Criminal reactions to drug-using offenders: A systematic review of the effect of treatment and/or punishment on reduction of drug use and/or criminal recidivism

Introduction

In the search for effective responses, within the justice systems, for individuals who use substances and are involved in the criminal justice system, it is important to explore the role of treatment and/or punishment in reducing recidivism and/or consumption of psychoactive substances. So, we conducted a systematic literature review following PRISMA’s guidelines.

The association between psychoactive substances (PAS) and crime, although frequent (1–5), is not linear (3, 5, 6), and there are different interpretations of the phenomenon (7). A single model cannot explain the association between PAS and crime (8), because if PAS leads to crime, then treatment would reduce crime, whereas if crime led to PAS use, then treatment would not be effective and the focus should be on reducing crime (9). However, both the substance-using and the offending populations are heterogeneous, and the paths through which PAS use and crime intersect can be diverse (8).

Furthermore, it is likely that PAS use and crime share risk factors (10), since both criminal behavior and PAS use seem to be related to individual, environmental, psychosocial, developmental, and biological factors (3, 10–12). Crime also exists without PAS, since it appears associated with a set of social forces that potentiate and stimulate it (9). Thus, although crime and PAS are associated, using drugs does not, in itself, entail the commission of crimes (3).

Criminal reactions to substance-using offenders

Traditional policies to combat PAS, as criminalization, as well as war on drugs, promoted campaigns to eradicate, apprehend and detain all those involved in these contexts (13, 14). As a result of the application of these policies, there was an increase in PAS-related violence and corruption, as well as in the number of inmates, leading to overcrowding in prisons, while the production, trafficking and use of PAS continued, rather than ended. So, alternatives to incarceration began to be studied in these cases. These may be understood as any interventions that aim to: limit the use of incarceration as punishment; reduce the pressure on countries’ criminal justice systems, especially prisons; and decrease the time of deprivation of liberty for substance-related individuals who are also involved in the criminal justice system (13). Thus, incarceration should be used as a last resort and only for high-risk individuals who commit violent crimes (13, 15).

Alternatives to punishment/coercive sanctions for individuals with substance use disorders, namely treatment, education, aftercare, rehabilitation, and social reintegration, can be useful for problems of different orders (16, 17). At the individual level—to address addictive problems and reduce the stigma associated with them; at the social level—to reduce substance-related problems, especially with regard to acquisitive crimes, as well as to reduce problems associated with public health and other types of damage to society; at the state level—to reduce pressure on the criminal justice system and resources used by courts and prisons (17).

Several alternatives to incarceration have been discussed in the specialized literature, frequently appearing grouped and designated in a distinct way. Some alternatives exist only at the theoretical level and the implementation of others occurs in specific contexts. One of the ways to organize different responses of the formal social control system to substance-related crime is to differentiate them into: (i) administrative responses and (ii) responses of the criminal justice system.

Administrative responses are understood as interventions that take place before opening judicial proceedings, in order to prevent entry into the criminal justice system (15, 18), and encourage involvement in treatment (15, 17). These alternatives are associated with three fundamental approaches: decriminalization, depenalization, and pre-detention diversion mechanisms (18).

Decriminalization means that the behavior or action is no longer a criminal offense (13, 19–23). This does not imply that the behavior is legal, since it can be subject to administrative sanctions (21, 22). Therefore, with regard to PAS, behaviors such as possession, acquisition and consumption are no longer considered a criminal offense, although they may constitute administrative offenses and be sanctioned administratively (13, 20, 23). Concerning decriminalization, in some countries, there is a distinction between offenses related to PAS use and offenses associated with PAS possession. So, in some countries, behaviors such as smoking, injecting, inhaling or swallowing PAS are separate crimes from that of being in possession of PAS. As such, in countries like Cyprus, Finland, Spain, Portugal, Armenia and Chile, for example, substance use is a specific criminal offense. Countries such as Spain, Portugal, and Croatia apply non-criminal, and therefore non-custodial, sanctions for PAS use, with preference for the application of fines, suspended sentences, warnings/suspension of proceedings, and/or community work (24). Countries such as Germany, Belgium, Denmark, Slovakia Italy, Poland, and the Czech Republic do not sanction PAS use (20, 21, 25, 26).

Regarding substance possession, Spain, Italy, Luxembourg and Portugal, Estonia, Australia, Jamaica, Mexico, and Peru are examples of countries in which possession of PAS does not constitute a criminal offense (20, 25, 26). However, the definition of criminal offense for substance possession varies according to the legal context of each country. This variation has to do with the possession of: (i) A certain PAS, e.g., in Luxembourg, possession of cannabis resin is not criminally punishable, while possession of other PAS may lead to incarceration; or (ii) any PAS, e.g., in Spain the possession of any PAS in a public place is considered a violation of public safety;—(ii.a) with specific quantities, e.g., in Portugal, the possession of any PAS, above the quantity determined for average individual consumption for 10 days, is defined as a criminal offense; or (ii.b) without specific quantities, e.g., in Italy, punishment does not vary according to the quantity, although exceeding the limits assigned by the Ministry of Health and Justice may be considered possession for sale. In the United States of America (USA), the State of Maryland decriminalized possession of PAS, while the States of California, Connecticut, and Utah consider possession of PAS as a less serious offense (25). Regarding drug trafficking, in the European Union (EU), the sentences applied are preferably prison sentences, most of which are suspended, e.g., Czech Republic and Portugal, and/or community work (Netherlands and United Kingdom) (24).

Depenalization aims to close judicial cases without application of the prison sentence (17), as happens in Germany. The prohibition and criminalization of behavior remain, but incarceration is no longer a strategy to be used, even if other criminal sanctions, e.g., criminal record, are used (18, 21).

The diversion mechanisms available in a pre-detention phase, before criminal charges, include warnings by law enforcement agents, formal bail bonds and procedures involving assessment, education, and/or treatment (15, 17, 27). The warnings/bail bonds are often used in conjunction with referrals to educational sessions, assessment and/or brief interventions or treatment, rather than being charged with an offense. Some of these strategies are applied in countries such as the United Kingdom, Ireland, Malta, and Portugal, and the law enforcement agents, in conjunction with local services, refer individuals with substance use disorders to treatment (17). Thus, a conduct that could be punished with incarceration is diverted to rehabilitation interventions, such as referral to monitoring or treatment systems, or other non-punitive interventions, such as educational interventions (13, 18).

Alternatives to incarceration through the criminal justice system arise in the course of the development of judicial proceedings, varying from country to country, but include the stages of charge/pre-trial, trial/sentence, and post-sentence (15, 16, 18). In the charge/pre-trial phase, police officers and prosecutors have the possibility to decide whether the individual should appear before a court or be referred to alternatives, such as treatment, in cases where they are identified as having a substance-related disorder (13, 15, 16), or referral to other health, and/or social services. Thus, the substance-using individuals involved in the criminal justice system admit their guilt and avoid going to trial (17, 27), with this stage including alternatives such as: suspension of the charge and conditional release in the form of a bail (15, 28). The suspension is applied in cases of first offenses and those of lesser severity, in which the PAS appear to have had an impact on the motivation for criminal conduct. The charge can be suspended upon compliance with a set of conditions, including the termination of treatment, medical and/or psychological, or participation in special treatment programs. Conditional bail can be granted on the condition of participation in treatment. Treatments can be more intensive, such as long-term residential treatment, or less intensive, with release under acknowledgment of the obligations presented (15, 27).

In the trial phase, there may be a deviation from punitive interventions, through legal proceedings such as suspension under judicial supervision (13, 15) and, after conviction, through deviation by substitution mechanisms or reduced sentences, e.g., Probation—alternative measure to incarceration where the judge may choose to suspend the sentence or postpone his/her decision if the offender commits to fulfilling certain conditions (13, 18, 28). Probation involves greater supervision than in suspended sentences and can offer an opportunity to provide psychological, social, and material assistance, as well as to avoid violations of conditions that automatically lead to incarceration, although these approaches depend on the procedures adopted by supervision agencies. In the trial stage, referral to treatment can be used as an alternative, or as a compliment, to punishment (15, 27), depending on whether the sentence is granted or suspended (15, 16). These alternatives are used in less severe cases, when individuals involved in the criminal justice system fail the pre-trial alternatives, when it is unlikely that the offender will commit the offense again, and when treatment is likely to be completed. When the sentence is postponed, the facts are considered proven and sentencing takes place; however, the sentence is not pronounced and is postponed for a certain period of time, during which the offender may be diverted for treatment while under judicial supervision (15, 27). In the event of a sentence suspension, the judge pronounces the sentence, but suspends it for a certain period of time, under certain conditions with which individuals involved in the criminal justice system must comply. There is a declaration of guilt and the measure is added to the criminal record certificate, but there is no deprivation of liberty (15). As such, the punishment is declared, but may be suspended if the offender embarks on a rehabilitative trajectory; this option is available in different countries, such as the Czech Republic, Spain, France, Germany, Lithuania, Luxembourg, the Netherlands, Slovakia, and countries that have Drug Courts (17).

Drug Treatment Courts (DTC) allow the diversion of PAS addicts, from prison to treatment and rehabilitation, by decision of a judge (18, 27). The use of these courts can occur in the post-adjudication/sentence phases, where the offender pleads guilty and the sentence is granted or suspended, so as to allow for a diversion to treatment. After finalizing the court procedures, the sentence is waived or reduced. A diversion to treatment may also take place using DTC even before conviction—admission of guilt is not necessary and the offender is only convicted if he/she fails the completion of the program (13, 15). Contrary to other alternatives in the trial/sentence phase, in the Drug Courts it is the judge who defines the frequency, type, intensity, monitoring, and supervision of the programs; the programs focus not only on disorders related to drug (ab)use, but also on substance-related problems that affect the various domains of the individual’s life; the most intensive treatments are used in the beginning, followed by less intensive treatments in the later stages; and regular follow-up hearings are organized in order to monitor and support prosocial behavior (15). Despite this, DTC have been subject to some critique concerning: the capacity constraints, as the overload of cases (29, 30); the selection bias; the crossover between drug problems and mental health problems; the fact that the need of plea guilt and the criteria for defining the drug disorder and treatment is different among the courts; consequences of program failure; and overriding sentencing laws (30, 31).

In the post-sentence phase, the offender chooses to reduce the sentence of his/her incarceration and be released earlier, under conditional liberty, e.g., parole—early release from incarceration under individual conditions, while undergoing treatment, e.g., the individual must comply with certain conditions, such as treatment for substance addiction and/or social interventions such as education, community work, work/employment programs (13, 15, 27). This means that individuals involved in the criminal justice system may be released after a certain period and/or when a specific part of the sentence has been served, with the offender leaving under individualized post-release conditions and, in the case of substance use, these conditions refer to treatment (15). This type of measure may also include detention; however, it emphasizes the rehabilitation process instead of punishment (27). Examples of this type of measure are supervised treatment programs that aim to address substance-related problems and reintegrate individuals involved in the criminal justice system into the community, for example, community-based treatments (24h supervision) (27).

When an offense occurs, there are mechanisms that can be activated by different justice bodies, in an attempt to divert individuals involved in the criminal justice system from punitive interventions. Specifically, at the police level, authorities can refer detainees to partner entities that work with PAS services, as occurs in Ireland, Malta, and the United Kingdom, or refer them to specific Commissions, as is the case in Portugal. During the prosecution, proceedings may be suspended through PAS awareness courses, e.g., France, motivational interviews, e.g., Norway, and extra-judicial units, e.g., Malta. In court, there may also be suspension of proceedings, suspension of the punitive sentence, or sentencing to rehabilitation interventions and referral to DTC, e.g., Belgium, Ireland, United Kingdom, and Norway (17).

Over time, there has been a concern to gather information and identify intervention principles for this specific population. This concern is also expressed by the Council of the EU, by recognizing the need for Member States to provide and apply, within their legal parameters, alternative interventions to coercive sanctions in the case of substance-using individuals who are also involved in the criminal justice system. These interventions should aim toward preventing crime, reducing recidivism, and increasing the effectiveness and efficiency of the justice system (27, 32–34), taking into consideration the harm reduction in terms of public health and the minimization of social risks (33). It is also important to recognize that substance addiction is a chronic illness (14, 32, 35) that affects behavior. As such, the recovery of addictive behaviors requires effective treatment, followed by continued care (35, 36); thus, services must be adapted to the needs of this specific population. To this end, supervision by the criminal justice system must incorporate the planning of treatment (35).

The EU invites Member States to, whenever possible, offer alternative interventions to punishment or conviction, such as treatment, education, aftercare, rehabilitation, and social reintegration interventions for substance-using individuals who are also involved in the criminal justice system, as well as to identify and develop cost-effective and evidence-based approaches (32, 33). Although incarceration seems to convey the idea of public safety, in reality, it has proved ineffective in reducing recidivism. Specifically, substance-using individuals involved in the criminal justice system are more likely to return to prison, and show no reduction in substance use after incarceration (32, 36). In individuals involved in the criminal justice system with significant PAS-related problems, and whose risk of recidivism is high, treatment programs may be more effective in reducing recidivism than criminal sanctions (27). Thus, these individuals would benefit from alternative interventions that framed these behaviors within a health approach. Such interventions may include, in particular, voluntary treatment for substance-dependent individuals involved in the criminal justice system, community service and referral to health and/or social support services (23). In fact, non-punitive interventions seem to indicate better results than punitive interventions, showing more success in reducing recidivism (18). Specifically, studies suggest that treatment and counseling programs are more effective than incarceration when it comes to reducing addictive behaviors (14).

To conclude, there are currently many cases of substance-using individuals who are also involved in the criminal justice system worldwide which requires the adoption of effective responses to reduce their substance use and criminal recidivism. Therefore, alternatives to incarceration, namely the treatment of PAS use, seem to be effective strategies in reducing not only this practice, but also criminal recidivism, presenting better cost-benefit relationship than incarceration (13, 32, 36). As a matter of fact, these alternative interventions also increase the social inclusion of individuals with substance use disorders (33).

Although there are many approaches related to individuals who use substances and are involved in the criminal justice system, as mentioned above, knowledge about the effectiveness of punitive responses and of alternative responses to punishment, at this level, is still needs more compilation and integration. In addition, through a literature review, no systematic review has yet proposed to understand the criminal reactions to this type of population, as well as the role of treatment and/or punishment as responses of the justice system, in reducing substance use and/or criminal recidivism in substance-using individuals involved in the criminal justice system. Thus, in an attempt to contribute to filling these gaps in theory and seeking to clarify key points in this area, we conducted a systematic review to explore the role of treatment and/or punishment in reducing criminal recidivism and/or the use of PAS in individuals involved in the criminal justice system who use substances. Specifically, we intend to answer the following research question: What is the effect of treatment and/or punishment, as responses of the justice system, in reducing substance use and/or criminal recidivism, in substance-using individuals who are involved in the criminal justice system?

Materials and methods

This systematic review was conducted in accordance with the PRISMA guidelines (37). The PICO question is included in the title of this manuscript. The main research in databases was conducted on 19 April 2021 but since a systematic review is easily outdated, we conducted a new research on 27 April 2022.

Initially, we defined the research question. Then, we elaborated the best search expression, using synonyms for the variables included in the study and eliminating the terms that had no effect. The search term was introduced in the largest database available in Portugal (i.e., EBSCO, by Faculty of Psychology and Educational Sciences, University of Porto). All abstracts were analyzed by two independent reviewers and disagreements were analyzed by an independent third reviewer. The disagreement (Kappa) was calculated at the stage where there is usually the most discrepancy: the abstract analysis one.

Study search and selection strategy

The studies were identified using multiple databases from EBSCOhost, namely Academic Search Complete, Academic Search Ultimate, Business Source Complete, Criminal Justice Abstracts, PsycArticles, PsycInfo, and Sociology Source Ultimate. In addition, studies identified through manual search were included, in order to avoid bias and conditioning of the search and information. The search terms were: AB (Abstract) (Incarceration-based drug treatment OR drug treatment OR diversion program OR treatment sentences OR incarceration OR imprisonment OR drug treatment OR drug intervention OR rehabilitation) AND AB (sentence* OR criminal justice programs), AND AB (drug offenders OR addicted offenders OR drug user offenders OR drug misuser offenders OR dependent offenders). The manual search was conducted through a snowball approach, based on the reference lists of the included papers, and through web search using the keywords included in the search terms. The search was not restricted by any linguistic, cultural, or geographical elements.

Inclusion and exclusion criteria

As suggested by the PRISMA guidelines, studies were selected by two independent reviewers, so as to reduce missed studies or misclassifications (37). In order to choose the studies that would integrate the systematic review, the following inclusion criteria were used: (i) adult individuals involved in the criminal justice system (18–65 years); (ii) individuals who use substances, (iii) treatment programs of any kind, namely, intervention, social reintegration, prevention and/or reduction of recidivism/prevention and/or reduction of drug use, as well as studies on the efficiency of responses/sentences/judicial interventions, and/or (iv) punitive interventions.

The studies were analyzed taking into account the following exclusion criteria: (i) case and/or theoretical studies, (ii) children and adolescents up to 18 years, (iii) exclusive use of pharmaceutical drugs, medically prescribed, and (iv) presence of psychopathology that is not related to substance use/abuse, and/or intellectual disability.

Only articles with empirical and quantitative methodologies, from scientific and academic publications, were included in the study. The disagreement between reviewers was discussed, using an individual excel form and then meet to check out for disagreements, until a consensus was reached. The agreement index was assessed and revealed an almost perfect agreement; K = 0.87 p < 0.001 (38).

Identification and screening

A total of 155 studies, published between 1971 and 2022, were identified, through the databases and search methods, and a total of 110 studies were selected for analysis (n = 45 duplicates). Of these 110 studies, 57 are from Academic Search Complete, 28 from PsycInfo, 10 from Academic Search Ultimate, seven from Sociology Source Ultimate, four from Business Source Complete, two from Criminal Justice Abstracts, and two from PsycArticles. In the first phase, 60 articles were excluded, since they related to: (a) case studies (n = 2), (b) psychopathology not related to substance use/abuse (n = 3), (c) characteristics of the population (n = 14), (d) other theoretical studies/meta-analysis (n = 13), and (e) variables not related to the topic, particularly associated with: (f) treatment (n = 6); and (g) criminal reactions (n = 22). Of the 50 articles with full reading, three articles were added from manual search. At this stage, 30 articles were eliminated, as they did not answer the research question—specifically due to reasons associated with: (a) treatment (n = 3), (b) psychopathology unrelated to substance use/abuse (n = 3), (c) characteristics of the population (n = 4), (d) criminal reactions (n = 7), and (e) theoretical studies (n = 13)—and, therefore, do not meet the criteria initially established. Thus, a total of 23 articles were included in this review (cf. Flow diagram of the bibliographic search shown in Figure 1).

Results

A summary of the characteristics of the studies is presented in Table 1.

Drug-using offenders

There are characteristics that prove to be more common among substance-using individuals involved in the criminal justice system. Specifically, most are male (44, 49, 52, 56, 58, 60), unemployed (46, 48, 52), and have already undergone some type of treatment (48, 47). Mostly, these individuals involved in the criminal justice system are single (40) and ages between 29 and 31 years (40, 52, 58).

Regarding substance use, these individuals involved in the criminal justice system initiate this practice during adolescence (48), specifically before the age of 20 (40), and justify it with personal issues and the relationship they maintained with other individuals who use substances (48). The most popular PAS are heroin (40, 47, 48, 52), cocaine hydrochloride (40, 47, 56, 58), alcohol (40, 47, 58), crack (40, 47, 48), cannabis, and amphetamines (52).

Recidivism appears to be affected by variables such as gender, age (43, 46, 54, 58), criminal background (43, 46, 50, 54, 58), marital status (46), and type of offense (61). Specifically, men seem to be more likely to recidivate (49, 54, 60), and to engage in more severe forms of recidivism (46). Younger people recidivate more (54) and, therefore, as age increases, the probability of recidivism seems to decrease, regardless of gender (60). Married people are less likely to recidivate than unmarried people (46), and individuals involved in the criminal justice system with previous convictions have higher rates of recidivism (54, 58).

Regarding criminal background, most substance-using individuals also reveal histories of problems with justice since adolescence (48), thus the age of the first arrest appears to be related to the age they first started using substances (40).

Recidivism

Incarceration and probation

The results on incarceration indicate that this variable seems to have little impact on the reduction of criminal recidivism (46, 51, 53), since it does not effectively prevent the development of criminal behavior. There is no evidence that individuals sentenced to incarceration delay their re-entry into crime; and incarcerated individuals have a recidivism rate of 1.35 vs. 0.72 of those in probation (53). The probability of a new arrest increases with the time the offender spends in prison (55).

Data on the deterrent effect of incarceration does not seem to reach consensus. In some studies, incarceration seems to have a deterrent effect on individuals involved in the criminal justice system with better social integration (46, 51), and it is possible to verify that incarceration seems to have a greater deterrent power than probation (M = 1.217 probation vs. M = 0.896 incarceration) (49). For this reason, these individuals seem to respond to the incentives and constraints of the justice system, namely the number of police officers that exist in the surrounding areas (49). Miller et al. (50) study points that for drug-related recidivism, criminal history was the only significant predictor compared to no prior offenses (one prior offense: OR = 2.04, p< 0.05; 2–5 prior offense: OR = 3.01, p < 0.001; more than 5 pior offenses: OR = 5.33, p < 0.001). In Finland, incarcerated individuals do not manifest significantly higher rates of recidivism than individuals with conditional incarceration or fines. But prisions in Finland are much different than in the United States, so custodial sanctions may be as effective of a deterrent as to community sanctions when conditions of incarceration are alike to Finland (50).

Other studies argue that there is no evidence of the effect of punitive interventions as a deterrent to criminal recidivism (53–55), while there is some evidence that experiencing incarceration can be criminogenic in itself in individuals who committed substance-related crimes (54, 55). So, even if incarceration does not harm the offender’s behavior, its impact on employment, housing, family structure, and reintegration puts at risk and increases the likelihood of recidivism in PAS use and crime, due to the absence of sources of informal control and social ties (46, 53, 54).

Incarceration seems to increase the probability of recidivism, both in crimes related and unrelated to PAS (44, 51, 54). It was found that individuals sentenced to prison increase the proportion of recidivism (overall recidivism increased by 0.11 and PAS-related crimes by 0.8), with this data being statistically significant for caucasian individuals involved in the criminal justice system (51). Compared to those accused of PAS-related crimes, individuals accused of crimes related to theft seem to be 61% more likely to recidivate, and 37% more likely than individuals accused of other crimes, in 12 months (61). Individuals involved in the criminal justice system appear to be more likely to recidivate when incarcerated (53, 54). Namely, after 4 years, these individuals who commited PAS-related crimes are five to six times more likely to recidivate, and this data is statistically significant (54). Thus, individuals sentenced to incarceration are more likely to be, once again, arrested and charged with a new crime (53, 54).

Individuals sentenced to incarceration have higher rates of recidivism, and recidivate more quickly than individuals on probation (53, 54); 65% of individuals sentenced to prison for PAS-related crimes were charged with a new crime during the 4-year follow-up period vs. 36% on probation (53). Individuals sentenced to probation take longer to recidivate (53, 54), with the average number of months elapsed until a new prison offense being 18.12 vs. 33.5 on probation (53). Supervision under probation appears to reduce involvement in criminal behavior; in particular, crimes associated with methods to fund PAS use, such as shoplifting, decreased from 54%, before supervision, to 17% (48).

Treatment programs

Participation in a Drug Treatment Alternative to Prison (DTAP) program decreases recidivism rates, compared to individuals sentenced to prison (42, 43, 55). After 1 year, the likelihood of a new arrest is 23% in DTAP vs. 45% sentenced to prison, with this data being statistically significant (42). Program participation through DTCs appears to be equally effective in reducing recidivism (43). DTC participants who recidivate exhibit less severe offenses, in addition to the average time in jail being lower for DTC participants than for non-DTC participants (44 days vs. 126 days, p < 0.0001) (43). The results point to a decrease in new convictions for all types of crime among DTAP participants, with only 8% of the DTAP sample presenting a new conviction for PAS-related crimes vs. 18% of those sentenced to prison, especially for participants who finished treatment. DTAPs seem to improve public safety by involving high-risk individuals involved in the criminal justice system in treatment, including those selling PAS, who are often excluded from programs (42). Drug Courts had fewer arrest charges (p < 0.01) and conviction charges (p < 0.05) each year than participants allocated to tradicional adjudication in a 15-years analysis (62).

Compared with individuals on probation, the number of individuals on parole who finish the treatment is lower, completion of the treatment program on probation 38 vs. 24% on parole, and these are the individuals who recidivate more quickly (45). After 12 months, the arrest rate is higher for individuals on parole (38 vs. 24% on probation) (45). Regarding offenders on parole, the probability of recidivism was 1.6 times higher among those who did not receive treatment (58). New serious charges in the 12 months after the program are compared between the DTC and probation cases. DTC have less new serious charges than probationers (92.1% DTC avoid a new serious charge vs. 79.6% probationers, p < 0.01) (56).

The completion of programs appears to function as a protective factor in terms of criminal recidivism (56, 61). Participants who fail to complete the programs exhibit a higher risk of recidivism than those who complete it (43, 44, 52, 55, 60, 58, 61). After 3 years, 23% of DTAP participants who successfully completed the program are once again arrested vs. 52% of participants who did not complete the program (44). Participants of the MERIT, who did not complete the program, have a 50% higher risk of criminal recidivism (61). After 12 months, participants who completed the MERIT exhibit fewer charges for PAS-related crimes, theft and robbery (31% MERIT vs. 54% non-MERIT participants) (52). DTC participants who successfully complete the program are less likely to recidivate (30% DTC vs. 46% N/DTC, p = 0.01) (43), and avoid serious reoffense compared to participants who were unsuccessful (56). Graduates were 26.3 percentage points more successful to avoid new conviction than unsuccessful cases [χ² (1, N = 199) = 14.39, p < 0.001] (56).

The risk of new arrest is 61% lower in participants who completed the RIP/Danda program, even if these programs are not statistically significant in reducing recidivism (60). In addition, completion of the programs also appears to have an impact on the severity of criminal recidivism; in particular, the 4% of participants who criminally reoffended were detained for non-violent crimes (44). Of the participants who committed more severe offenses, 69% completed the DTAP successfully vs. 74% non-participants vs. 76% who did not complete the program (44).

Individuals involved in the criminal justice system who complete the programs take longer to criminally recidivate than those who do not complete them (41, 43, 52, 55, 60). Of the individuals who completed treatment, 11.8% were convicted of a new crime vs. 29% of those who did not complete treatment. Thus, 6 months of treatment appears to be sufficient to reduce involvement in new criminal offenses (58). Participants who remain in treatment longer are less likely to reoffend than those who have been in treatment less time (43, 55). The longest time without recurrence is seen in the DTC treatment group. For those who re-committed criminal practice, the average number of days without a re-offense was 614 for program participants vs. 463 for those who did not participate in the program (43).

Over 2 years, among DTC participants, those who were referred for supervision exhibited higher recidivism rates than those who were referred for treatment (62.4% under supervision recidivated vs. 40.8% under treatment recidivated), and treatment appears to be the most consistent and most significant indicator of the longest time without criminal recidivism (41). The implementation of programs within systems, whether they are jail or prison, seems to demonstrate that, in both, the rates of treatment completion are high (65%) (40).

Thus, treatment appears to be an effective alternative in reducing criminal recidivism (40–44, 52, 55, 60, 57, 47–62).

Treatment programs: Practical implications

In comparison with other responses from the justice system, there is a greater number of individuals on parole who are arrested again after treatment. The reason pertains to this specific population being subjected to closer observation by law enforcement officers, which increases the likelihood of detecting individuals who are not complying with the law, compared to individuals without strict monitoring (39). As such, it is necessary to take this into account when comparing the high number of new incarcerations (39, 45, 48). Individuals involved in the criminal justice system integrated in programs, as an alternative to prison, receive more severe convictions, although the programs significantly reduce the likelihood of new charges, arrests and convictions and, thus, prove to be an effective alternative to incarceration (47). This can be understood by taking into consideration studies on probation, which report that substance-using individuals who do not comply with treatment plans, or have more severe substance-related problems, have their measure more easily revoked (48).

Reduction of substance use

Incarceration seems to decrease PAS use, while the offender is incarcerated and even after release (49). However, the longer the time elapsed since incarceration, the greater the likelihood of using substances again (49).

Regarding TASC, it allowed the reduction of PAS use in three of the five States where it was implemented (39). The treatment of PAS use among individuals involved in the criminal justice system has shown that individuals who used cannabis have higher rates of program completion (24.3%), followed by individuals involved in cocaine use (16.2%), when they undergo residential treatment programs (40).

Individuals on probation, at a higher rate, tend to undergo outpatient treatment, 86.8 vs. 81.2%, and individuals on parole, at a higher rate, undergo residential treatment, 18 vs. 13.2%, and it is from this type of treatment that parolees tend to benefit most (45). However, individuals on probation have higher rates of program completion than individuals on parole, and treatment success, 37 vs. 24.2% on parole (45). It should also be noted that supervision under probation seems to decrease the PAS use (48). Treatment seems to be effective in reducing PAS use, namely by enabling individuals to acquire strategies that allow them to deal with it (57). However, there is a need to adopt a pragmatic approach with this type of population, while admitting that relapse is inherent to the substance (ab) use treatment process, and that professionals who work with these individuals must have knowledge about this phenomenon (48).

Discussion

Using strict criteria and following the guidelines of PRISMA, we attempted to answer the following research question: what is the role of treatment and/or punishment, as responses of the justice system, in reducing substance use and/or criminal recidivism in individuals who use substances and commit crimes?

The results of this systematic review indicate that incarceration appears to have little impact on criminal recidivism (46, 51, 53). This finding is in accordance with what is reported in the specialized literature, and it is emphasized that punishment, per se, seems to be an ineffective response to the problem of PAS abuse in substance-using individuals who are also involved in the criminal justice system (36, 63, 64). The literature also points to the potential criminogenic effect¹ that the incarceration of low-risk individuals seems to exhibit (14, 27, 36, 65, 66), in terms of employability, parenting, and the ability of these individuals to become active members of society (36), which increases the likelihood of recidivism (14, 65). Similar evidence was found in the present systematic review, which verified that the experience of incarceration can be criminogenic (54, 55). In particular, criminal recidivism can be greater with the time of incarceration (55), in addition to increasing deficits in the different areas of functioning of these substance-using individuals involved in the criminal justice system (46, 53, 54).

Individuals on probation have lower recidivism rates than individuals who are incarcerated (53, 54), which corroborates the idea that probation has a lower cost than incarceration (15) and that prison sanctions does not seem to reduce recidivism more effectively than suspended sentences (65). Specifically, the cost of supervising an individual in the community is less than the cost of keeping the individual in prison (15). In addition, supervision under probation appears to decrease involvement in criminal behavior (48, 67). Studies suggest that probation involves greater monitoring than a suspended sentence, and that existing revocations must be understood and explained, as most probationers have seen this measure overturned for moderate violations, e.g., failure to maintain employment, non-completion of the program, leaving their area of residence without permission, in addition to the fact that probation agents seem to regard failure in the program as undeserving of flexibility interventions, leading to greater revocation of cases and consequent incarceration (15, 68). Therefore, the approaches used by the supervision agencies must be taken into consideration, since the opportunity for psychological and social support this measure provides is undeniable.

Individuals placed on probation also have better program completion rates than individuals on parole (45). Nonetheless, it is important to note that probation is an alternative available in the trial phase, while parole is available in the post-sentencing phase, necessarily involving compliance with a certain period of time in incarceration (15). Furthermore, as mentioned above, a longer incarceration time is associated with greater criminal recidivism (55). Nevertheless, the results of this work also suggest that criminal recidivism among individuals placed on parole is greater in those who did not receive treatment (58).

As for treatment, the present study found that this is the most consistent and significant indicator of the longest time without recidivism (41, 58), thus making it an effective alternative in reducing criminal recidivism (40, 42–44, 55, 60, 57, 47, 61, 52). Therefore, treatment should be an alternative to incarceration, offered to substance-using individuals involved in the criminal justice system, since it is effective in reducing criminal recidivism and/or substance use (15, 17, 69). Literature on the effectiveness of criminal reactions considers that there are alternatives that appear to be more effective than others, namely: methadone and heroin treatments, therapeutic communities, psychosocial approaches, Drug Courts, supervision under probation, and parole. Thus, the benefits may be greater if certain types of interventions are prioritized over others (34).

Participation in treatment programs reduces recidivism rates compared to incarceration (42, 43, 55). As such, treatment can be a more effective alternative in promoting public safety than incarceration (42). It should also be noted that completion of programs seems to be an important indicator in terms of criminal recidivism (61, 70, 5) and its severity (44), since the failure to conclude the program increases the risk of criminal recidivism (43, 44, 52, 55, 60, 58, 61). The literature also suggests that the length of stay in treatment is also related to the likelihood of criminal recidivism (70, 5). This is corroborated by this systematic review, which found that individuals involved in the criminal justice system who spend less time in treatment are more likely to recidivate (43, 55, 70).

The present systematic review also pointed out that treatment is effective in reducing PAS use, allowing individuals to acquire strategies to deal with their substance use (57). This finding had already been highlighted in previous studies, which found that substance-using individuals involved in the criminal justice system are more likely to be re-incarcerated (36), and do not exhibit a reduction in substance (ab) use after incarceration. Among possible explanations for these findings are the causes leading to the first incarceration not having been addressed, as well as the possible existence, when individuals are released, of a set of factors that increase the risk of substance use relapse, such as social stigma and the difficulty to access legitimate employment as a means of survival (32, 36).

Research in the area of PAS use and crime is varied and largely uncoordinated (2), and the data available in the EU are often complex, fragmented, and difficult to compare (71). Despite the various guidelines and recommendations for knowledge sharing among the scientific community, most EU countries do not have data to assess the alternative interventions available, which makes it difficult to evaluate effectiveness (17). In addition, some results are based on a low number of study participants, which does not allow them to draw significant implications and conclusions (2). This situation can be explained by the absence of shared rules on data recording and collection, but also by the overlapping of structures responsible for developing the reports (71), which relates to the lack of monitoring and evaluation of the interventions applied (17). For many diversion programs, there are no methods of evaluating, collecting, and publishing data that allow the assessment of their effectiveness in terms of cost reduction and recidivism (18).

The diversity of studies, collection methods, databases, and methods of analysis are evident in this systematic review, which makes it difficult to analyze certain variables. Specifically, the analysis of substance use is difficult, so these findings should be interpreted with some reservation. Particularly, in some contexts, using a PAS represents a criminal offense, thus, results related to PAS use may appear grouped in the data about criminal recidivism. In many studies, it is not possible to disconnect one variable from the other and, therefore, to distinguish whether there is data on the reduction of PAS use, among the reduction of criminal recidivism. Furthermore, the different contexts in which these issues are applied and studied enhance the inconsistencies in the vocabulary related to some terms, namely due to the diversity of studies and laws. Thus, terms related to substance abuse, such as e.g., drug user, abuser, problem user, and addict, make the harmonization of concepts a challenge (17), and this also occurs with terms related to the type of offense, e.g., drug offenses, drug-involved offenses, drug crimes, drug-related crimes. Another constraint in the specialized literature is due to the fact that most studies are conducted in the USA (34), which is also evident in the present review, as there are more studies (n = 16) related to the American context and some (n = 29) were excluded for being theoretical studies. As such, it is important to be alert to the possibility of bias in the research (5).

The growing awareness and adoption of alternative proposals to incarceration, for substance-using individuals involved in the criminal justice system, comes from the increasing recognition of PAS abuse as an illness that requires treatment (13, 35–36, 70). Thus, PAS use should be seen as a health-related issue, and a perspective of risk reduction and evidence-based treatment should be adopted, both for the substance-using population and for individuals who have committed substance-related crimes (13). Many of the substance use/abuse disorders can be effectively treated through a variety of psychopharmacological and psychosocial interventions, in different treatment settings. Therefore, opportunities for screening and assessing disorders, namely those related to substances, must be present in all points of contact with the justice system (15, 70). It should be noted that, according to the literature, the treatment option exists at all stages of the criminal justice system (prosecution/pre-trial, trial, and post-sentence).

The results of this systematic review point to the existence of characteristics that prove to be more common among substance-using individuals involved in the criminal justice system, and that the results of the programs may be influenced by the characteristics of the individuals. Thus, it would be useful to obtain more in-depth information about the characteristics of the program participants, namely life history and motivation for change. However, studies only present basic sociodemographic data, and more detailed information about these individuals involved in the criminal justice system is lacking (34). It is, therefore, essential that a comprehensive medical and psychosocial assessment (15, 17), conducted by specialists (18), be carried out, so as to identify the services from which the offender would benefit most. This way, it would be possible to avoid incoordination and duplication of procedures within the justice system (5), by assessing the needs of the individuals and developing an appropriate treatment plan for each one (15, 17, 70), which, later, allows one to analyze which programs seem to work more with certain characteristics of the individuals. The justice system can, thus, play an important role in identifying and evaluating these individuals (15).

In addition, the services provided must be sensitive to gender issues (13, 23, 5). The present study allowed us to verify that men are more likely to recidivate (49, 54, 60), with their recidivism being more severe (46) than in women. Thus, as the literature reports, in comparison with men, women have different: patterns of use/abuse (5, 72); crime (5, 73); and social, psychological, and economic circumstances (5). For these reasons, there must be differences in the adoption of alternative interventions (28), and in the programs applied. We also suggest the use of a comprehensive and integrated approach, in order to maximize the success of the treatment and to reduce the damage within the community, without jeopardizing public safety, nor the accountability of the individuals involved in the criminal justice system (70, 5).

It is important to note that not all individuals who use substances need treatment; in case they do need treatment, evidence-based treatment should be offered as an alternative to incarceration, and when there is no addiction, they should be referred to harm reduction services (13, 70). However, self-referral remains the most common route for specialized treatment for the use/abuse of PAS. In Europe, the treatment of PAS addiction is predominantly performed on an outpatient basis, with specialized treatment centers being the largest providers of care for individuals who use PAS. As an example, in 2017: (i) 973,000 individuals who used PAS received outpatient treatment, namely in specialized treatment centers; (ii) 64,000 individuals who used PAS underwent an inpatient regime, namely residential hospitalization; (iii) and 81,000 individuals received treatment in prison (74).

In short, alternative interventions to punitive policies, namely treatment, seem to provide useful tools in solving problems of different orders for these individuals, including at the personal and social levels. However, for the treatment to be adequate and meet the expected goals, it is necessary that the strategy and intervention plan be specific to that user. Thus, it is pertinent to take into account the characteristics of each individual and, specifically, the link between the needs of the individuals involved in the criminal justice system, their problems, and resources (15, 17, 70, 5), and the intervention programs available (17). Given the specificity of this population, there does not seem to be a single model for intervention, since no treatment is exceptional and universally applicable. Thus, the type of treatment, its modalities, as well as restrictions and levels of supervision, must be assessed on a case-by-case basis (70, 5). As such, treatments must be available and accessible, as well as attractive and appropriate for the needs of those who attend them. In addition, ethical standards in the treatments provided must be ensured and evidence-based (15). Therefore, it is important to invest in the development and evaluation of all types of treatment, especially those that demonstrate effectiveness (74).

Alternative interventions to incarceration vary from context to context and over time, so it is difficult to identify them in practice (17). It is important to take into account the context where the alternatives are implemented, since an alternative can work well in one context and fail in others. Thus, the capacity of the institutions and the way they function, as well as cultural differences, public opinion about alternatives to incarceration, and restrictions in terms of legislation and budgets must be taken into account (18). Likewise, there are alternatives that may work for some individuals involved in the criminal justice system and not for others (1). The key to the success of alternative interventions to punishment/incarceration seems to be the availability of a variety of interventions that can be adapted to the needs of substance-using individuals involved in the criminal justice system, with different types and levels of substance-related problems (26).

The justice and treatment systems are effective when they work together for the successful treatment of substance-using individuals involved in the criminal justice system (13, 44, 48). Therefore, cooperation efforts between the various justice departments and the joint elaboration of programs are needed (13, 39, 58, 48), in order to guarantee that low-risk individuals involved in the criminal justice system do not overburden or cripple the criminal justice systems. Cooperation between services allows the provision of health care, risk reduction and treatment, and/or ensures social and/or economic conditions for this specific population, in order to provide support for the prevention of recidivism and the promotion of social reintegration (13). Treatment should be promoted through coordination between the criminal justice system and social services (15).

Across Europe, crimes related to substances need intervention, and this type of crime is responsible for the incarceration of 10–25% of inmates with a final and unappealable sentence. The psychological and social impact of incarceration is undeniable, although it also becomes an opportunity for the development of programs aimed at removing problematic substance use. The transversality of the problem, in national and European terms, demonstrates the need to promote substance treatment in prisons, both due to the association of this problem with public health issues or because of the trajectories of poverty and social exclusion to which these substance-using individuals involved in the criminal justice system tend to be subjected (24). It is crucial to ensure the continuity of the treatments provided, entry and release of incarcerated individuals, so that the treatment benefits initiated during incarceration be maintained when individuals are released. Thus, contacts should be made with health and social services for the reintegration of the offender into society, valuing work within a network (23).

In short, treatment is effective in reducing criminal recidivism and/or substance use, with the risk of arrest being lower in individuals involved in the criminal justice system who complete the programs, even if these do not show statistically significant results in terms of criminal recidivism (60). Therefore, priority should be given to adopting alternative interventions to incarceration, namely interventions that include treatment, with the need for continuous scientific evaluation, monitoring, and publication that allow data collection. It is also essential to adapt treatment to each case.

Conclusion

The present systematic review allowed us to conclude that punishment shows little impact in reducing criminal recidivism and/or PAS use. Treatment, in turn, presents itself as an effective response in reducing substance use and/or criminal recidivism.

Despite the recommendations of several organizations, in order to find alternatives to incarceration/punishment for substance-using individuals, there are still many barriers to treatment. We refer to barriers related not only to the lack of recognition of the relevance of treatment, but also to the scarcity of economic resources, infrastructure, and means necessary to serve this specific population, as well as technical personnel with knowledge about substance-related issues (36).

In conducting this systematic review some difficulties were faced, which are mainly related to: (i) the fact that studies on alternative interventions to punishment are conducted mainly in the USA, which implies approaches to the problem that are different from those adopted in the EU; (ii) the existence of different terms and concepts, as well as laws and specificities related to the subject under study; and (iii) the lack of rigorous evaluation, monitoring, and publication of alternative interventions to punishment, namely in the EU.

In addition, this review has some limitations, which are related, in particular, to a possible bias in the information collected: (i) potentially biased factors listed in the articles analyzed: number of sample (41, 57); variables (41, 47, 54); group comparison (43, 48, 53); samples (48); logistical and methodological concerns (44, 46, 48, 58, 43); characteristics of the participants (45, 48, 61, 58); contextual and demographic factors (45, 48, 57), type of consumed substances (61); judge’s decision regarding the type of sentence (53); omitted data (45); (ii) the systematic review itself can contribute to bias related to selection, selective outcome reporting, clinical or statistical inconsistency, and imprecision that may lead to systematic and random errors (75, 76). The non-performance of the quality table is also a limitation of the present study, this quality assessment would explain the evaluation of the methodological quality of studies and is recommended to integrate systematic reviews. However, this evaluation was not elaborated and so it may influence the robustness of the paper.

Despite the obstacles and limitations presented, the present systematic review allowed us to analyze what has already been published in the literature on the subject under study, and the compilation of this information made it possible, in turn, to draw some conclusions, of which the following stand out: (i) incarceration is not an effective alternative for substance-using individuals involved in the criminal justice system, and may even have a criminogenic effect on them; (ii) treatment seems to be the most effective alternative for reducing substance use and criminal recidivism; and (iii) treatment success is associated with participation, length of stay, and conclusion of programs. PAS use continues to be a socially stigmatized behavior that, at times, is not regarded by the justice system under a medical approach, which does not allow the guarantee of treatment, as happens for other medical conditions (36). The growing awareness that substance abuse/addiction must be understood as a health issue can foster greater openness and referral for treatment. In this referral process, the evaluation of these individuals involved in the criminal justice system is of special importance, recognizing that there is no single model/program that is effective for all substance-using individuals involved in the criminal justice system, given the heterogeneity of these populations. It is, therefore, essential to take into account the individual characteristics, type and levels of problems related to PAS abuse/addiction, for the success of the treatment.

Nevertheless, there is still a long way to go with regard to alternative interventions to incarceration. Despite studies, over time, pointing to the ineffectiveness of incarceration, responsible crimes directly and indirectly related to PAS are for 15–20% of incarceration in Portugal (77). In reality, there remains a need to monitor and evaluate the effectiveness of alternative approaches to punishment, as well as better documentation and recording of practices associated with them, so as not to miss opportunities for change and future improvements (17). Specifically, given the potential of treatment, it is urgent to evaluate the programs that are being implemented, as well as the characteristics of their participants. It is also important to understand with which participants the different programs seem to be more successful. Similarly, it is necessary to recognize that treatment policies, services, procedures, and approaches must be constantly monitored and evaluated (15, 33). In fact, it is important to emphasize the need to adapt the programs to the needs and individual characteristics of each offender in order to achieve a successful intervention.

There is a greater need than ever to adopt PAS policies based on reliable scientific data (71). This is also materialized by the growing incentive and challenge, on the part of formal institutions with connections to the States, to seek and adopt alternative interventions to incarceration/punishment in the case of substance-using individuals involved in the criminal justice system. Thus, the present study helps establish starting points for the evolution of the interventions adopted until then, working toward enhancing treatment, instead of incarceration, in substance-using individuals involved in the criminal justice system. This seems all the more important if we take into account that not treating individuals involved in the criminal justice system with substance-related problems is a missed opportunity to promote public health and safety (32). Thus, integrating treatment into the criminal justice system allows it to reach individuals who, otherwise, would not have access to it (36).

Summary

This systematic review, conducted according to PRISMA guidelines, investigated the efficacy of treatment and punishment in reducing drug use and criminal recidivism among substance-using offenders. The complex, non-linear relationship between substance use and criminal behavior necessitates a nuanced approach, recognizing the heterogeneity of both populations and the diverse pathways connecting them. The review analyzes various criminal justice responses, examining their impact on recidivism and substance use reduction.

Criminal Reactions to Substance-Using Offenders

Traditional punitive approaches, such as incarceration, have proven largely ineffective in reducing recidivism and substance use among this population. Consequently, alternative interventions, encompassing treatment, education, and social reintegration, have emerged as potential solutions. These alternatives aim to minimize incarceration, alleviate pressure on criminal justice systems, and reduce the duration of imprisonment for individuals with substance use disorders involved in the justice system. Treatment is posited as a last resort, reserved for high-risk individuals who commit violent crimes.

Study Search and Selection Strategy

The systematic review employed a comprehensive search strategy across multiple EBSCOhost databases, supplemented by a manual search to mitigate bias. Inclusion criteria focused on adult substance-using offenders (18–65 years) involved in the criminal justice system, encompassing studies of treatment programs (intervention, social reintegration, recidivism/drug use reduction) and punitive interventions. Exclusion criteria eliminated case studies, studies involving those younger than 18, individuals exclusively using prescribed pharmaceuticals, and those with unrelated psychopathology or intellectual disabilities. The inter-rater reliability for abstract analysis demonstrated near-perfect agreement (κ = 0.87, p < 0.001).

Identification and Screening

A total of 155 studies were initially identified, with 23 ultimately included in the review after a multi-stage screening process based on defined inclusion and exclusion criteria. This process involved removing duplicates, excluding studies based on population characteristics, methodology, and relevance to the research question. The final selection reflects a rigorous approach to ensuring the quality and relevance of included studies.

Drug-Using Offenders

Analysis of included studies revealed common characteristics among substance-using offenders: predominantly male, unemployed, single, aged 29-31, with substance use initiation in adolescence (before age 20). The most commonly abused substances included heroin, cocaine, alcohol, crack, cannabis, and amphetamines. Offenders often cited personal problems and association with other substance users as reasons for initiating substance use. A history of justice system involvement since adolescence was also prevalent.

Recidivism

Incarceration and Probation

Findings regarding incarceration revealed limited impact on criminal recidivism reduction. Incarceration did not effectively deter criminal behavior and increased the likelihood of recidivism, potentially due to negative impacts on employment, housing, family, and social reintegration. Conversely, probation demonstrated a potentially lower recidivism rate than incarceration, possibly linked to community supervision and support services. The deterrent effect of incarceration requires further investigation.

Treatment Programs

In contrast to incarceration, treatment programs, including Drug Treatment Alternatives to Prison (DTAP) and Drug Courts, demonstrated notable efficacy in reducing recidivism rates compared to prison sentences. Successful program completion was a significant predictor of lower recidivism rates and less severe offenses. Treatment programs also contributed to improved public safety, particularly for high-risk offenders. DTC participants demonstrated a significantly reduced number of arrests and convictions compared to those undergoing traditional adjudication.

Treatment Programs: Practical Implications

The review highlighted a higher recidivism rate among parolees compared to those on probation, possibly attributed to increased law enforcement scrutiny. Successful program participants, even with more severe initial convictions, experienced significantly lower rates of re-arrest and re-conviction. Treatment program completion emerged as a robust predictor of reduced recidivism. Longer treatment durations also correlated with lower recidivism rates.

Reduction of Substance Use

Incarceration, while temporarily reducing substance use during confinement, did not demonstrate long-term efficacy in preventing relapse. Treatment programs, particularly those providing comprehensive and tailored interventions, were more effective at reducing substance use, although relapse remains a recognized challenge in addiction treatment.

Discussion

The systematic review's findings corroborate existing literature, highlighting the ineffectiveness of incarceration as a primary means of reducing recidivism and substance use among this population. Treatment, particularly when completed successfully, emerged as a far more effective alternative in both reducing substance use and lowering recidivism. The criminogenic potential of incarceration, along with the benefits of probation and treatment, underscore the need for a shift toward a treatment-focused approach.

Conclusion

This systematic review concludes that punitive measures demonstrate limited effectiveness in reducing criminal recidivism and substance use among substance-using offenders. Treatment programs, however, consistently show significant promise in reducing both recidivism and substance use, emphasizing the importance of comprehensive, evidence-based treatment approaches integrated into the criminal justice system. Addressing the systemic barriers to treatment access remains a crucial step in achieving effective and sustainable outcomes.

Summary

This systematic review examines the effectiveness of treatment versus punishment in reducing drug use and criminal recidivism among offenders with substance use disorders. The research explored the complex relationship between psychoactive substance (PAS) use and crime, acknowledging the heterogeneity of both populations and the diverse pathways through which they intersect. The review analyzes various criminal justice responses, including incarceration and alternatives such as decriminalization, depenalization, pre-detention diversion, and Drug Treatment Courts (DTCs). The primary research question addresses the impact of treatment and/or punishment on reducing substance use and recidivism in this population.

Criminal Reactions to Substance-Using Offenders

Traditional punitive approaches, such as incarceration, have proven largely ineffective in reducing drug use or recidivism. Alternatives focus on limiting incarceration, reducing pressure on the criminal justice system, and decreasing time spent in prison for substance-involved offenders. Treatment, education, aftercare, rehabilitation, and social reintegration are presented as valuable alternatives targeting individual addictive problems, reducing substance-related crime, and alleviating pressure on the justice system. Different responses are categorized into administrative responses (before judicial proceedings) and criminal justice system responses (during judicial proceedings).

Study Search and Selection Strategy

The review followed PRISMA guidelines, employing a comprehensive search strategy across multiple EBSCOhost databases and manual searches. Inclusion criteria focused on adult offenders (18–65 years) with substance use disorders, encompassing various treatment and punitive interventions. Exclusion criteria eliminated case studies, studies involving minors, those solely focusing on prescribed pharmaceuticals, and those with unrelated psychopathology. The rigorous selection process resulted in 23 articles for analysis, demonstrating a high inter-rater reliability (κ = 0.87, p < 0.001).

Drug-Using Offenders and Recidivism

The reviewed studies reveal common characteristics among substance-using offenders, including a predominantly male population, high unemployment rates, and prior treatment experiences. PAS use often begins in adolescence, with heroin, cocaine, alcohol, crack, cannabis, and amphetamines being commonly cited. Recidivism rates are influenced by factors such as gender, age, criminal history, and marital status. Men generally exhibit higher and more severe recidivism rates, while younger individuals and those with prior convictions have a greater likelihood of re-offending.

Incarceration and Probation

Findings regarding incarceration indicate limited impact on reducing criminal recidivism. Incarceration does not effectively prevent future criminal behavior, and may even increase recidivism due to negative consequences on employment, housing, and social reintegration. While some studies suggest a deterrent effect of incarceration for better-integrated offenders, others find no such evidence and even indicate a criminogenic effect. Probation, in contrast, demonstrates lower recidivism rates compared to incarceration, also presenting a lower cost alternative.

Treatment Programs

Participation in Drug Treatment Alternative to Prison (DTAP) programs and Drug Treatment Courts (DTCs) significantly reduces recidivism rates compared to incarceration. Program completion emerges as a crucial factor, with successful completers exhibiting substantially lower recidivism rates and less severe offenses. Longer treatment durations are associated with lower recidivism, highlighting the importance of sustained intervention. While parolees have lower program completion rates than probationers, those who complete treatment on parole experience lower recidivism rates.

Reduction of Substance Use

Incarceration, while reducing PAS use during confinement, shows limited long-term effects. Treatment programs, particularly DTAPs and DTCs, are more effective in reducing PAS use, providing offenders with coping strategies. However, return to use is acknowledged as a common aspect of addiction treatment, requiring a pragmatic and informed approach from professionals.

Discussion and Conclusion

The review confirms that incarceration is ineffective in reducing recidivism and substance use, while treatment emerges as a far more effective approach. Treatment programs, especially those emphasizing program completion and longer durations, demonstrably reduce both recidivism and PAS use. The study highlights the need for increased collaboration between the justice and treatment systems to provide appropriate and accessible treatment options for substance-using offenders. Limitations include regional biases (with a preponderance of U.S. studies), inconsistencies in terminology and data collection methods, and the potential for bias in the studies included. The review underscores the urgent need for evidence-based, adaptable treatment approaches that address the heterogeneity of this population and the various barriers to treatment access.

Summary

This systematic review examines the effectiveness of treatment versus punishment for substance-using offenders in reducing drug use and criminal recidivism. Researchers analyzed existing studies to determine which approach—treatment or punishment—is more successful in preventing future offenses and substance abuse. The study's findings are then discussed and limitations are outlined.

Criminal reactions to substance-using offenders

Traditional "tough on crime" approaches, such as incarceration, have proven largely ineffective at reducing drug use or recidivism among offenders with substance use disorders. These approaches often lead to overcrowded prisons and increased violence without addressing the underlying addiction. Therefore, alternatives to incarceration, focusing on treatment and rehabilitation, have gained traction. These alternatives aim to reduce prison populations, lessen the burden on the justice system, and decrease the time offenders spend incarcerated. Incarceration should be reserved for high-risk individuals who commit violent crimes.

Study search and selection strategy

Researchers used multiple databases (EBSCOhost) to locate relevant studies. The search terms focused on incarceration, drug treatment, diversion programs, sentencing, drug offenders, and related concepts. A manual search also helped ensure comprehensive coverage. The search was not limited by language, culture, or geography.

Inclusion and exclusion criteria

Studies included focused on adult (18–65 years) substance-using offenders involved in the criminal justice system. Studies had to examine the effectiveness of treatment programs or punitive interventions on recidivism and drug use. Case studies, studies involving individuals younger than 18, those focusing solely on prescribed medication, and studies focused on unrelated psychopathology were excluded. Only empirical, quantitative studies from academic publications were included.

Identification and screening

The initial search yielded 155 studies. After removing duplicates and excluding irrelevant studies based on the inclusion/exclusion criteria, 23 articles were included in the final review.

Drug-using offenders

Substance-using offenders share certain characteristics: they are predominantly male, often unemployed and single, and tend to initiate drug use in adolescence. Common substances of abuse include heroin, cocaine, alcohol, crack, cannabis, and amphetamines.

Recidivism

Incarceration and probation

Incarceration generally shows little impact on reducing criminal recidivism. Some studies suggest a deterrent effect for well-integrated offenders, but others indicate incarceration can be criminogenic, potentially increasing the likelihood of future offenses. Probation appears to be more effective than incarceration in reducing recidivism, and it costs less.

Treatment programs

Treatment programs, particularly Drug Treatment Courts (DTC) and Drug Treatment Alternatives to Prison (DTAP), are significantly more effective at reducing recidivism than incarceration. Program completion is a crucial factor; those who complete treatment programs demonstrate lower recidivism rates and less severe offenses. The duration of treatment also plays a significant role, with longer treatment associated with lower recidivism.

Treatment programs: Practical implications

While parolees participating in treatment have higher rearrest rates than probationers, this may be due to increased monitoring, not necessarily a failure of treatment. Successful program participation leads to fewer charges, arrests, and convictions, proving treatment is a strong alternative to incarceration.

Reduction of substance use

Incarceration may temporarily decrease substance use, but this effect tends to diminish after release. Treatment programs are far more effective in long-term reduction of substance use. Treatment success is highly correlated with program completion.

Discussion

This review confirms that incarceration is generally ineffective in reducing recidivism among substance-using offenders. Treatment programs, on the other hand, prove significantly more effective, particularly when completed successfully. Limitations of the review include biases in data collection, variations in study methodologies, and the disproportionate number of studies conducted in the USA.

Conclusion

Punishment has a minimal effect on reducing recidivism and substance use. Treatment provides a far more effective response, substantially reducing both. Barriers to widespread treatment implementation include a lack of resources, infrastructure, and adequately trained personnel. The review itself has limitations related to data bias and methodological inconsistencies across the included studies. Despite these limitations, the conclusion remains that treatment should be prioritized over incarceration for substance-using offenders.

Summary

This study looked at how punishment and treatment affect people who use drugs and get into trouble with the law. Researchers wanted to see if punishment or treatment was better at helping these people stop using drugs and committing crimes. They looked at many studies to find out.

Criminal reactions to substance-using offenders

For a long time, the main way to deal with people who use drugs and commit crimes was to punish them, like sending them to jail. This didn't work very well; it didn't stop them from using drugs or committing more crimes, and prisons got overcrowded. So, people started to explore other ways to help, like treatment programs.

Study search and selection strategy

Researchers looked at lots of studies from different places to see what worked best. They used special words to find studies about drug use, treatment, and punishment. They carefully chose which studies to use in their review.

Inclusion and exclusion criteria

The researchers only used studies about grown-ups (ages 18-65) who used illegal drugs and were involved in the justice system. They didn't include studies about children, people with other mental health issues, or people who only used prescription drugs.

Identification and screening

The researchers found many studies, but many didn't fit their rules. After checking all the studies, they chose only those that answered their question about treatment and punishment.

Drug-using offenders

Most people in the studies were men, not working, and had tried treatment before. They usually started using drugs when they were teenagers and used drugs like heroin, cocaine, and alcohol.

Recidivism

Incarceration and probation

Going to jail didn't stop most people from committing more crimes. Actually, people who went to jail often ended up back in jail sooner than people who were on probation (like being supervised in the community instead of jail).

Treatment programs

Treatment programs worked much better than jail. People who went to treatment programs were less likely to commit new crimes. Completing the program was very important; people who finished their treatment were less likely to get into trouble again.

Reduction of substance use

Jail might make people stop using drugs while they're locked up, but they often started again afterward. Treatment programs were much better at helping people stop using drugs long-term.

Discussion

This study showed that jail is not a good way to help people who use drugs and break the law. Treatment is much more effective at reducing drug use and preventing future crimes. It's important for the justice system and healthcare to work together to help these people.

Conclusion

Punishment doesn't help much, but treatment does a much better job of helping people stop using drugs and committing crimes. More research is needed to find out the best ways to treat people with drug problems who are also involved with the justice system. There are lots of challenges, like finding the money and staff for treatment programs.