Reentry Interventions that Address Substance Use: A Systematic Review

Reentry Interventions that Address Substance Use: A Systematic Review is sponsored by National Institute of Mental Health (NIMH). Supports research on interventions addressing substance use among individuals reentering communities after incarceration.

## [](https://pmc. ncbi. nlm.

nih. gov/articles/PMC6459737/)Abstract Justice-involved individuals with substance use problems have heightened risk of relapse and recidivism after release from incarceration, making reentry a critical time to provide evidence-based treatments (EBTs) for substance use; however, the extent to which reentry interventions incorporate EBTs for substance use is unclear.

This systematic review identified studies of reentry interventions in the past 10 years that address substance use, assessed whether EBTs were used, and explored which interventions were effective in reducing substance use and recidivism post-release. Eligible studies included interventions that began during incarceration and continued post-release or began within 3 months of release, and addressed substance use in some capacity.

112 full text articles were reviewed and 38 met inclusion criteria, representing 34 unique interventions. Of the 34 interventions, 21 provided substance use treatment whereas 13 facilitated connections to treatment.

Of the 21 interventions providing treatment, the primary modalities were cognitive behavioral therapy (_n_ = 6), motivational interviewing (_n_ = 2), medication assisted treatment (_n_ = 2), therapeutic community (_n_ = 2), psychoeducation/12-step (_n_ = 5), and 4 did not specify the modality.

Of the 31 studies that assessed recidivism outcomes, 18 found reduced recidivism for the treatment group on at least one indicator (e.g., re-arrest, re-incarceration). Of the 13 studies that assessed substance use outcomes, 7 found reduced substance use for the treatment group on at least one indicator.

Results were not consistent for any particular treatment approach or modality and highlight the need for consistent integration of EBTs for substance use into reentry interventions. **Keywords:**reentry intervention, substance use, offenders, cognitive-behavioral therapy, evidence-based treatment ## [](https://pmc. ncbi.

nlm. nih. gov/articles/PMC6459737/)Present Study The period after release from incarceration (i.e., reentry) is a critical time to effectively provide treatment for substance use; however, the extent to which reentry interventions utilize EBTs for substance use, and more broadly use evidence-based reentry practices, is unclear.

The purpose of this systematic review was to identify a comprehensive list of studies in the past 10 years that evaluate reentry interventions addressing substance use, determine the extent to which these interventions include EBTs for substance use as well as other evidence-based reentry practices (e.g., individualized treatment tailored to risk level, aftercare), and better understand which reentry interventions that address substance use are most effective in reducing substance use and recidivism post-release.

## [](https://pmc. ncbi. nlm.

nih. gov/articles/PMC6459737/)Method ### Search Strategy and Inclusion Criteria PsycInfo, PubMed, and MedLine databases were searched for the following combination of search terms: reentry/post-release, treatment/intervention/program, prison/jail/incarceration/offender, substance abuse/addiction/alcohol use/drug use (_n_ = 1,079 records). In addition, crimesolutions.

gov programs were filtered to identify “reentry/aftercare” programs with a focus on “drug/substance use” (_n_ = 38 records). Peer-reviewed articles and published program evaluation reports to agencies that were written in English and published between 2007 and July 2017 were eligible. The population of interest included participants who were currently or recently incarcerated and received an intervention that addressed substance use.

Eligible interventions began during incarceration and continued post-release or began within 3 months of release, and addressed substance use in some capacity. Interventions that only occurred during incarceration (and did not extend post-release) were not included, and reentry interventions that did not identify substance use as a program target were not included.

Eligible studies were quantitative and included outcome data; no studies were excluded based on the type of outcomes analyzed or the type of study design used in order to compile a comprehensive list of reentry interventions being delivered in the field. The PRISMA chart detailing search processes and study selection is shown in Figure 1.

In addition to the articles identified though database searching, 10 potential articles were identified when reviewing full text articles for eligibility. A total of 112 full text articles were reviewed and 74 studies were excluded (Figure 1).

For articles analyzing multiple studies in aggregate (i.e., systematic reviews, multi-site evaluations), individual study eligibility was assessed when possible, and studies meeting eligibility criteria were included. A total of 38 studies met all eligibility criteria and were included in this review. Table 1 in the online supplement contains details for the 38 studies.

This review documents key elements of reentry interventions that address substance use, including the sample size and gender breakdown of participants who received the treatment (and those in the comparison group, if applicable), eligibility criteria used to select inmates for participation, type of institution the intervention was delivered in (i.e., jail vs. prison), and study design (i.e., single group, quasi-experimental, or randomized controlled trial [RCT]).

Elements of the intervention structure were coded, including whether the intervention began during incarceration and extended post-release (i.e., in-reach with aftercare) and length of the intervention during the reentry period after release.

We documented specific elements of the intervention content including 1) the primary substance use treatment modality (e.g., cognitive behavioral therapy [CBT], motivational interviewing [MI], therapeutic community [TC], contingency management [CM], medication assisted treatment [MAT], self-help [e.g., Alcoholics Anonymous], psychoeducation, or not specified), 2) whether peer mentors were used, 3) the general intervention approach (i.e., categorized as outpatient individual/group counseling; case management [i.e., referrals/facilitated connections to services], residential individual/group counseling, or reentry court), 4) other areas addressed by the intervention in addition to substance use (i.e., housing, employment/education, mental health, physical health/dental, basic needs, finances, documents [e.g., driver’s license, social security card], transportation, family, religion/spirituality, or antisocial attitudes/behaviors), and 5) results of outcomes analyzed.

Coding of study and intervention elements was based on information presented in the article and elements that were unclear/difficult to code were discussed and resolved. When studies used multiple analyses with varying quality (e.g., bivariate correlations and multivariate analyses including control variables), the most rigorous analysis is reported.

In addition, single group pre- to post-test results are only reported when no other analysis was conducted. For studies that used both official records and self-report methods to assess substance use or recidivism, official records are reported. ## [](https://pmc.

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gov/articles/PMC6459737/)Results ### Participant Characteristics and Study Design The 38 studies reviewed here represent 7 program evaluation reports and 31 peer-reviewed publications. Of the 38 studies, 35 are original studies evaluating intervention outcomes and 3 are follow-ups on the same sample at a later point in time.

Of the 35 original studies, 24 were implemented with prison inmates/people exiting prisons, 9 were implemented with jail inmates/people exiting jails, and 2 were implemented with combined jail/prison samples. Twenty one of the 35 original studies used quasi-experimental study designs, 9 used RCTs, and 5 used single group designs.

Thirteen of the 35 studies delivered the intervention to an all-male sample, 17 were provided to both men and women (though 6 of these studies had treatment samples over 90% male), 4 were provided to only women, and 1 program evaluation report did not specify the gender of participants.

Nine of the 35 original studies excluded inmates due to serious mental illness or the seriousness of their index offense (e.g., violent, sex, arson offenses), whereas 10 studies only included inmates deemed to be at heightened risk (i.e., scored high on violence risk assessment, had serious mental illness), and 16 studies did not mention excluding/including inmates based on level of risk.

Over half (_n_ = 18) of the 35 studies reported selecting inmates based on the presence of self-reported substance use problems or co-occurring mental health and substance use disorders. Less than half (_n_ = 13) of the 35 studies reported selecting inmates based on the length of their sentence or amount of time remaining on their sentence.

Interventions generally described excluding individuals who would not be returning to a particular geographic location post-release, and other common exclusion criteria included the presence of pending charges (see supplemental Table 1). ### Intervention Structure Within the 35 original studies, 1 intervention (Serious and Violent Offender Reentry Initiative [SVORI]) is represented twice (i.e., 34 unique interventions).

The majority (_n_ = 23) of the 34 unique interventions used an in-reach approach, initiating some level of service prior to release from jail or prison, while 11 interventions only offered services post-release. Of the 23 interventions utilizing in-reach, all included an assessment of reentry needs prior to release, though the point at which this occurred varied from entry into the correctional facility to 1 month prior to release.

The length and characteristics of the intervention offered during incarceration varied, ranging from one meeting with a case manager to determine reentry needs to 12 months of group/individual counseling (see supplemental Table 1).

The duration of intervention post-release also varied; 4 studies did not specify the duration of post-release services, 3 studies described that services were no longer provided upon connection with a community provider post-release, and the other 27 studies had post-release services ranging from 1 month to 4 years.

Almost all of the interventions included multiple treatment approaches to address the many needs of offenders returning to the community after incarceration and were tailored in some way to the individual offender.

Thirteen of the 34 interventions described providing case management only (rather than providing direct treatment services), in which a case manager or team of people conducted needs assessments and provided referrals and/or facilitated connection to substance use and other services in the correctional facility and/or community post-release.

Within these 13 interventions, some only provided referrals to treatment while others facilitated connections with needed services by making appointments for inmates, providing transportation to appointments or accompanying them to appointments, or providing vouchers or financial assistance to pay for treatment (see supplemental Table 1).

In contrast, 21 of the 34 interventions described directly providing some form of treatment services and often also provided case management.

Within these 21 interventions, the primary overall therapeutic approaches described were individual/group counseling during incarceration and/or on an outpatient basis post-release (_n_ = 16), post-release residential treatment programs involving a combination of individual/group counseling (_n_ = 3), and reentry courts which mandated individuals to needed treatments and used court-imposed sanctions for non-engagement (_n_ = 2).

There was variability in the use of EBTs for substance use within the 21 interventions that provided direct treatment services and many used multiple substance use treatment modalities.

The primary substance use treatment modalities described in the 21 interventions included MI around substance use (_n_ = 2), MAT for opioid use (_n_ = 2), cognitive-behavioral therapy for substance use (e.g., _n_ = 4; moral reconation therapy [MRT] _n_ = 1; community reinforcement and family treatment [CRAFT] _n_ = 1), therapeutic communities (n = 2), and psychoeducation (i.e., chemical dependency, overdose prevention, relapse prevention) and/or 12-step (_n_ = 5).

Four interventions did not specify the substance use treatment modality used in therapy. Within the two therapeutic communities, 1 described using a CBT and psychoeducation curriculum (Sacks, Chaple, Sacks, McKendrick, & Cleland, 2012) and the other used “milieu therapy” as is typical in TCs, but did not specify the modality of group counseling around substance use (Robbins, Martin, & Surratt, 2009).

No interventions reported using contingency management explicitly, though one reentry court intervention (Hamilton, 2010) and one individual/group counseling intervention (Friedmann et al. , 2013) described using incentives or contingent reinforcers to encourage positive behavior change.

Only 9 interventions included a peer mentorship component in which people with a history of addiction and/or incarceration were available to provide informal support, case management, and mentoring to offenders. All but 1 of the 34 reentry interventions described addressing other problem areas (either by referral or direct access to treatment) in addition to substance use, depending on individual needs.

The issues most often reported to be addressed were employment and/or education (_n_ = 28), housing (_n_ = 25), and mental health (_n_ = 21). Less often addressed areas included instruction in finances (_n_ = 12), family or parenting services (_n_ = 10), and social support (n = 11).

Interventions rarely reported addressing transportation (_n_ = 9), physical health (_n_ = 8), basic needs such as food or clothing (_n_ = 7), documentation such as driver’s license or social security card (_n_ = 6), antisocial behavior/attitudes (_n_ = 5), and religion/spiritual needs (_n_ = 5). Only 2 interventions reported addressing sexual health/HIV risk.

It is important to note that some articles may not have provided a comprehensive list of all services offered in the intervention. The primary outcome analyzed across the 38 studies included in this review was recidivism (i.e., re-arrest, re-conviction, re-incarceration, technical violations/revocation of probation or parole; _n_ = 33).

Excluding the 5 single group studies, out of the 31 quasi-experimental or RCT studies analyzing recidivism, 11 found no differences in recidivism indicators between the treatment and control/comparison groups, and 18 found that at least one indicator of recidivism decreased more for intervention participants compared to the control/comparison group, though 5 of these 18 studies also found no differences between treatment and control/comparison groups on additional indicators of recidivism (see supplemental Table 1).

The length of follow up for recidivism outcomes varied widely from 3 months to 4 years. In addition, the type of recidivism assessed (arrest vs. conviction vs. incarceration vs. probation violation vs. number of arrests vs. time to arrest) varied between studies, as did the use of control variables (e.g., initial risk level, criminal history) in analyses.

Two studies found that the treatment group had more recidivism than the comparison/control group; Hamilton (2010) found no differences in rearrest rates between reentry court participants and the comparison group, but reentry court participants had lower re-conviction rates and higher rates of reincarceration, technical violations, and revocations at 1, 2, and 3 years post-release.

Another study (Severson, Bruns, Veeh, & Lee, 2011) found that the SVORI intervention participants had a greater risk of returning to prison than the comparison group, but they were less likely to get new convictions.

#### Substance use and substance use treatment Excluding the single group studies (_n_ = 5), 13 quasi-experimental or RCT studies analyzed substance use outcomes and 5 of these found that substance use was lower for intervention participants compared to the control/comparison group, 5 found no differences in substance use between groups, 2 found that some indicators of substance use were lower for treatment participants whereas there were no differences on other indicators of substance use, and 1 (Grommon, Davidson, & Bynum, 2013) found treatment participants had higher substance use compared to the control group.

Of note, some studies utilized urinalysis to detect substance use and others used self-report. Eight studies examined engagement in community-based substance use treatment as an outcome; 5 studies found intervention participants were more likely to engage in substance use treatment and 3 found no differences in engagement between treatment and control/comparison groups. ## [](https://pmc.

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gov/articles/PMC6459737/)Discussion The purpose of this systematic review was to identify studies of reentry interventions in the past 10 years that address substance use, determine the extent to which these interventions use EBTs for substance use, and describe the effectiveness of these interventions in reducing substance use and recidivism post-release.

We included both peer-reviewed publications as well as program evaluation reports to identify a comprehensive list of interventions being implemented in the field. The 38 studies reviewed here represent a wide variety of reentry interventions that address substance use, ranging in length, approach, treatment modality, and effectiveness.

Out of the 34 unique reentry interventions reviewed herein, 21 provided some degree of treatment within the community agency itself, whereas 13 utilized case managers to facilitate connections to outside agencies. The use of a case management approach to reentry for substance-using offenders has been somewhat debated over the past decade (Prendergast, 2009).

Meta-analyses have shown case management to be ineffective for reducing substance use and recidivism among offenders with substance use problems (Aos, Miller, & Drake, 2007); however, the type of case management strategy utilized may matter.

The 13 interventions that primarily utilized case management approaches reviewed here often described offering more intensive or personalized case management than is typical for offenders reentering the community.

For example, several programs reported that their case managers had reduced caseloads (e.g., 20 offenders per case manager as opposed to 80), provided transportation or vouchers that facilitated access to treatment, or emphasized participant preference for service type/location (Ray, Grommon, Buchanan, Brown, & Watson, 2017).

Difficulties with case management approaches typically involved lack of follow up on referrals; some studies that used a case management approach note that less than half of participants received services they were referred to (Severson et al. , 2011).

In addition, the disconnect between community-based substance use treatment systems and correctional systems is longstanding (Prendergast, 2009), and in addition to strained communication between systems, providers may also be less comfortable interacting with clients referred from the criminal justice system (Skeem & Louden, 2006), leading to less effective treatment.

The modality of substance use treatment was rarely described in the 13 interventions that referred offenders to outside agencies for treatment, and thus we focused on the 21 interventions that directly provided treatment when examining the extent to which EBTs for substance use were utilized. Of the 21 interventions that provided treatment, 12 explicitly described using EBTs for substance use (i.e., CBT, therapeutic community, MI, MAT).

The most common EBT was CBT (_n_ = 6) provided in an individual or group format, though the specific type of CBT protocol was only mentioned in 2 of the 6 studies (i.e., CRAFT and MRT). CBT is an effective treatment for substance use among offenders that also reduces recidivism (Landenberger & Lipsey, 2005) and thus its inclusion in reentry interventions is encouraging.

Six interventions reported using psychoeducational groups or self-help; however, these are not EBTs for substance use and are recommended only for low-risk offenders (Prendergast, 2009). Four interventions reported non-descript counseling (i.e., no treatment modality mentioned), which is problematic because that may indicate that the reentry intervention lacks theoretical or research foundations (Lipsey & Cullen, 2007).

Almost all studies assessed recidivism outcomes; however, despite all interventions noting substance use as a primary concern for reentering offenders, very few (13 out of 31) assessed substance use outcomes. Over half of the studies comparing substance use (7 out of 13 studies) and recidivism (18 out of 31 studies) between reentry intervention participants and controls found positive effects for intervention participants.

Follow-up timepoints varied widely across interventions, and there was evidence that intervention effects may not persist over time. Zortman et al. (2016) found that participants in the Pennsylvania Reentry Program had lower re-incarceration rates (19% vs. 28%) 1 year post-release, but this difference was not significant 3 years post-release (Zortman, Powers, Hiester, Klunk, & Antonio, 2016).

In their study of MAT provided at release from jail, Kinlock and colleagues (2008, 2009) found participants were less likely to report engaging in crime at 3 and 6 months post-release, but there were no differences in re-arrest 12 months post-release (Kinlock, Gordon, Schwartz, Fitzgerald, & O’Grady, 2009; Kinlock, Gordon, Schwartz, & O’Grady, 2008).

In addition, a few studies found a negative effect of the reentry intervention on recidivism or substance use, which was attributed to increased oversight and monitoring that detected misbehavior more readily in intervention participants compared to controls (Hamilton, 2010; Severson et al. , 2011).

Research on reentry best practices for offenders with substance use problems suggests matching services to risk level, with the highest risk offenders getting more intensive services such as individual CBT (Prendergast, 2009). Almost half of the studies reviewed selected inmates based on some categorization of risk level and only some interventions selected offenders based on the presence of problematic substance use.

Because justice-involved individuals reentering the community have so many potential challenges, interventions were often broadly offered to offenders and intended to tackle several areas of need; however, this may lead to a dilution of treatment for those at the highest risk.

In addition, although most reentry interventions reviewed here were multifaceted, very few addressed antisocial attitudes/behaviors; this is concerning given that solely treating mental health or substance use alone, without addressing other criminogenic needs contributing to recidivism risk, is unlikely to reduce recidivism.

The methodological quality of studies varied, and many studies did not specify the treatment modality used, impacting our ability to draw conclusions about the effectiveness of strategies across studies.

In addition, factors that may have a significant impact on the effectiveness of reentry intervention, such as therapist level of training, adherence to the intervention protocol, or therapeutic alliance with clients, were not assessed or reported and thus could not be commented on in relation to intervention effectiveness.

The operationalization of recidivism (e.g., technical violations vs. rearrest vs. reincarceration) and methods used to assess recidivism (official records vs. self-report) varied greatly, which may have contributed to the mixed findings. Further, only some analyses controlled for sociodemographic variables, leading to different levels of confidence in the results.

Finally, substance use was rarely tracked as an outcome in reentry intervention studies and when it was, biochemical confirmation was often not used, which is problematic given that reentering offenders under community supervision may not be forthcoming about relapse and substance use. Only a subset of reentry interventions that address substance use currently utilize EBTs and reentry best practices.

Reentry interventions for substance-using offenders should utilize best practice approaches which involve matching the intervention to the client risk level and needs, utilizing evidence-based approaches to treat substance use including effective therapeutic structure (i.e., individualized), modality (i.e., CBT, MAT, TC, CM, MI), and dose, treat additional areas of need that impact reintegration (e.g., physical health, mental health, antisocial behaviors), and use wrap-around approaches that foster continuity of care between treatments delivered during incarceration and services received post-release.

Further, reentry interventions (and correctional interventions, broadly) should continue striving to be methodologically rigorous, including the use of appropriate study designs (i.e., RCTs or quasi-experimental designs), high-quality assessment techniques (e.g., biochemical confirmation of substance use, official records of arrest), and comprehensive assessment of key impact and process outcomes of interventions.

Further, cost-effectiveness analyses are critically important, as they often indicate the benefit of providing high-quality treatment services and can be used to tackle system-level barriers to implementing EBTs in correctional systems. ## [](https://pmc. ncbi.

nlm. nih. gov/articles/PMC6459737/)Supplementary Material ## [](https://pmc.

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gov/articles/PMC6459737/)Acknowledgments This work was supported by funding from NIDA T32DA019426-12 (KEM) and the Department of Mental Health and Addiction Services, State of Connecticut. The work described in this article does not express the views of the funders. The views and opinions expressed are those of the authors.

Funders of this study had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication. The authors have no conflicts of interest to declare. ## [](https://pmc.

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