Early intervention and support: Corrections' Methamphetamine Pilot
Senior Adviser, Service Development, Department of Corrections
Caitlin specialises in the design and implementation of alcohol and other drug (AOD) rehabilitation programmes. Caitlin has both worked on and led various AOD projects including residential AOD programmes, offender digital health services, the AOD Aftercare Worker Pilot and the methamphetamine screening and treatment pilot. Prior to her senior adviser role, Caitlin worked as a probation officer in Auckland.
Methamphetamine use was first identified in the general New Zealand population in the late 1990s and reached a peak in the early 2000s (Prasad, Rychert, Wilkins, & Wong, 2015). Research conducted by the Ministry of Health found amphetamine/methamphetamine use amongst New Zealanders aged 16 to 64 declined from 2.7% of the population in 2003 to 1.1% in 2015/16 (Ministry of Health, 2016). Despite this decline within the general New Zealand population, high levels of methamphetamine use amongst the prison population remains. The Department of Corrections commissioned a study in 2015 which looked at comorbid methamphetamine use disorders and mental health disorders amongst people in prison. The study revealed that over half (56%) of people in prison have used methamphetamine over the course of their life, and of these 58% reported they had used methamphetamine in the past year (Indig, Gear and Wilhelm, 2016). Furthermore, 38% of people in prison had either an abuse or dependence disorder*  at some point during their lives, while 16% were identified as having abused or been dependent on methamphetamine in the past 12 months (Indig et al., 2016).
In light of the significant harms associated with methamphetamine abuse and dependence disorders, with funding from the Proceeds of Crime Fund, the Department has implemented new services aimed at early intervention, treatment and support for people with mental health and methamphetamine-related needs. Treatment and care was expanded in 2017 for people in prison and on community-based sentences and orders experiencing mild to moderate mental health issues. In the same year, the Department introduced a pilot for screening and targeted treatment for methamphetamine users. The pilot included three key components:
- Screening, Brief Intervention and Referral to Treatment (SBIRT)
- group-based methamphetamine-specific programmes
- a group-based mental health and wellbeing programme.
This article will focus on describing SBIRT and one of the group-based programmes.
Screening, Brief Intervention and Referral to Treatment (SBIRT)
SBIRT is an evidence-based practice developed to provide universal screening, early intervention and referrals to treatment for people who use alcohol and drugs (SAMSHA, 2011). It was originally developed to be used in primary care and other health settings such as hospital emergency rooms, and was predominantly focused on screening for risky alcohol use only. It has, however, been more widely adopted, and is often used in other settings such as police stations and prisons, and is used to screen for problematic drug use as well.
SBIRT is made up of three components:
- Screening - people are screened for problematic substance use using a standardised tool. The results provide an indication of the level of substance-related risk and the required level of intervention.
- Brief intervention - a single session providing feedback and advice using a motivational approach.
- Referral to treatment - for those who are identified as needing additional support or treatment.
It is a brief but comprehensive process, with the initial screening component completed in approximately ten minutes, and the brief intervention lasting between five minutes and one hour.
SBIRT is unique, as the universal screening component allows health care professionals to identify people with problematic or risky substance use even if they are not actively seeking support or treatment (Prendergast, Cartier, & Lee, 2014). While not all individuals who use drugs require treatment, drug use creates risks of developing abuse or dependence disorders (Prendergast, McCollister, & Warda, 2017). Experts argue that screening and early intervention, appropriate to the identified level of risk, can help low and moderate users to identify and change risky behaviour, preventing progression to more problematic AOD use in the future (SAMSHA, 2013). In criminal justice settings, this can have significant effects on public health and public safety by reducing criminal behaviour and increasing psychosocial functioning (Prendergast & Cartier, 2013).
In September 2017 the Department contracted Odyssey, a community-based AOD treatment provider, to deliver SBIRT at Mount Eden Corrections Facility (MECF). For a number of reasons this prison was identified as a good location to trial the SBIRT approach. Firstly, it is the largest remand facility in New Zealand, housing approximately 1,000 men of remand accused, remand convicted, and sentenced status. The significant remand population (approximately 90%) and the high percentage of people on short sentences means there is a high turnover, with a throughput of approximately 38,000 per year. Such a fast-moving environment was considered an ideal location to trial SBIRT, as it could be used to screen a large number of people in a very short timeframe, increasing the pilot’s reach and maximising potential benefits.
Implementing SBIRT at MECF also presented an opportunity to address a gap in AOD service delivery for people on remand and short sentences. Given many are only in MECF for a short period of time, they are often released before they have undertaken AOD screening with a nurse or case manager. With a target to complete an SBIRT with each individual within two to seven days of reception, implementing the pilot at MECF would significantly increase the number of people on remand and short sentences being screened for AOD, as well as maximise opportunities for early intervention.
Focusing on remand prisoners may also lead to improved outcomes for the SBIRT itself. Research suggests that people on remand are ideal candidates as their recent incarceration can precipitate a “teachable moment”. They may be in custody for an alleged drug-related crime or as a result of their alcohol or drug use, which could also be a source of motivation to address their substance use issues (Prendergast et al., 2014).
Further to this, the potential for prevention and early intervention could be maximised by implementing the service at MECF, which houses the largest youth population under 25 in New Zealand. Findings from the 2015 comorbidity study showed that people in prison aged 17 to 24 years had the highest rates of methamphetamine use in the past 12 months, however the rates of methamphetamine abuse and dependence disorders in this group was lower than those in the 25 to 44 year age group. Furthermore, those under 25 developed stimulant dependence within 10 months of having first used; two and a half times faster than those aged 45 years and older (Indig et al., 2016). This suggests that targeting people under 25 with SBIRT could maximise outcomes of the methamphetamine pilot, particularly early identification and intervention.
The Alcohol and Substance Involvement Screening Test (ASIST)
The Department opted to use the ASIST  as the screening tool for the SBIRT. ASIST is used by frontline staff, including probation officers, case managers and nurses, across the Department to screen for problematic AOD use. It was agreed that it was important to use the same tool to ensure the data collected through the SBIRT could be used by Departmental staff in future. Evidence shows the ASIST is an effective screening tool as it has strong psychometric properties and is easy to use, with minimal training required (Wolff & Shi, 2015).
The first phase of Corrections' methamphetamine pilot included making a change to the ASIST tool by adding methamphetamine as a specific option under the “amphetamine type” stimulant drug category. The standard ASIST screens for amphetamine type drugs, options for which were listed as “speed”, diet pills and ecstasy. Thus, there was no way to specifically identify methamphetamine use. With the modified version, those completing the ASIST would provide either a “yes” or “no” response when asked if they have ever used methamphetamine, as well as how often they have used methamphetamine in the past three months.
Using the enhanced ASIST as the screening tool for SBIRT has allowed for the clearer identification of methamphetamine users and presented an opportunity for early intervention. It is also intended to help the Department to better track levels of methamphetamine use in both the prison and community offender population, not only over the pilot period but also in the years to come.
SBIRT: Brief Intervention and Referral to Treatment
Options for brief intervention and referral to treatment are largely dependent on the participant's prison status and the results of their ASIST. All participants identified as methamphetamine users are referred to the “Meth and Me” short course delivered and developed by Odyssey. The course is delivered to small groups of people in two-hour blocks over two sessions. Participants gain an understanding of the effects of methamphetamine use. They then learn relapse prevention strategies, such as managing cravings and risky situations. It was specifically designed as a brief, psycho-educational course, so it would be suitable for remand accused, remand convicted and sentenced prisoners with varying levels of AOD need. As people with high needs usually require additional and ongoing treatment, Odyssey staff are expected to work closely with participants' case managers to ensure that they are aware of the participants' treatment needs and can undertake sentence planning, and initiate referrals, as appropriate. For those without a case manager, referral to treatment activities involves sharing information with participants about various treatment and support options in prison and the community.
Uptake and success to date
Between September 2017 and February 2018, 225 people in MECF have completed SBIRT with an Odyssey staff member. Uptake is around 80%, with only 20% of eligible people who are offered SBIRT declining. Reasons for declining include lack of interest or self-reported nil AOD use. Of the 225 people that have agreed and have completed SBIRT with an Odyssey staff member, 161 (72%) have indicated they have used methamphetamine either in the last three months or at some point over their lifetime. The majority of these people (144) were referred to the “Meth and Me” short course, and some with high AOD needs were also referred to Odyssey's residential treatment in the community.
The identification of methamphetamine users and the subsequent referral to appropriate courses and treatment is one of the key successes of this pilot to date. Another success of the pilot is the demonstration of collaborative work between the prison and the contracted provider, Odyssey. Both parties worked closely to ensure the pilot was implemented smoothly, and collaboration continues as Odyssey staff engage with case managers and corrections officers on a daily basis in their work at the prison. In addition, feedback questionnaires completed at the end of SBIRT and the “Meth and Me” short course are demonstrating that the services are received well and considered helpful by participants, with some thanking staff for providing information and resources they did not know were available to them.
Although the pilot is still in the early stages of implementation, the Department and the provider are already working through key challenges in an effort to refine the service. Working in a remand prison is the biggest challenge for a number of reasons. Firstly, a significant number of SBIRT participants have not been in prison long enough to be allocated a case manager, which makes it difficult for Odyssey staff to refer people with high needs to suitable treatment. This is because people in prison often have multiple needs which need to be addressed, and decisions regarding timing and sequencing of treatment need to be made by case managers, who have a broader understanding of how an individual's different needs are best responded to. This issue is exacerbated by the high number of participants with remand accused status, as it is difficult to predict the outcome of their future court appearances, in particular whether they will remain in prison or be released into the community.
The Department is currently working closely with Odyssey to overcome these challenges, and strengthen the referral to treatment component of SBIRT, particularly those with remand accused status. Approximately 40% of this group have an active community sentence and an allocated probation officer. Odyssey staff will increase communication and liaison with participants' probation officers to inform pre-sentence reports and help with planning for community-based treatment and support for those that are released. Progress with this work will be monitored through monthly reporting data.
The Department will continue to work with Odyssey to identify opportunities to further enhance the service at MECF. Additional information regarding the pilot's progress to date, areas for improvement and potential opportunities for expansion are expected to be gleaned from an evaluation, which is due for completion later this year.
 Abuse is when a person uses alcohol or drugs regularly, despite the fact that it causes issues in their life. Dependence is characterised by a person developing a tolerance to a substance, going through withdrawal symptoms without it, and struggling to cut back on it.
 The ASIST is a modified version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) developed by the World Health Organisation. ASIST does not include tobacco, as prison health services already have a comprehensive screening process linked to the provision of nicotine replacement therapy. The ASIST screens for a range of substances and determines a risk score for each substance (i.e. lower, moderate or high).
Indig, D., Gear, C. & Wilhelm, K., (2016) Comorbid substance use disorders and mental health disorders among New Zealand prisoners, Department of Corrections, 2016.
Ministry of Health (2016). Methodology Report 2015/16: New Zealand Health Survey. Wellington: Ministry of Health.
Prasad, J., Rychert, M., Wilkins, C. & Wong, K.(2015). Recent Trends in Illegal Drug Use in New Zealand, 2006-2014, Massey University, 2015.
Prendergast, M. L., & Cartier, J. J. (2013). Screening, brief intervention, and referral to treatment (SBIRT) for offenders: protocol for a pragmatic randomized trial. Addiction science & clinical practice, 8(1), 16.
Prendergast, M., Cartier, J., & Lee, A. B. (2014). Considerations for Introducing SBIRT into a Jail Setting. Offender programs report, 17(6), 81.
Prendergast, M. L., McCollister, K., & Warda, U. (2017). A randomized study of the use of screening, brief intervention, and referral to treatment (SBIRT) for drug and alcohol use with jail inmates. Journal of substance abuse treatment, 74, 54-64.
Substance Abuse and Mental Health Services Administration (SAMSHA) (2011). Screening, Brief Intervention and Referral to Treatment (SBIRT) in Behavioral Healthcare.
Substance Abuse and Mental Health Services Administration (SAMSHA) (2013) SBIRT: Screening, Brief Intervention, and Referral to Treatment Opportunities for Implementation and Points for Consideration. Access at https://www.integration.samhsa.gov/SBIRT_Issue_Brief.pdf
Wolff, N., & Shi, J. (2015). Screening for substance use disorder among incarcerated men with the Alcohol, Smoking, Substance Involvement Screening Test (ASSIST): a comparative analysis of computer-administered and interviewer-administered modalities. Journal of substance abuse treatment, 53, 22-32.