HEALTH TECHNOLOGY ASSESSMENT

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1 HEALTH TECHNOLOGY ASSESSMENT VOLUME 19 ISSUE 6 JANUARY 2015 ISSN The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using cass A drugs: a systematic review and economic evauation Karen P Hayhurst, Maria Leitner, Linda Davies, Rache Fentje, Tim Miar, Andrew Jones, Carene King, Michae Donma, Michae Farre, Seena Faze, Rochee Harris, Matthew Hickman, Charotte Lennox, Soraya Mayet, Jane Senior and Jennifer Shaw DOI /hta19060

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3 The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using cass A drugs: a systematic review and economic evauation Karen P Hayhurst, 1 Maria Leitner, 2 Linda Davies, 3 Rache Fentje, 4 Tim Miar, 1 Andrew Jones, 5 Carene King, 6 Michae Donma, 5 Michae Farre, 7 Seena Faze, 8 Rochee Harris, 9 Matthew Hickman, 10 Charotte Lennox, 6 Soraya Mayet, 11 Jane Senior 6 and Jennifer Shaw 6* 1 Institute of Brain, Behaviour and Menta Heath, University of Manchester, Manchester, UK 2 Schoo of Heath Sciences, University of Liverpoo, Liverpoo, UK 3 Manchester Centre for Heath Economics, Institute of Popuation Heath, University of Manchester, Manchester, UK 4 Heath Insights Ltd, Burton Springs Farm, Cheshire, UK 5 Nationa Drug Evidence Centre, Institute of Popuation Heath, University of Manchester, Manchester, UK 6 Offender Heath Research Network, Institute of Brain, Behaviour and Menta Heath, University of Manchester, Manchester, UK 7 Nationa Drug and Acoho Research Centre, University of New South Waes, Sydney, NSW, Austraia 8 Department of Psychiatry, University of Oxford, Oxford, UK 9 West Yorkshire Probation Service, Wakefied, UK 10 Schoo of Socia and Community Medicine, University of Bristo, Bristo, UK 11 Tees, Esk and Wear Vaeys NHS Foundation Trust, County Durham, UK *Corresponding author Decared competing interests of authors: Linda Davies provided expert consutancy advice to the Home Office funded by grants to the University of Manchester (Drug Data Warehouse; panned evauation of drug strategy). Pubished January 2015 DOI: /hta19060

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5 This report shoud be referenced as foows: Hayhurst KP, Leitner M, Davies L, Fentje R, Miar T, Jones A, et a. The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using cass A drugs: a systematic review and economic evauation. Heath Techno Assess 2015;19(6). Heath Technoogy Assessment is indexed and abstracted in Index Medicus/MEDLINE, Excerpta Medica/EMBASE, Science Citation Index Expanded (SciSearch ) and Current Contents / Cinica Medicine.

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7 Heath Technoogy Assessment HTA/HTA TAR ISSN (Print) ISSN (Onine) Impact factor: Heath Technoogy Assessment is indexed in MEDLINE, CINAHL, EMBASE, The Cochrane Library and the ISI Science Citation Index and is assessed for incusion in the Database of Abstracts of Reviews of Effects. This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) (www.pubicationethics.org/). Editoria contact: The fu HTA archive is freey avaiabe to view onine at Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: Criteria for incusion in the Heath Technoogy Assessment journa Reports are pubished in Heath Technoogy Assessment (HTA) if (1) they have resuted from work for the HTA programme, and (2) they are of a sufficienty high scientific quaity as assessed by the reviewers and editors. Reviews in Heath Technoogy Assessment are termed 'systematic' when the account of the search appraisa and synthesis methods (to minimise biases and random errors) woud, in theory, permit the repication of the review by others. HTA programme The HTA programme, part of the Nationa Institute for Heath Research (NIHR), was set up in It produces high-quaity research information on the effectiveness, costs and broader impact of heath technoogies for those who use, manage and provide care in the NHS. Heath technoogies are broady defined as a interventions used to promote heath, prevent and treat disease, and improve rehabiitation and ong-term care. The journa is indexed in NHS Evidence via its abstracts incuded in MEDLINE and its Technoogy Assessment Reports inform Nationa Institute for Heath and Care Exceence (NICE) guidance. HTA research is aso an important source of evidence for Nationa Screening Committee (NSC) poicy decisions. For more information about the HTA programme pease visit the website: This report The research reported in this issue of the journa was funded by the HTA programme as project number 09/109/04. The contractua start date was in Juy The draft report began editoria review in October 2013 and was accepted for pubication in January The authors have been whoy responsibe for a data coection, anaysis and interpretation, and for writing up their work. The HTA editors and pubisher have tried to ensure the accuracy of the authors report and woud ike to thank the reviewers for their constructive comments on the draft document. However, they do not accept iabiity for damages or osses arising from materia pubished in this report. This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views and opinions expressed by authors in this pubication are those of the authors and do not necessariy refect those of the NHS, the NIHR, NETSCC, the HTA programme or the Department of Heath. If there are verbatim quotations incuded in this pubication the views and opinions expressed by the interviewees are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HTA programme or the Department of Heath. Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Pubished by the NIHR Journas Library (www.journasibrary.nihr.ac.uk), produced by Prepress Projects Ltd, Perth, Scotand (www.prepress-projects.co.uk).

8 Editor-in-Chief of Heath Technoogy Assessment and NIHR Journas Library Professor Tom Waey Director, NIHR Evauation, Trias and Studies and Director of the HTA Programme, UK NIHR Journas Library Editors Professor Ken Stein Chair of HTA Editoria Board and Professor of Pubic Heath, University of Exeter Medica Schoo, UK Professor Andree Le May Chair of NIHR Journas Library Editoria Group (EME, HS&DR, PGfAR, PHR journas) Dr Martin Ashton-Key Consutant in Pubic Heath Medicine/Consutant Advisor, NETSCC, UK Professor Matthias Beck Chair in Pubic Sector Management and Subject Leader (Management Group), Queen s University Management Schoo, Queen s University Befast, UK Professor Aieen Carke Professor of Pubic Heath and Heath Services Research, Warwick Medica Schoo, University of Warwick, UK Dr Tessa Criy Director, Crysta Bue Consuting Ltd, UK Dr Peter Davidson Director of NETSCC, HTA, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Professor Eaine McCo Director, Newcaste Cinica Trias Unit, Institute of Heath and Society, Newcaste University, UK Professor Wiiam McGuire Professor of Chid Heath, Hu York Medica Schoo, University of York, UK Professor Geoffrey Meads Professor of Heath Sciences Research, Facuty of Education, University of Winchester, UK Professor John Powe Consutant Cinica Adviser, Nationa Institute for Heath and Care Exceence (NICE), UK Professor James Raftery Professor of Heath Technoogy Assessment, Wessex Institute, Facuty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Keijnen Systematic Reviews Ltd, UK Professor Heen Roberts Professor of Chid Heath Research, UCL Institute of Chid Heath, UK Professor Heen Snooks Professor of Heath Services Research, Institute of Life Science, Coege of Medicine, Swansea University, UK Pease visit the website for a ist of members of the NIHR Journas Library Board: Editoria contact: NIHR Journas Library

9 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 Abstract The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using cass A drugs: a systematic review and economic evauation Karen P Hayhurst, 1 Maria Leitner, 2 Linda Davies, 3 Rache Fentje, 4 Tim Miar, 1 Andrew Jones, 5 Carene King, 6 Michae Donma, 5 Michae Farre, 7 Seena Faze, 8 Rochee Harris, 9 Matthew Hickman, 10 Charotte Lennox, 6 Soraya Mayet, 11 Jane Senior 6 and Jennifer Shaw 6* 1 Institute of Brain, Behaviour and Menta Heath, University of Manchester, Manchester, UK 2 Schoo of Heath Sciences, University of Liverpoo, Liverpoo, UK 3 Manchester Centre for Heath Economics, Institute of Popuation Heath, University of Manchester, Manchester, UK 4 Heath Insights Ltd, Burton Springs Farm, Cheshire, UK 5 Nationa Drug Evidence Centre, Institute of Popuation Heath, University of Manchester, Manchester, UK 6 Offender Heath Research Network, Institute of Brain, Behaviour and Menta Heath, University of Manchester, Manchester, UK 7 Nationa Drug and Acoho Research Centre, University of New South Waes, Sydney, NSW, Austraia 8 Department of Psychiatry, University of Oxford, Oxford, UK 9 West Yorkshire Probation Service, Wakefied, UK 10 Schoo of Socia and Community Medicine, University of Bristo, Bristo, UK 11 Tees, Esk and Wear Vaeys NHS Foundation Trust, County Durham, UK *Corresponding author Background: The societa costs of probematic cass A drug use in Engand and Waes exceed 15B; drug-reated crime accounts for amost 90% of costs. Diversion pus treatment and/or aftercare programmes may reduce drug-reated crime and costs. Objectives: To assess the effectiveness and cost-effectiveness of diversion and aftercare for cass A drug-using offenders, compared with no diversion. Popuation: Adut cass A drug-using offenders diverted to treatment or an aftercare programme for their drug use. Interventions: Programmes to identify and divert probematic drug users to treatment (vountary, court mandated or monitored services) at any point within the crimina justice system (CJS). Aftercare foows diversion and treatment, excuding care foowing prison or non-diversionary drug treatment. Data sources: Thirty-three eectronic databases and government onine resources were searched for studies pubished between January 1985 and January 2012, incuding MEDLINE, PsycINFO and ISI Web of Science. Bibiographies of identified studies were screened. The UK Drug Data Warehouse, the UK Drug Treatment Outcomes Research Study and pubished statistics and reports provided data for the economic evauation. Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

10 ABSTRACT Methods: Incuded studies evauated diversion in adut cass A drug-using offenders, in contact with the CJS. The main outcomes were drug use and offending behaviour, and these were pooed using meta-anaysis. The economic review incuded fu economic evauations for adut opiate and/or crack, or powder, cocaine users. An economic decision anaytic mode, estimated incrementa costs per unit of outcome gained by diversion and aftercare, over a 12-month time horizon. The perspectives incuded the CJS, NHS, socia care providers and offenders. Probabiistic sensitivity anaysis and one-way sensitivity anaysis expored variance in parameter estimates, onger time horizons and structura uncertainty. Resuts: Sixteen studies met the effectiveness review incusion criteria, characterised by poor methodoogica quaity, with modest sampe sizes, high attrition rates, retrospective data coection, imited foow-up, no random aocation and pubication bias. Most study sampes comprised US methamphetamine users. Limited meta-anaysis was possibe, indicating a potentia sma impact of diversion interventions on reducing drug use [odds ratio (OR) 1.68, 95% confidence interva (CI) 1.12 to 2.53 for reduced primary drug use, and OR 2.60, 95% CI 1.70 to 3.98 for reduced use of other drugs]. The cost-effectiveness review did not identify any reevant studies. The economic evauation indicated high uncertainty because of variance in data estimates and imitations in the mode design. The primary anaysis was uncear whether or not diversion was cost-effective. The sensitivity anayses indicated some scenarios where diversion may be cost-effective. Limitations: Neary a participants (99.6%) in the effectiveness review were American (Caifornian) methamphetamine users, imiting transfer of concusions to the UK. Data and methodoogica imitations mean it is uncear whether or not diversion is effective or cost-effective. Concusions: High-quaity evidence for the effectiveness and cost-effectiveness of diversion schemes is sparse and does not reate to the UK. Importanty this research identified a range of methodoogica imitations in existing evidence. These highight the need for research to conceptuaise, define and deveop modes of diversion programmes and identify a core outcome set. A programme of feasibiity, piot and definitive trias, combined with process evauation and quaitative research is recommended to assess the effectiveness and cost-effectiveness of diversionary interventions in cass A drug-using offenders. Funding detais: The Nationa Institute for Heath Research Heath Technoogy Assessment programme. viii NIHR Journas Library

11 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 Contents List of tabes List of figures List of boxes List of abbreviations Pain Engish summary Scientific summary xiii xv xvii xix xxi xxiii Chapter 1 Background 1 Cass A drugs 1 Prevaence of cass A drug use 1 Cass A drug use and crime 2 Poicy context 3 Current service provision 3 Rationae for this study 4 Chapter 2 Definition of the decision probem 7 Popuation 7 Intervention 7 Contro 7 Outcomes 7 Aims and objectives 8 Chapter 3 Review of effectiveness 9 Methods 9 Advisory pane 9 Search strategy 9 Incusion criteria 10 Quaity assessment 11 Data extraction 11 Data synthesis 11 Resuts 11 Study fow 11 Seection of incuded studies 12 Profie of incuded studies 12 Quaity assessment 14 Participant profie 25 Detais of offending behaviour 34 Bivariate and meta-anayses 34 Pubication bias 38 Meta-anayses 39 Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ix

12 CONTENTS Chapter 4 Review of economic evauations 49 Methods 49 Search strategy 49 Incusion criteria 49 Data extraction 50 Resuts 50 Study fow 50 Partia economic evauations 50 Chapter 5 Economic mode: methods and data 51 Approach 51 Data sources 51 Economic mode 52 Popuation 52 Mode structure 52 Variabe estimation 55 Likeihood of events 55 Probabiity distributions 57 Resource use and costs 57 Outcomes, utiity vaues and quaity-adjusted ife-years 58 Anaysis of economic mode 59 Sensitivity anaysis and key assumptions 60 Key assumptions 60 Chapter 6 Economic mode: data inputs and resuts 61 Data inputs 61 Resuts 64 Primary anaysis 64 Sensitivity anayses 66 Summary of economic mode anayses 66 Chapter 7 Discussion 69 Summary of key findings 69 Scope of avaiabe effectiveness evidence 69 Evidence of effectiveness 69 Evidence of cost-effectiveness 70 Strengths and imitations of the assessment 70 Effectiveness 70 Cost-effectiveness 76 Economic mode 76 Chapter 8 Concusions 81 Impications for service provision 81 Suggestions for research priorities 82 Deveopment and standardisation of interventions 82 Deveopment of core outcome set 84 Evauation of specific interventions 84 Acknowedgements 87 References 89 x NIHR Journas Library

13 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 Appendix 1 List of trigger offences (with effect from 1 August 2007) 97 Appendix 2 Commissioning brief 99 Appendix 3 Search strategy for the effectiveness review 103 Appendix 4 Incusion/excusion form for the cinica effectiveness review 105 Appendix 5 Data extraction form for the effectiveness review 107 Appendix 6 Effectiveness review suppementary tabes 111 Appendix 7 Search strategy for the economic review 127 Appendix 8 Eigibiity form for the economic review 129 Appendix 9 Data extraction form for the economic review 131 Appendix 10 Economic mode suppementary tabes 141 Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xi

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15 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 List of tabes TABLE 1 Study description 13 TABLE 2 Design profie and quaity indicators based on the Maryand Scae of Scientific Methods 15 TABLE 3 Outcomes of statistica anayses by type of outcome measure and study 20 TABLE 4 Profie of interventions evauated in incuded studies 25 TABLE 5 Demographic profie of incuded studies 26 TABLE 6 Indicators of participant menta and physica heath status 28 TABLE 7 Participant drug use history 29 TABLE 8 History of offending behaviour 35 TABLE 9 Outcomes reported compared with outcomes avaiabe for meta-anaysis 37 TABLE 10 Meta-anaysis: continued primary drug use 40 TABLE 11 Meta-anaysis: continued use, drugs other than primary drug 42 TABLE 12 Meta-anaysis: treatment competion 46 TABLE 13 Probabiity of treatment 61 TABLE 14 Summary of probabiities for next recorded offence 62 TABLE 15 Summary of probabiities for arrest and sentences and subsequent offences 62 TABLE 16 Unit costs of DIP, drug test and treatment services, UK pounds, TABLE 17 Estimated probabiity of a drug test 62 TABLE 18 Unit costs of offences, by type of offence, UK, TABLE 19 Average cost per person of offences, arrests and sentences for primary anaysis, UK, TABLE 20 Utiity vaues of events 64 TABLE 21 Expected costs and QALYs: 12-month time horizon, DIP vs. no DIP 65 TABLE 22 Resuts of sensitivity anayses for data estimates 67 TABLE 23 Resuts of sensitivity anayses for mode structure and design choices 68 Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xiii

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17 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 List of figures FIGURE 1 Fow chart of incuded studies 12 FIGURE 2 Funne pot to assess pubication bias 38 FIGURE 3 Continued primary drug use: forest pot 41 FIGURE 4 Continued other drug use: forest pot 43 FIGURE 5 Treatment competion: forest pot 47 FIGURE 6 Fow diagram for identifying studies for the systematic review of economic evidence 50 FIGURE 7 Decision tree, year 1 53 FIGURE 8 Decision tree, year 1 (continued): subsequent offending pathway 54 FIGURE 9 Markov states in subsequent cyces for onger time horizons 56 FIGURE 10 Cost-effectiveness pane, primary anaysis 65 FIGURE 11 Cost-effectiveness acceptabiity curve of DIP, primary anaysis 65 Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xv

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19 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 List of boxes BOX 1 Research priority 1 83 BOX 2 Research priority 2 83 BOX 3 Research priority 3 84 BOX 4 Research priority 4 85 BOX 5 Research priority 5 85 BOX 6 Research priority 6 86 Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xvii

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21 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 List of abbreviations ACMD ASI Advisory Counci on the Misuse of Drugs Addiction Severity Index NB NDTMS net benefit Nationa Drug Treatment Monitoring System CaOMS CEAA CEAC CI Caifornia Outcomes Measurement System cost-effectiveness acceptabiity anaysis cost-effectiveness acceptabiity curve confidence interva NHS EED NICE NIHR NTORS NHS Economic Evauation Database Nationa Institute for Heath and Care Exceence Nationa Institute for Heath Research Nationa Treatment Outcome Research Study CJS crimina justice system NTP Narcotic Treatment Programme CMR CSEW DDW DIP DTORS Circumstances, Motivation and Readiness Crime Survey for Engand and Waes Drug Data Warehouse Drug Interventions Programme Drug Treatment Outcomes Research Study ONS OR PNC PSA QALY RCT ROSIE Office for Nationa Statistics odds ratio Poice Nationa Computer probabiistic sensitivity anaysis quaity-adjusted ife-year randomised controed tria Research Outcome Study in Ireand DTTO HTA ICER ID ITT LSD MTP drug treatment and testing order Heath Technoogy Assessment incrementa cost-effectiveness ratio identifier intention to treat ysergic acid diethyamide Methamphetamine Treatment Project SACPA SD TAP TAU TR WTPT Substance Abuse and Crime Prevention Act standard deviation Treatment Aternative Program treatment as usua Transforming Rehabiitation agenda wiingness-to-pay threshod Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xix

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23 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 Pain Engish summary Cass A drugs, such as heroin and crack cocaine, are beieved to have a high impact on society, with a cost of about 15B per year. Most of this cost is thought to be due to drug-reated crime. Identifying peope who commit crimes and aso use drugs to direct them into drug treatment (as part, or instead, of their sentence) may reduce drug-reated offending. This is referred to as diversion and typicay takes pace in the crimina justice system, when a person is arrested. This study asked whether or not diversion improves outcomes or reduces costs, compared with not doing this. To answer these questions, we reviewed other studies aready carried out on this topic. We deveoped an economic mode. The economic mode used data from a sampe of Engish arrested heroin and/or crack users, nationa databases and pubished studies to ook at the costs and possibe benefits of diversion. The review of studies, which identified mosty US-based research, found that diversion may reduce drug use. However, the effect on reducing offending was uncear. The review did not find any studies abe to answer the question of whether or not diversion can save money. The economic mode, which focused on the use of the Drug Interventions Programme in the UK, found that diversion may be cost-effective. However, there is a ot of uncertainty about the reevance and quaity of data. This uncertainty means that it is not cear whether or not diversion is cinicay effective or cost-effective. More research is needed to identify whether or not diversion is cinicay effective in the UK and who may benefit from diversion into treatment. Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxi

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25 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 Scientific summary Background Cass A drugs are those which attract the strongest ega penaties for possession or suppy. The cass incudes drugs associated with probematic use and addiction, such as heroin and crack cocaine. The prevaence of cass A drug use among 20- to 24-year-ods in Engand and Waes reached amost 6% in the past year ( ). The natura history of drug-user offending and the inks between cass A drug use and acquisitive crime, in particuar, are uncear and not yet fuy deineated. The societa costs of probematic cass A drug use in Engand and Waes are estimated to be over 15B, and drug-reated crime accounts for amost 90% of these costs. It is suggested that diverting arrested cass A drug-using offenders into treatment to reduce their substance misuse has the potentia to accrue significant savings through a reduction in eves of drug-reated crime. This is based on the assumption that offending is a way to generate income to fund continued drug use. Offenders in the community are an under-researched group, in comparison with offenders in prison settings, and there is a ack of cear, robust evidence on the effectiveness and cost-effectiveness of diversion programmes. Objectives The objective of the study was to evauate whether or not diversion and aftercare strategies for cass A drug-using offenders are ikey to be cinicay effective or cost-effective compared with no diversion or aftercare within the crimina justice system (CJS). Specific objectives were to: 1. carry out a systematic review of the iterature to assess the effectiveness of diversion or aftercare for cass A drug-using offenders 2. carry out a systematic review to evauate the cost-effectiveness of diversion or aftercare specificay for opiate- and/or cocaine (crack or powder)-using offenders 3. use an economic decision mode to evauate the cost-effectiveness of diversion through the examination of a sampe exposed to the UK diversion mode [Drug Interventions Programme (DIP)] 4. identify the eve of uncertainty and need for further research. Methods Thirty-one eectronic databases (incuding MEDLINE, EMBASE and PsycINFO) were searched for studies pubished between January 1985 and January The economic review aso searched the American Economic Association s eectronic bibiography, NHS Economic Evauation Database and UK government onine resources. Searches were suppemented by screening bibiographies of identified studies. Studies examining adut cass A drug-using offenders, in contact with the CJS and subject to a diversionary scheme, were incuded in the review of effectiveness. Data on drug use, offending behaviour, treatment competion and other outcomes, such as empoyment status, were extracted. Bivariate anaysis of outcomes informed the pooing of data using meta-anaysis. The presence of pubication bias in the avaiabe iterature was assessed by the meta-anaysis. For the cost-effectiveness review, studies were restricted to those reporting outcomes for adut opiate and/or cocaine (crack or powder) users, which reported a fu economic evauation of diversion compared with an aternative intervention or no diversion. Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxiii

26 SCIENTIFIC SUMMARY An economic decision anaytic mode was used to synthesise avaiabe cinica and economic data and estimate the cost-effectiveness of diversion and aftercare interventions for cass A drug-using offenders. The primary anaysis was restricted to offenders with a community-based sentence, or no sentence, as a resut of the index contact with the CJS. The economic anayses used the perspective of the CJS, NHS and socia care providers and offenders. The anaysis used cost-effectiveness anaysis and estimated the incrementa cost-effectiveness ratio (ICER) of diversion. Bootstrap simuations were used to generate 10,000 pairs of net cost and outcomes. These were used to estimate cost-effectiveness acceptabiity curves, the ikeihood of the estimated ICER and net benefit (NB) statistic. Heath benefit was measured using the quaity-adjusted ife-year (QALY) for the primary anaysis. Aternative measures of participant benefit were expored in the sensitivity anaysis. The time horizon for the primary anaysis was the 12 months foowing the index contact with the CJS. Longer-term impact (5 and 10 years) was expored in sensitivity anayses, using a Markov approach to mode subsequent cyces. One- and mutipe-way sensitivity anayses were used to expore the uncertainty associated with the choice of data estimates and mode design. Probabiistic sensitivity anaysis (PSA), using Monte Caro simuation (with 10,000 iterations) was used to expore variance and associated uncertainty in the parameter estimates. PSA assessed parameter uncertainty for the primary anaysis and each of the one- and mutipe-way sensitivity anayses. For the economic mode, the main sources of data were the UK Drug Data Warehouse, the UK Drug Treatment Outcomes Research Study and pubished government statistics and reports. Resuts Sixteen studies (reported in 14 papers) met the incusion criteria for the effectiveness review. Ten were US-based, four were based in the UK, one in Canada and one in Austraia. The US evauations were dominated by US drug court diversion interventions. These focused, in particuar, on the impact of the Caifornian Substance Abuse and Crime Prevention Act (SACPA) referra. This ed to a focus on methamphetamine-using offenders. Over 99% of participants incuded in the review were from Caifornia and evauations of SACPA. Ony haf of the incuded studies reported outcomes for offences other than drugs offences and one study ony incuded a comparator group of non-offenders. Incuded studies were generay of poor methodoogica quaity and characterised by modest sampe size, high attrition rate, retrospective data coection, imited foow-up and no random aocation of participants. There was aso evidence of pubication bias in the avaiabe iterature. Limited meta-anaysis of pooed studies was possibe, pointing to a potentia but sma impact of interventions on outcomes for drug use. Estimated odds ratios (ORs) were 1.68 [95% confidence interva (CI) 1.12 to 2.53] for reduced primary drug use and 2.60 (95% CI 1.70 to 3.98) for reduced use of other drugs. For the outcome of treatment competion, pooed outcomes did not favour cass A drug users. In comparison with users of other primary drugs, cass A drug users were significanty more ikey to be expeed or drop out of treatment eary (OR 0.89, 95% CI 0.80 to 0.96). The use of conceptuay different measures to evauate the outcome of reductions in offending behaviour prevented the pooing of data for meta-anaysis for this key variabe. The resuts of individua incuded studies pointed to minima impact of interventions on offending. For exampe, ony one study evauated the outcome of drug-reated arrests and arrests for vioent offending with statistica anaysis. This concuded that treatment competion had no independent impact on the ikeihood of subsequent rearrest for either offence type. The outcomes of genera arrest were sighty more equivoca, with one of three studies reporting a statisticay significant but sight reduction in rearrest as a resut of treatment (β = 1.34 treated vs. untreated). Too few studies addressed other potentia outcomes such as empoyment, training or famiy support/confict. The outcome measures used were too diverse to draw any substantive concusions regarding the impact of treatment. In addition, very few studies reported on heath-reated outcomes. A noticeabe absence being any focus on physica or menta heath, or onger-term impacts, such as hospita admission or mortaity. xxiv NIHR Journas Library

27 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 The review of the cost-effectiveness of diversion and aftercare did not identify any reevant studies. The primary anaysis of the economic mode indicated wide variance in net costs (net cost 147; 95th percenties 17,573 to 16,317) and sma net gain in QALYs (net QALY 0.005; 95th percenties to 0.065) from diversion. The 95th percenties for both net cost and net QALYs cross zero, suggesting no statisticay significant differences in cost and outcome. The anaysis suggests that the ikeihood that diversion is cost-effective is just over 50%. The 95% CI of estimates of net cost, net outcome and NB crossed zero for a the primary and sensitivity anayses indicating a high eve of uncertainty about parameter estimates. For many of the anayses, the ikeihood that diversion is cost-effective, if decision-makers were wiing to pay up to 30,000 to gain one additiona QALY for arrested drug users, was between 48% and 52%. These findings suggest that there is a ack of evidence either way, which is supported by the use of mutipe-way sensitivity anayses to refect changes in more than one parameter at a time. Concusions The quaity of the studies incuded in the effectiveness review was poor. In addition, the overwheming majority of participants incuded in the review anayses were American (Caifornian) methamphetamine users. This reduces the generaisabiity of pooed findings. There are obvious differences between the US and UK CJSs and methamphetamine users currenty account for ony 0.1% of the Engish drug treatment popuation. No reevant studies were identified for the cost-effectiveness review. The main reason for excusion of economic anayses was that they did not conduct a fu economic evauation that compared diversion to an aternative and incuded a measure of heath benefit (effectiveness, QALY or monetary vaue of participant heath and we-being) or estimated either an ICER or cost benefit ratio. Concusions derived from the economic anaysis were imited by the constraints of avaiabe data and uncertainty about structura aspects of the mode. It remains uncear whether or not the UK mode of diversion (DIP) had no impact compared with no diversion, or whether or not the evidence is insufficient to identify an existing difference. Importanty, this research identified a range of methodoogica imitations in existing evidence. These highight the need for research to conceptuaise, define and deveop modes of diversion programmes and identify a core outcome set. A programme of feasibiity, piot and definitive trias, combined with process evauation and quaitative research is recommended. The aim of the research is to assess the effectiveness and cost-effectiveness of diversionary interventions in cass A drug-using offenders. Within this programme, arge-scae evauations are needed, to examine which groups of cass A drug-using offenders are most ikey to benefit from diversionary interventions, in terms of primary drug use, ength of drug use, drug treatment history, pattern and history of offending. Funding Funding for this study was provided by the Heath Technoogy Assessment programme of the Nationa Institute for Heath Research. Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxv

28

29 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 Chapter 1 Background Cass A drugs A range of drugs is incuded in the category of cass A substances, which is a ega cassification under the Misuse of Drugs Act The Act identifies three casses of drugs (A, B and C). Those designated as cass A carry the most severe ega penaties for possession or suppy. Cass A comprises a heterogeneous group of drugs, incuding (but not imited to): powder cocaine crack cocaine ecstasy LSD (ysergic acid diethyamide) psiocybin heroin methadone. Some of these (e.g. powder cocaine, ecstasy, LSD and psiocybin) are more commony associated with a pattern of recreationa use. Heroin, methadone and crack cocaine are more commony associated with chronic and dependent use. Prevaence of cass A drug use The Crime Survey for Engand and Waes (CSEW) 2 provides estimates of the past year prevaence of cass A drug use. The CSEW is a survey of approximatey 50,000 househods in Engand and Waes. Estimates derived from the CSEW (2012/13) suggest that a tota of 846,000 [95% confidence interva (CI) 763,000 to 930,000] individuas aged years had consumed a cass A drug in the previous year. Individuas who had used drugs such as powder cocaine (627,000 individuas, 95% CI 555,000 to 699,000 individuas); ecstasy (415,000 individuas, 95% CI 357,000 to 474,000 individuas); amphetamines (211,000 individuas, 95% CI 169,000 to 253,000 individuas) and haucinogens (121,000 individuas 95% CI 90,000 to 153,000 individuas) accounted for the majority of drug use. The CSEW 2012/13 estimates the prevaence of opiate use as 38,000 individuas (95% CI 20,000 to 56,000 individuas) and crack use as 47,000 individuas (95% CI 27,000 to 67,000 individuas), in Engand and Waes. These estimates for use of opiates or crack cocaine are much ower than the 164,671 opiate and/or crack users known to have received treatment for substance misuse in Engand during Surveys are unikey to capture those margina popuations at high risk of dependent use of opiates/crack adequatey, such as prisoners or the homeess. Estimates of the prevaence of opiate and/or crack cocaine use based on indirect estimation methods, not subject to the same biases as survey approaches, suggest that there were 298,752 (95% CI 294,858 to 307,225) opiate and/or crack cocaine users aged years in Engand during 2010/11. 4 Combining the mid-point estimate with treatment figures suggests that around 58% of the opiate- and/or crack-using popuation were in receipt of drug treatment services during This proportion is higher than that estimated for most other European countries and comparabe with that seen in Austraia and the USA. 5 The use of crack or cocaine nationay increased from approximatey 14% of treated drug users at the time of the Nationa Treatment Outcome Research Study (NTORS) in to at east 40% in 2010/11. 7 The argest proportion were treated crack users (72,000 treated crack users, with < 10,000 treated cocaine users). Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 1

30 BACKGROUND There is considerabe debate concerning the precise nature of the reationship between drug use and crimina behaviour. Reguar, recent use of opiate drugs and/or crack cocaine is very common among UK sampes of arrestees. Use is at rates that are very much greater than prevaence rates in the genera popuation. 8 The buk of those arrestees consider that they are dependent on these drugs. 9 Experience of cass A drug use is aso consideraby higher among the prison, than the genera, popuation. Across European countries, prisoners have a ifetime prevaence of 6 53% for cocaine use and 15 39% for heroin use. This compares with % and < 1%, respectivey, in the genera popuation. 10 Athough the prevaence of other types of cass A drug misuse is much greater, it is estimated that opiate and/or crack users account for 99% of the socia and economic costs associated with cass A drug use. 11 Opiate and/or crack users are the group primariy served by substance misuse treatment services. In the UK, they are the main focus of crimina justice system (CJS) diversion initiatives for drug misusers. Hence, it is the primary focus of the work described in this report. Cass A drug use and crime Crimina justice system referra is an increasingy important route through which drug users access the treatment system. In 2010/11, 30% of cients starting new treatment journeys did so via a CJS referra. The Drug Interventions Programme (DIP) referras accounted for 14% of referras overa. 7 Nevertheess, arrest referra services were argued by some to do itte to introduce hidden cient groups to treatment opportunities. 12 Offenders who misuse drugs often have more serious drug probems than the genera popuation of drug users and they are potentiay ess responsive to treatment The pattern of offending differs somewhat between drug users and non-drug users. Sampes of arrestees in Engand and Waes indicate that, for exampe, assaut accounts for 29% of arrests yet just 4% of these were individuas reporting at east weeky use of heroin and/or crack. Conversey, shopifting accounted for 10% of arrests yet 45% of these were probem drug users. 16,17 Indeed it has been estimated that over haf of a such recorded acquisitive crime in the UK is drug reated, motivated by the need to obtain income for drugs, rather than vioence associated with pharmacoogica effects or drug markets. 18,19 However, the iterature suggests a more compex association between drug misuse and acquisitive offending than a simpe causa reationship Not a drug users commit acquisitive offences. Acquisitive crime often pre-dates probem drug use. 15,24 Drug use and criminaity may deveop in parae, 25 perhaps via a third factor such as socioeconomic deprivation. 23 The Drug Treatment Outcomes Research Study (DTORS) 26 evauation found that behavioura and demographic factors were stronger predictors of invovement in acquisitive crime than drug use expenditure. This suggests that the need to finance drug use is not necessariy the main factor driving acquisitive offending by drug users. 27 Use of cocaine, in particuar crack cocaine, has been inked to acquisitive crime. In the Research Outcome Study in Ireand (ROSIE), 28 peope using cocaine/crack were more ikey to report crimina activity than those not taking cocaine or crack. 29 In NTORS, predictors of acquisitive offending incuded reguar use of cocaine (powder and/or crack). 15 Age may aso predict crimina invovement: two-thirds of a 2009 cass A drug-using offender cohort were aged < 35 years and arrestee surveys highight the ikeihood of acquisitive crime decining with increasing age among drug users. 16,30 Poysubstance-using offenders commit twice as many offences as those not reporting mutipe drug use. 31 High eves of poydrug use are recorded among drug-using arrestees NIHR Journas Library

31 DOI: /hta19060 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 6 Poicy context The UK poicy focus on reducing drug-reated crime first emerged during the 1990s, most visiby with the pubication of a series of reports by the Advisory Counci on the Misuse of Drugs (ACMD). These considered responses to drug misuse within the CJS and highighted the prevaence of cass A drug misuse, particuary opiate use, among acquisitive offenders. 32 The issue gained poitica prominence in 1994 with the Labour Party stating, whie in opposition, that a haf of the 4B cost of recorded theft was attributabe to drug misuse. This contrasted with the government estimate of between 58M and 864M for the cost of heroin-reated acquisitive crime in Engand and Waes. 33 A subsequent, and independent, estimate suggests that the wider socia and economic costs of probematic cass A drug use in Engand and Waes was 12B (range 10.1B 17.4B) during Drug-reated crime accounted for approximatey 88% of that tota. 34 Notwithstanding the accuracy of the above estimates, there was concern about the socia consequences of probem drug use, particuary drug-reated crime. This cuminated in a strong emphasis on the potentia for effective treatment to contain or reduce these consequences. The ACMD highighted that,... there is now an onus on these [drug treatment] agencies to take a broader view and deveop their focus to incorporate community safety as we as care of the individua drug misuser. ACMD 32 The contemporary government drug strategy incuded the objective to, reduce the incidence of drug-reated crime. 35 Athough focusing primariy on aw enforcement, the strategy recommended diversion of arrested drug misusers into treatment. A ater review of drug misuse services 36 concuded that contact with the CJS provided opportunities to engage probem drug users with treatment. In addition, the need to safeguard communities was reaffirmed within the subsequent government strategy for tacking drug misuse, which incuded the aim to protect our communities from drug-reated antisocia and crimina behaviour. 37 In the atest government drug strategy document, 38 covering Engand and Waes, CJS diversionary schemes continue to be a focus of contact with drug users. The coaition government expresses its desire to... ensure that offenders are encouraged to seek treatment and recovery at every opportunity in their contact with the CJS. 38 The 2010 strategy identified the importance of eary intervention for young peope and famiies to hep those who may be at risk of invovement in crime and antisocia behaviour. Current service provision Drug treatment and rehabiitation services are commissioned and provided in four tiers. Tier 1 reates to primary-care services. Tier 2 provides open-access and non-structured drug treatment services; information, advice and harm-reduction services; screening for drug misuse and referra to speciaist drugs services. Tier 3 provides structured community-based drug treatment and rehabiitation services. Services in tier 4 provide residentia drug treatment and rehabiitation, aimed at individuas with a high eve of presenting need. Tier 3 and 4 services account for around 70% of tota drug treatment costs. Foowing the introduction of arrest referra schemes 14 the nationa DIP was introduced in DIP aimed to identify and work with drug-misusing offenders at each stage of their contact with the CJS from the custody suite through to community The core remit of DIP is to address drug misuse and offending to hep individuas get out of crime and into treatment and other support. 39 The programme incudes both custodia and community components, with vountary and coercive eements. The buk of provision, in terms of its diversionary Queen s Printer and Controer of HMSO This work was produced by Hayhurst et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 3

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