicate that they sometimes wonder whether they are not in control of their drug abuse, are hurting other people, are an addict, or all three. Participants with high Taking Steps scores indicate that they are already doing things to make positive changes regarding their drug problem or want help in making such changes. A positive correlation has been found between total SOCRATES scores and the development of readiness for treatment. Also, drug abusers with higher scores were found to remain in treatment longer in a short-term intervention done for poorly motivated drug abusers.
We had developed a Japanese version of the SOCRATES-8D by a procedure that included back-translation. In the present study it was administered at the same four time-points as the SOCRATES-8D. Although the Japanese version has not been submitted to a standardization process, each item of the scale has face validity. The Japanese version as a whole has also been demonstrated to have excellent internal consistency (Cronbach's α = 0.798) and concurrent validity with the DAST[3, 6] which reflects the severity of drug-related problems, and with the SSDD, which reflects confidence in drug abusers' ability to cope with drug cravings. In addition, total scores on the Japanese version of the SOCRATES-8D were shown to have increased after use of a self-teaching workbook at juvenile classification homes and after a substance use disorder treatment program for inpatients. However, our Japanese version of the SOCRATES-8D differs from the original version in regard to its sub-factors. As a result, it has a two-factor structure instead of the three-factor structure of the original. Because of this difference, in the present study we evaluated only the changes in total scores and not the changes in sub-factor scores.
Agreement between the director of the National Institute of Mental Health, National Center of Neurology and Psychiatry, where the first author works, and the director of the HRPC, where the research was conducted, was concluded prior to the start of this study. The study was approved by the Ethics Committee of the National Center of Neurology and Psychiatry.
Changes in scores on the SSDD and the total score on the SOCRATES-8D during the pre-intervention period, the self-teaching workbook phase, and group therapy were compared. The Wilcoxon signed-rank test was used for comparisons between the two groups. All of the statistical analyses were conducted using spss for Windows 17.0 (IBM Corporation, Chicago, IL, USA), and the significance level was set at P < 0.05, two-tailed.
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.
|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.
|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).
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.
This study was supported by a Health Labour Sciences Research Grant from the Ministry of Health and Welfare, Comprehensive Research on Disability Health and Welfare, for ‘A study on development and evaluation of cognitive behavioral therapy for drug dependence (Principal Investigator, Matsumoto T)’. We declare that we have no conflicts of interest in relation to this study.