Community sentencing options for people with substance use problems: review findings summary

Annex 1: Evidence review of good practice in court mandated treatment

The evidence base related to court supervised, community based treatment for people with both substance use problems and criminal charges is complex and mixed. A 2020 systematic review of substance use and community supervision found that "internationally, there is a high prevalence and complexity of substance uses amongst people under community supervision. Despite clear benefits to individuals and the wider society through improved health, and reduced reoffending, it is still difficult to identify the most effective ways of improving health outcomes for this group in relation to substance use from the literature" (Sirdifield et al). The authors recommend a detailed, and up-to-date profile of this population's needs is essential to designing and planning interventions – notably something Scotland does not currently have.

Drug treatment itself is generally associated with reduced offending. For example, one study (Bukten et al, 2011) estimated that crime rates halved in a three year follow up, for people using opiates who entered treatment. There is also evidence that diverting people away from prosecution can help address their needs better than criminal prosecution can. A systematic review and meta-analysis looking at diversion from prosecution for people who use class A drugs, found that although class A drug users were less likely to complete treatment than users of other drug classes, there was still evidence of reduction in drug use and a limited impact on offending behaviour for those diverted to drug treatment.

However, not all people can or should be diverted away from prosecution and if a person's alleged offending behaviour reaches a threshold of seriousness or repetition, in line with the COPFS prosecutorial guidelines, prosecutors may bring that person before court, and the court must respond to them in the way they deem most appropriate in line with Scotland's sentencing laws. This Annex reports on the evidence base for developing effective court ordered, non-custodial treatment based court responses that can support people in the justice system.

1. Understanding drug use, recovery and desistance

1.1 Substance use and its relationship to offending

Substance use disorder and offending behaviour are both extremely complex phenomena. They both have a wide array of causes, many of which overlap or are correlated with one another.

It is beyond the scope of this report to attempt to disentangle the fundamental causes and effects involved in the development of either substance use disorder, a pattern of offending behaviour, or both. However, to understand how our policies and criminal sentences can best respond to people in this position, it is important to first define problematic substance use, and then understand how the experience of substance use, offending, recovery and desistance happens.

Like all complex and contested concepts, there are many different definitions of problematic or disordered substance/ drug use, and every person affected will have a unique experience. Its symptoms manifest in a variety of ways: cognitive (affecting the person's thoughts and the way they think), behavioural (affecting the actions the person takes) and physiological (affecting processes and chemistry in the person's body, especially their brain, the organ that coordinates their thoughts and actions).

The medical description of this experience is well summarised by the Diagnostic and Statistical Manual of Mental Disorders (5^th ed), which lists, as diagnostic criteria, the types of things people experience:

• Impaired self-control – such as consuming larger amounts, over longer periods than initially intended. This is the experience of deciding (cognitively, in your brain) that you want to reduce or cease usage, but finding yourself using drugs again anyway, often because of strong cravings (which are intense physical feelings experienced in your body, and thoughts about obtaining and using the substance, experienced in your brain).
• Social impairment – such as failing to meet obligations at work, school or home, or giving up valued relationships or activities. This is the experience of valuing a person or part of your life, but finding yourself doing the behaviour of using drugs instead of behaviours that maintain that relationship or part of your life, even though you know that this may harm that person or your relationship with them.
• Risky use – such as injecting, sharing equipment, using large doses, or obtaining drugs through means that may risk violence, sexual victimisation or criminalisation. This is the experience of being aware of a potential risk to your safety, wellbeing or health, but doing the behaviour of continuing to obtain and use drugs instead of the behaviour of seeking to avoid this risk.
• Tolerance and withdrawal – which may be seen in requiring larger quantities to achieve the same high, or experiencing negative physical symptoms when they stop taking the substance. This experience varies greatly between different substances, but often includes a range of general somatic symptoms associated with many illnesses, such as nausea, headache, diarrhoea, sweating, shaking, aches and cramps.

This experience is overall characterised by a lack of control over one's own thoughts or actions - the person can perceive the potential or real harm to themselves and their loved ones,yet experience an inability to turn these thoughts into a different behaviour, and possibly suffers acutely when they try. This must be borne in mind when thinking about how our services, and their policy environment, can best support people recovering from problematic substance use. In particular, it is worth highlighting that the process of recovery and desistance described in the next section, is made up entirely of mental and behavioural steps that the person misusing substances can only take using their own brain. While these steps may appear straightforward to people who have not experienced dependency before, it must be borne in mind that those who actually need to take them are operating in the circumstances described above.

Researchers have suggested a number of different pathways that might explain the relationship between this experience of substance use, and its well documented correlation with offending behaviour. These include: criminal behaviour conducted to support a substance dependency (eg acquisitive crime or drug dealing), lowering of inhibitions secondary to substance use (ie, offences committed as a consequence of impaired judgment due to intoxication), and/or exposure to anti-social or pro-criminal peers and environments. Such exposure may be due to multiple factors including the fact that drugs can only be sold illegally, are typically distributed via serious organised crime groups, and can cause isolation from more pro-social relationships (White and Gorman, 2000).

If we ask what it is that causes some people to both develop substance problems and commit offences, there are many answers depending on how the question is approached. The person's thoughts and behaviours are produced by their brain, so that is perhaps the first place to look. The brain's main function is to manage the flow of different signals and chemicals, in order to keep a person's body alive and functioning. A crucial one is dopamine, a "reward" chemical that has evolved as a tool our brains use to signal that we are doing something that is good for our survival – it feels positive and thus rewards our brain for producing that behaviour. However, drugs can also produce large, artificial spikes in dopamine, despite not reflecting a behaviour that aids survival.

If the person experiences these large artificial spikes in dopamine repeatedly over time, their brain will start to normalise this and apply the excess dopamine not just to the substance itself, but to behaviours, environments or other cues that are merely associated with the substance for that person. Volkow et al (2011) suggest that over time, the person's brain chemistry shifts in such a way that the excess dopamine becomes associated with increasing engagement in behaviours that are associated with obtaining and using drugs. Depending on the person's circumstances and legal context, this might often involve behaviours like lying, stealing, following impulsive or compulsive urges, spending time with drug dealers and their networks, or spending time in places where drugs are used. The authors summarise thus: "their behaviours are now governed by the uncontrollable overvaluing of the drug and by growing insensitivity to the deterrent value of potential punishments".

It is important to note that this neurological model of drug use only partially answers the question of why some people experience substance use problems and offend. It is well documented that a host of familial, social and economic circumstances contribute to both criminogenic risks, and the risk that someone will start to use drugs, or that their drug use will escalate. Fully explicating the complex relationship between substance use and offending behaviour is beyond the scope of this review (and indeed, of current human knowledge), but the two share many other frequent correlates such as adverse childhood experiences, trauma, victimisation, bereavement, learning difficulties and neurodivergences, economic and social exclusion, and mental health difficulties.

1.2 Recovery, desistance and agentic change – what can we expect from "treatment" for this group?

There are a number of theoretical models of how recovery from problematic substance use and desistance from crime each work. They generally show many similar considerations as well as some key differences. However, theories that focus on one or other problem are not necessarily apt to apply to the population of people at the intersection of both categories.

The idea that perhaps most consistently appears in relation to both, though, is the person's identity and their degree of (bounded) agency in determining their own behaviour. This idea is key to many leading models in the present literature^[4]. There are some models such as the Life Course Theory of Desistance (e.g. Laub and Sampson, 2003; Hser et al, 2007), or the Cognitive Theory of Transformation (e.g. Giordano et al, 2002; Coleman and Vander, 2012) that seek to identify external or causative factors that can support desistance and recovery. But, ultimately all models rely on some degree of intrinsic individual motivation to change, and all models to date have failed to identify consistent types of external events that can make someone change. Rather, the most consistently reported experiences of change are not linked to an external "cause" but instead depend on the person's self-motivated decision to use their own agency to change their behaviour.

Recent work by Streisel (2021) provides the most detailed accounts of this process, and is supported by an unusually long follow up period – whereas most studies on recovery or reoffending report outcomes over 6 months–2 years, Streisel explores participant's justice and treatment related experiences and outcomes over a 20 year period. Although the study draws on a relatively small sample, the length and breadth of experience the participants bring, and detailed qualitative analysis conducted, make it a useful source. Drawing on Identity Theory of Desistance, Streisel finds extensive evidence for a congruous account of recovery and desistance along the following lines:

1. The person must experience a genuine "crystallization of discontent" – meaning that they must come to truly believe that the behaviour (whether that is offending or substance use) is causing other problems or failures in their life, and that the benefits and rewards no longer outweigh the risks and consequences. In Streisel's sample:

a. For desistance from crime, this typically revolved around feeling out of control or unable to have a normal life, and the impact on loved ones.

b. For recovery from substance use, this typically revolved around the physical and mental effects of drug use, and the drugs becoming less effective at their original purpose in the person's life (eg self-medication or escape from reality).

c. "Failure" in treatment was often linked to the person not experiencing crystalised discontent because, for example, they were heavily involved with or reliant on peers who used, they used substances in order to manage chronic stress or past trauma, or they did not understand their substance use as a problem (perhaps in the context of other, perceived bigger problems or because they were still finding pleasure in their substance use).

2. The person must experience a genuine "vision of the feared self" – meaning that they must come to see themselves as being on a trajectory that will lead them to become a person they do not want to be. In Streisel's sample:

a. This was the primary motivation for most of those who had desisted from both drug use and offending.

b. The person often reached this point through both personal experience and by witnessing peers.

3. The person makes an "agentic decision" to change – meaning that, as a result of the experiences above, their personal agency guides them logically to the decision to change their behaviour, because it has become what they themselves want (regardless of motivations linked to what external forces like what their family members or employers want). In Streisel's sample:

a. For both desistance and recovery, commitments to change and engagement in treatment were typically only successful when the person had undergone this agentic change.

b. When the person's commitment to change was done for the sake of others, such as to appease family or employers, change was either impossible, or did not last.

4. The person then embodies and takes action on that decision, through "changing preferences and supports" – meaning that, once a person makes a genuinely agentic decision to change, their preferences will naturally begin to align with a more "pro-social" lifestyle and identity, and they can then safeguard those changes by putting supports such as treatment services and lifestyle changes in place. In Streisel's sample:

a. People desisting from crime made changes to their daily routines and the people they spent time with, and some found connecting with organised religion helped them find alternative ways to deal with hardship.

b. People recovering from substance use made similar changes, and also engaged with treatment and support groups, and sought to learn more about managing stressors and resolving past traumas.

Notably, while this process was similar for both desistance and recovery, the ability for these two processes to influence one another does not appear to be symmetrical. In general, when a person first made an agentic decision to stop using drugs, this most often led to them also ceasing offending behaviour. However, when a person first made an agentic decision to stop committing crimes, ending substance use did not always follow.

Recognising that this process of agentic choice must be at the core of anyone's recovery or desistance if it is to last, highlights the importance of considering very carefully what "success" or "progress" might look like for the population of people receiving court sentences. There is some evidence that mandated treatment can be as effective as voluntary treatment (eg NIDA, 2014), and other evidence contesting this claim (eg Van Wormer and Davis, 2016). What is clear is that mandated treatment cannot be effective if it does not first address the person's motivation and readiness to change.

There is evidence to support the suggestion that practitioner interactions and interventions can serve to enhance a person's intrinsic motivation (summarised well in Wallace, 2019). People mandated to treatment are responding primarily to external pressure (ie, an order from the courts), which is unlikely to be adequate to sustain long term change. However, if their practitioner can help the person to identify and reflect on their own concerns or problems, this can create an opportunity for the person to, (in Streisel's language) reach a stage where their discontent with their drug use becomes more "crystalised", and they are able to contemplate possible futures if they remain on the same trajectory.

Wallace notes that early on (what might be considered before the agentic decision to change), people will generally have a range of internal and external concerns related to their drug use, but may also suffer from ambivalence, a lack of confidence or self-efficacy in making change, or from insufficient coping skills to manage any other way than the one they already know. These are all barriers that interventions such as motivational interviewing or relapse prevention with specific skills training components can help to reduce, so that the person's concerns may be amplified into an intrinsic motivation to change over time (Patterson, 2018). To put it most simply: there are two groups of clients who may enter mandated treatment:

• those who have already made a genuine agentic decision to change, and for whom drug treatment will be helpful in enacting that decision and maintaining consequent lifestyle changes.
• those who have not yet made a genuine agentic decision to change, and for whom treatment may be useful to either help them reach that point, or provide knowledge they can utilise in the future when they reach that point themselves.

It is fair, therefore, to share Hunt and Stevens (2004) concern that substantial investment in coerced or mandated treatment may waste scarce resources on more uncertain, coercive interventions than those delivered to entirely voluntary clients, and divert staff from treatment modalities with better-known efficacy. However, this analysis misses two important points: first, this type of intervention can in fact be effective, if the goals and modes of delivery are set appropriately, with cognisance of the need to foster the person's agentic change rather than putting them through a general "treatment" they are not yet ready for; and second, that those populations with lower treatment efficacy may still be efficient investments, considering that the costs and harms of their chronic condition and frequent contact with the justice system are likely also higher.

1.3 Role and aims of treatment for this population

With the above in mind, what role can treatment play in improving the health, circumstances and offending behaviour of people who have both substance use problems and criminal charges?

It has long been recognised that recovery from substance use (and other addictive behaviours) is a process that takes time and has a number of phases. The most common model based on the person's experience is the Stages of Change, as described by Prochaska and DiClemente (1983), while many others relate these experiences to the treatment process (for example Wallace's Phases of Treatment and Recovery (1996), and similar constructions (Mercer and Woody, 1999, Daley and Mercer, 2002, McLellan, 2003)). The Stages of Change, as typically understood, are:

• Precontemplation: before the change process begins, the person is living with the thoughts and behaviours of problematic substance use and is not even thinking about changing
• Contemplation: the person begins to think about ideas related to change, such as imagining what it would be like to change and wondering whether they should change their behaviour
• Preparation: the person has made a decision that they want to change and are preparing to do so, but have not yet taken tangible actions
• Action: the person begins to take actions and change their behaviour
• Maintenance: the person has made the key changes they wish to, and now works to maintain and strengthen their new identity and lifestyle to prevent relapse.

In reality, of course, these steps are not so discretely defined, and the process is not linear, meaning people regularly relapse from one stage to the previous one as they work on their recovery.

As typically presented, the traditional phases of the drug treatment process can be very broadly characterised as follows:

• Withdrawal phase (also called detoxification or stabilisation of care, lasting several days)
• Prolonging abstinence (also called intermediate stage of care, lasting several weeks to months)
• Pursuing lifetime recovery (also called continuing care, lasting one or more years)

However, this model of care, beginning with the "Action" step of withdrawal, leaves an expectation the person will contemplate and prepare for change, and indeed take the first action by reaching out for treatment, before they start to receive specialised support. This makes sense for a tradition rooted in voluntary treatment that works primarily with people who have made an agentic choice to change. But for people who are attending treatment due to a court order, many will not have been through these internal steps, making it inappropriate to begin immediately with such action steps.

In light of this, as well as the extremely diverse needs of people mandated to treatment, Wallace proposes practitioners use a broader, and more flexible approach. She recommends thinking of this process as simply:

• Approximately 6 months "Early Phase", which may include moving the client from pre-contemplation through contemplation and preparation, and into withdrawal, or possibly even prolonging abstinence.
• Thereafter, a "Mid-to-late Phase", which may include action in order to prolong abstinence and/or maintain recovery.

This has important implications for both what we expect is a realistic amount of progress for someone mandated to treatment to make in a set period of time, and also for the types of interventions and services we provide. Wallace highlights that since mandated treatment must meet the person exactly where they are, there is a significant role for:

• Integrating the earlier stages of change (contemplation, preparation) into the treatment process, rather than commencing with withdrawal. This means a greater emphasis on education and consciousness raising and interpersonal techniques like motivational interviewing (described in more detail in the next section).
• Using a "gradualist" approach that integrates Harm Reduction and Moderation Approaches, potentially but not necessarily in the pursuit of abstinence

Additionally, Wallace (2019) also notes that it may not be possible to identify the extent of problems such as depression, anxiety, PTSD, paranoia or hallucinations until the person has been abstinent for at least four weeks. This highlights the importance of frequent reassessment of the person's symptoms and needs, and treatment plans and pathways that are flexible and able to incorporate contemporaneous mental health treatment if the need emerges.

There is certainly a role for drug treatment for the population of people who have substance related problems and also criminal charges. However, the evidence above demonstrates that such treatment must be cognisant of this population's different starting point in the stages of change, compared to people voluntarily entering treatment. In order to foster lasting change in people's lives and behaviour, treatment must focus on fostering a genuine agentic change in the person's worldview.

It is also worth noting that the court process and judicial supervision have the potential to either support or disrupt the development of this agentic change. Since a necessary step is for the person to develop a genuinely held belief in the connection between their drug taking behaviour and other problems in their life, clear communication and timely processing can help the person to draw this connection, while decisions that seem arbitrary or so slow as to become disconnected from the precipitating behaviour may sever this connection in the person's mind.

2. Features of evidence based mandated treatment

If we accept, then, that there can be a useful role for treatment for at least some people mandated through the justice system, the next question is what we might hope that treatment looks like. There is a large body of research, and many different sets of principles or frameworks for what constitutes effective or evidence-based interventions for this population. A relatively comprehensive example is the US National Institute on Drug Abuse's 13 principles of effective treatment, which are:

• Drug dependency is a complex but treatable disease that affects brain function and behaviour. Changes in brain structure and function persist long after cessation of drug use, resulting in a risk of relapse even after long periods of abstinence.
• No single treatment is appropriate for everyone.
• Treatment needs to be readily available.
• Effective treatment attends to multiple needs of the individual, not just his or her drug use.
• Remaining in treatment for an adequate period of time is critical.
• Behavioural therapies including individual, family or group counselling, are the most commonly used forms of drug abuse treatment.
• Medications are an important element of treatment for many patients, especially when combined with counselling and other behavioural therapies.
• An individual's treatment and services plan must be assessed continually and modified as necessary to meet all the person's changing needs
• Many people with substance use problems also have other mental disorders or illnesses
• Medically assisted detoxification is only the first stage of treatment, and by itself does little to change long term drug abuse
• Treatment does not need to be voluntary to be effective (if it can foster a person's readiness to make an agentic choice to change, or if it gives them skills and knowledge to minimise harm or help themselves change when they are ready)
• Drug use during treatment should be monitored, as lapses occur and should be addressed honestly in treatment
• Treatment programmes should also offer testing for blood borne viruses and infections that are known to be associated with some drug use practices.

These principles vary significantly in their specificity, and in how directive of practice they are. On the other hand, Wallace's (2019) guidelines for deploying a unified theory and model for mandated drug treatment can be abbreviated into the following process:

1. Understand client's context and past experiences

2. Perform thorough individualised assessments

3. Deliver evidence-based interventions, tailored and individualised to the person's needs, preferences and culture as required

4. Respond to multi-problem clients with an integrated and comprehensive care package

5. Engage in continuing reassessment and ongoing observation to adapt to the client's changing needs and progress.

These are important practices that require a well-trained workforce and an enabling policy context. But this outline only gets us a limited distance – it is a model for deploying good practice, but does not in itself tell policy makers what they should be prioritising. What are the "evidence based" interventions that should be delivered, and how are they best implemented? Before answering that question, we must consider what "effectiveness" and "evidence based" mean in this space.

As with all complex interventions in complex systems, there is a wide range of ideas about what outcomes should be sought, how to measure those outcomes and also how to prioritise them when they may be in tension. Substantial practical, legal and ethical challenges make it very rare for studies in this space to utilise the most rigorous methodologies like randomised controlled trials (RCTs) or robust quasi-experimental or matching approaches, meaning that researchers seldom have access to a meaningful comparator group that would allow them to confidently attribute impact. Prochaska (2008) points out that thorough evaluations of effectiveness can generally only take place where a single intervention targets a single behaviour or problem – which is of limited utility when in actuality the people accessing these services typically have multiple problems and health disparities, with myriad roots, necessitating multiple interventions, and most psychological interventions treat more than one symptom or behaviour.

One consequence of this is that the body of literature that assesses interventions for this population may be significantly biased in favour of interventions and outcomes that lend themselves to rigorous study designs and measurement, rather than those that make the most difference to people in actuality. For example, Wallace points out that field effectiveness studies using longitudinal designs are not considered a highly rigorous methodology by traditional empirical research standards "yet have provided the most extensive empirical knowledge of the effectiveness of the three main publicly funded treatment modalities [in the US]: methadone maintenance, drug free outpatient, as well as residential therapeutic communities".

This means that, overall, while there is extensive literature on drug treatment and on recidivism from crime, there is a lack of high quality, comparable evidence to draw on in relation to people at the intersection of both issues. To help overcome this limitation, Wallace argues that policy makers and practitioners should expand their ideas of evidence for "effectiveness" for this group. In particular, since we do know that people in this population are to some extent, (In Wallace's language) "inherently multi-problem", it is essential to deploy multiple interventions that impact on multiple behaviours. She points out that interventions delivered from a multi-behaviour paradigm cannot be classed as "evidence-based" in the strictest, traditional sense because they have not been extensively evaluated and validated in RCTs or similar studies. However, these approaches can instead be considered "state of the art", as they are "in use, promising, valued" and based on evidentially supported components, despite the overarching approach not being empirically validated.

Additionally, Streisel's (2021) study exploring people's 20 year outcomes and experiences found that treatment may still be helpful to those for whom it "fails". Her participants had found treatment helpful in two ways:

• While in treatment the support system, sense of security, and daily structure were all reported to be helpful in maintaining sobriety for a period.
• After treatment participants reported that knowledge gained in treatment, about drug dependency as a chronic disease, how to cope with stress or trauma, and what practical steps they can take to avoid triggering cravings, was helpful. This was both for maintaining sobriety, but also even if the person relapsed – they reported drawing on this information to help them reduce harm while using, and to re-engage with treatment later once they had experienced an internal agentic change.

This highlights the importance of broadening ideas about what we regard as "effectiveness" when thinking about this population. This delayed effect is another example, alongside harm reduction practices and the short-term protectiveness of treatment engagement, that may not be captured by simple "recovery success" metrics.

Moreover, Streisel further complicates the idea of identifying "what works", by highlighting that many things that are helpful in treatment for some people, are viewed as unhelpful or even harmful by others. For example, group work that facilitated learning from other's experiences was highly engaging and effective for some participants, but others found some group work to be overly backward-looking and some even reported feeling it triggered them to use drugs again because of the cravings these conversations provoked

With these complexities stipulated, this section summarises the current available knowledge on effective interventions for this group. It is organised based on Wallace's (2019) "Recommended Menu of Evidence Based Addiction Treatment" from the leading textbook on mandated drug dependency treatment, supplemented with evidence from the wider literature on addressing people's complex needs in this setting.

2.1 Gold Standard: The Matrix Model

Combining many of the considerations in this section, Wallace (2019) proposes that the ideal approach to delivering effective mandated treatment is the "Matrix Model". This involves medically supervised detoxification if required, then the person being enrolled in a day-treatment / outpatient model that is:

1. Intensive (4-5 days per week),

2. Extensive (minimum 18 months including continuing care), and

3. Comprehensive (incorporating multiple approaches including a therapeutic alliance, various forms of individual and group counselling / therapy, drug testing, education and family / peer involvement). In essence, this model makes many of the features laid out below available, and matches people to those best suited to their needs at any given time.

2.2 Feature: Thorough Individualised Assessment and Targeting

Assessment and targeting are crucial to ensuring people receive the right interventions for their circumstances and needs. This should begin with thorough assessment at intake, and continue throughout treatment.

From a treatment perspective, Wallace (2019) summarises the best practice: "adherence to one theoretical model or a particular method of treatment is not required and not recommended" but rather "it is essential for practitioners to exercise both some degree of fidelity to evidence based treatment interventions as well as flexibility in responding to individual client needs via individually tailored treatment".

This then enables practitioners to adapt interventions in response to each person's:

• 1. degree of dependence on substances, and related problems.
• 2. stage of developing their readiness to change, as covered in previous sections.
• 3. learning or communication needs, which are relevant to both how interventions are delivered, and also understanding their wider support needs. This may also reveal the need to refer to specialist assessment for previously unidentified neurodivergences that would warrant support and/or treatment, such as Autism Spectrum Disorder (ASD), Attention Deficit/ Hyperactivity Disorder (ADHD), or Dyslexia.
• 4. wider needs including shelter, housing security, safety, food, income, meaningful use of time, and social bonds. This informs both what should be prioritised in holistically supporting the person, and what can realistically be accomplished in terms of substance use reduction.
• 5. each person's unique background. This might include incorporating aspects of their cultural background, religion, sexual orientation, gender identity, or family context where these are helpful to strengths-based identity formation, or being sensitive to the diverse and potentially negative experiences some people may attach to these identities.

In the literature on offending, there is a similarly longstanding and well-validated principle relating individual assessment and careful targeting to improved outcomes. This comes from Andrews and Bonta's (1990) framework referred to as "Risk, Need, Responsivity" or RNR. The RNR model for all offending behaviour can be broadly summarised as follows:

• Risk: Different people have different levels of risk for offending. These risks can often be identified or measured by looking at 8 "major risk factors" which are:
  • A personality pattern that is anti-social, impulsive and/or "restlessly aggressive"
  • Attitudes that are pro-criminal or negative towards the law
  • Having friends and family members with the above attitudes, especially in the absence of friends and family members with more pro-social attitudes
  • Substance use
  • Poor family or marital relationships
  • Poor performance, disengagement from, or low satisfaction with school or work
  • Lack of involvement in pro-social recreational activities or positive uses of time
• Need: When people offend, it is usually to meet some underlying need that they have. In order to desist from offending, people must find alternative ways to meet these needs. For example:
  • attitudes and peer groups are likely to have been shaped by economic circumstances and past experiences that impact how and when the person feels safe
  • pro-criminal, or otherwise dysfunctional relationships with friends or family may persist because they represent the only meaningful relationships and sources of support and human connection that the person has
  • Substance use and disengagement from activities, learning and formal employment likely reflect struggling to cope with particular situations, and/or mental health difficulties or unresolved trauma.
• Responsivity: Different people respond differently to interventions. Interventions should provide cognitive behavioural treatment along with other support to reduce the person's risk by addressing their needs, in ways that are tailored based on factors that affect their responsiveness, such as the person's:
  • learning style
  • source and degree of motivation
  • abilities and strengths
  • personal circumstances, economic and social context

Adherence to the core RNR principles has been found to be associated with reductions in reoffending – adherence to all three principles has been found to result in a 17 per cent positive difference in average recidivism between treated and non-treated offenders for interventions in custodial settings, and a 35 per cent difference in community settings. In contrast, recidivism increases when there is a failure to adhere to any of the RNR principles (HM Inspectorate of Probation, 2020).

Marlowe summarises the most reliable predictors of risk amongst people who use drugs and commit crimes as being: younger age, male gender, early onset of substance use, prior convictions, previously unsuccessful treatment attempts, anti-social personality disorder, and a preponderance of antisocial peers (Marlowe, Patapis and DeMatteo, 2003).

Adaptive interventions adjust the dosage and type of services in response to participants clinical presentation or performance in treatment. For example, some US studies have suggested that high-risk participants were more likely to graduate from drug court programmes, provide more negative drug tests, and report less drug and alcohol use, when required to attend fortnightly court hearings rather than court hearings only as necessary. Marlowe et al (2006) found "evidence for the utility of prospectively matching drug offenders to different dosages of judicial supervision based upon an assessment of their risk status and clinical needs (Marlowe at al 2006). These findings are supported by subsequent meta-analytic evidence that specialised courts that adhere to the "risk and need" principle are related to greater reductions in offending compared to treatment as usual (Guttierrez et al, 2016; Gutierrez and Bourgon, 2012).

Apart from the cost implications, some have argued that the intrusion of the judge into the treatment process could be disruptive or harmful to the therapeutic alliance (eg Schottenfeld 1989). Moreover, being "treated like a criminal" by being brought into court regularly might produce counterproductive feelings like resistance or reactance, and may in fact strengthen the person's identity as a criminal or their tendency to identify with other criminal peers. The authors state it is therefore important to determine which offenders require intensive monitoring by a judge and which can be adequately supervised by clinicians or case managers.

Kearley and Gottfredson (2020) note that across the US, drug court eligibility criteria tend to be highly restrictive, often only serving low risk, non-violent offenders (Franco, 2010), despite evidence that suggests higher risk offenders do equally well or better (Marlowe et al, 2003; Marlowe et al, 2007; Rossman and Zweig, 2012). Lowenkamp's 2005 meta-analysis found the effect size for drug court participation was twice as large for high risk participants as low risk. In fact, placing low risk offenders into residential or group-based treatment can even have an iatrogenic effect – that is: it may in fact cause worse outcomes than if they had been left in a mainstream court process (Lovins et al, 2007; Lowenkamp and Latessa, 2005).

2.3 Feature: Strong therapeutic alliance

There is extensive evidence that the relationship between a person and their practitioner(s), (often referred to as a strong Therapeutic Alliance / Support System (TASS)), is a key factor in both treatment retention and success. There are multiple mechanisms through which this effect may accrue:

1. The practitioner demonstrating openness and social support creates the conditions for the person to feel comfortable sharing about themselves and their actions and experiences, an essential pre-condition for thorough and accurate assessment.

2. A positive experience and meaningful relationship developing at treatment appointments helps to engage the person and keep them returning so that interventions can be delivered.

3. Building trust between the person and the practitioner allows the person to feel comfortable confiding when they struggle or relapse. This enables the practitioner to support the person through the setback, rather than the person disengaging.

4. Over time, this relationship allows the practitioner to naturalistically observe the person, learn their patterns of cognition and behaviour, and their triggers for lapse and relapse, so interventions can be adapted flexibly to their needs.

5. By replicating the positive regard and care of a functional personal relationship, the practitioner can help the person to:

• develop their self-esteem and healthy ideas of how they can relate to others
• safely experience and express their emotions in a way that develops their skills for managing interpersonal relationships and related feelings in their wider lives.

The counsellor-client working alliance has proven to be a better predictor of positive treatment outcomes than any other variation of treatment models or theoretical orientation (Hauser and hays, 2010; Wampold et al, 1997). Because of this, Wallace (2019) states that strong therapeutic alliance from the very beginning of treatment, and throughout service delivery, is the foundation for almost all effective interventions. This is supported by Lebow et al's (2002) review of literature on relational factors in drug dependency treatment. They developed a set of principles for producing positive treatment outcomes, which are summarised below:

• When a stronger helping relationship is established at initial intake, the client is more likely to enter treatment.
• When a stronger alliance is established during treatment, the client is:
  • More likely to remain in treatment longer and complete treatment
  • Less likely to experience distress, and more likely to experience a pleasant mood during treatment
  • More likely to abstain from alcohol and drugs while in treatment
  • More likely to experience positive outcomes from treatment
• When the therapist is more confrontational, the client is more likely to show negative in-treatment behaviour.
• A strong treatment alliance may be especially beneficial for specific subgroups, including those with anti-social personality disorder or high levels of anger.
• Better outcomes are achieved for people who receive general social support as well as substance-related support during treatment, and for people who are part of non-substance-abusing-networks.
• Spouse, family or peer involvement in treatment may help engage clients in treatment and produce better outcomes, but the impact of family involvement may be complex and highly variable depending on the client, family and therapeutic circumstances.

Relatedly, meta-analytic studies have shown that practitioners who are "rigid, aloof, tense, uncertain, self-focussed and critical" tended to have poorer working alliances with clients, while those who demonstrated "dependability, benevolence, responsiveness and experiences" tended to foster most positive working alliances (Ackerman and Hilsenroth, 2001; 2003). This is consistent with qualitative drug court research that found participants who perceived treatment as being offered through a "punitive and judgmental" lens felt this hindered their engagement and ability to complete the programme (Gallagher et al, 2017), and also with Wallace's observation that "experiences of empathy and equality may be vital ingredients in those treatments tailored to meet the needs of those who have been marginalised".

Mechanistically, in this field of research the working alliance is generally conceived as developing through three main steps:

1. the creation of shared goals between the practitioner and client

2. the collaborative identification and allocation of tasks between the practitioner and client, in pursuit of the person's goals

3. the development of an interpersonal bond between the practitioner and client, begun during this process and growing as the practitioner and client work together on the tasks in pursuit of the shared goal.

An important question then, is how the therapeutic alliance is impacted when treatment is mandated in a criminal justice context. In the only significant study on this question to date, Zongrone (2022) studied therapeutic alliance formation in participants of a US drug court. She notes that mandated treatment does not align well with clinical practice because the goals and tasks are often pre-determined by the court. This poses a number of problems:

1. the goals and tasks may not align with the person's own goals or preferences.

2. by short-cutting the goal-setting process and the discussion and negotiation involved, the person is denied the opportunity to develop a goal for themselves that could ultimately help to crystalise their agentic choice and intrinsic motivation to change.

3. by short-cutting both goal-setting and task allocation, the person misses out on the process and experience of collaboratively working through these with their practitioner. This means that the initial alliance formation is truncated, leaving the person and practitioner in significantly worse conditions for bond development.

4. By reducing collaboration in the early stages, the relational dynamic between the client and expert may become less trusting, more power imbalanced, and more characterised by the practitioner being seen as a "consultant or expert" instead of the person's partner in a therapeutic alliance.

Additionally, qualitative findings from US drug courts indicate that "since treatment providers become an extension of the participant's probation officer – as they are required to report updates on progress as well as any lapses in their treatment – the participants were less likely to wholly trust their provider" and consequently "began to refrain from reporting lapses or struggles in their substance abuse counselling service for fear that it would be reported back to the court" (Gallagher et al, 2015).

Wider research from mandated mental health treatment supports this proposition. For example: Sheehan and Burns (2011) found that amongst mental health clients, a higher perception of coercion when entering treatment negatively impacted their therapeutic relationship with their assigned practitioner; Manchak et al (2016) found that mandated treatment relationships "involve substantially more therapist control and client submission" compared to voluntary participant research findings.

2.4 Feature: Integration and recognition of early stages of change

As noted earlier, mandated patients typically enter treatment at an earlier stage in contemplating or preparing for change, than the voluntary patients that most drug dependency treatment models are based on. Consequently there is a need to lengthen expectations regarding how long a person may take before being ready to make a change, and also to refocus treatment on fostering the conditions for the person to make an agentic choice to change and develop an internal motivation to maintain recovery.

A key tool for this is Motivational Interviewing / Motivational Enhancement Therapy, including incorporating identity development theory for clients with a minority identity. These approaches involve regularly meeting with a client in order to have collaborative, guiding but informal conversations aimed at helping the person to identify and strengthen their own internal motivation to change by positively reinforcing their goals and change talk, and compassionately exploring their misgivings or difficulties. This approach is rooted in over 30 years of empirical study (Naar-King and Safren, 2017), and supported by meta-analysis suggesting that MI is "associated with small to medium effect sizes across a variety of behavioural outcomes, with the strongest body of evidence being on addictive behaviour."

Millar and Arkowitz (2015) also note that this can be a circular and recursive process, further underscoring the time needed for this to take place before expecting a person to make significant behavioural changes.

2.5 Feature: Effective interventions

As noted earlier, defining and measuring "effective" interventions for this population is a fraught exercise. However, the following types of interventions are generally considered to be either effective or state-of-the-art (although only partially validated). They may form part of an evidence-based package of support for people with multiple complex needs including substance and justice related problems

1. Cognitive Behavioural Therapy/Relapse Prevention/Social Skills Training

These are forms of intervention that focus on helping the person understand their behaviour and develop the skills to behave differently in the future. These approaches typically involve compassionate, therapeutically oriented conversations between the client and practitioner, that explore the factors that are fostering the person's substance use or may be a relapse risk, and actions the person can take to manage those situations or risks. This may involve delivering psycho-education to the person about their brain as an organ, their substances of choice as chemicals, and the complex relationship between their past experiences including trauma, their brain, the drug and the behaviour that their brain produces. It may also involve developing alternative ways of coping with stress, traumatic memories, or interpersonal difficulties.

These approaches have a strong evidence base, but Wallace (2019) notes that they are most recommended for use alongside other interventions addressing the person's wider needs as well.

These interventions are also generally supported by the research on offending: Marlowe et al (2011) found that effective counselling interventions are highly structured, specified in a treatment manual, and behavioural or cognitive behavioural in orientation.

2. Twelve step facilitation / guidance using AA/NA/CA/CMA^[5] etc

Twelve step programmes have a longstanding tradition in recovery work, and a large body of evidence shows that in general these programmes can be effective in supporting people to maintain recovery and develop their self-efficacy and non-substance-using support network. Wendt et al (2017) found that this efficacy is enhanced when combined with other treatment, and when attendance is frequent and consistent.

Twelve Step Facilitation is a manualised approach practitioners can use to support and encourage people to participate in 12 step programmes. Treatment programmes can also support through formal referral, introducing people to potential sponsors in the programme, and addressing barriers to attendance such as childcare or transportation.

3. Individual Drug Counselling and/or Supportive-Expressive Psychotherapy

These are therapeutic approaches to supporting the person, based on person centred, psychodynamic therapeutic practice, and potentially integrating psychoanalytic therapeutic approaches as well, but distinct in their focus on shorter term or more behavioural goals, and priority placed on substance related issues. A common model of delivery may involve thirty six sessions over six months, with booster sessions afterwards. Both IDC and SEP have demonstrated effectiveness with both opioid and stimulant type drugs (Wallace, 2019), and have been shown to increase the effectiveness of other treatments when used in combination, including methadone assisted treatment and group drug counselling.

4. Community Reinforcement Approach/ Contingency Management

Contingency Management is an example of a behavioural intervention that can produce substantial benefits for people charged with drug offences (Marlowe and Wong, 2008). This is the practice of escalating rewards for attending and engaging in treatment. However, despite its effectiveness, CM is rarely used in correctional settings, typically because it does not sit well with many professionals to reward people for doing what they are legally required to do.

The inverse is a graduated sanction (such as a fine or a quick (eg one night) stay in custody), which are common in US drug courts, and available but rarely used in Scottish drug courts. There is some evidence from quality drug court studies that graduated sanctions can be helpful (Harrell and Roman, 2001; Marlowe and Kirby, 1999; Roman et al, 2011). However these findings were not replicated in Trood's rigorous and more recent meta-analysis of problem solving courts (2021), and it is unclear whether this is because of their ineffectiveness in general, or the other non-drug specialty courts included in the study.

Importantly, the authors also note that some practitioners have argued that sanctions, graduated or not, are inappropriate to mental health court clients (King, 2009; Trawver and Rhoades, 2012). Considering the high co-morbidity of drug problems and mental health problems, and the need for treatment to address both, this point is arguably equally applicable. The authors conclude that more research is needed on the most effective ways to deliver judicial supervision, including how and when to reprimand participants.

Collins (2019) also notes that the system of sanction and reward "essential to the US drug court model and its underlying philosophy of drug dependency, requires the imposition of a novel idea for the British courts system: the use of 'multiple sanctions', something without clear precedent (Bean, 2002)." This raises the important philosophical question of when a sanction becomes a "double punishment" for the original offence, and also a practical one, about the acceptability of this practice to Scottish jurists.

Considering the contested effectiveness of graduated sanctions, the Scottish judiciary's relatively low use of them, and the difficulty they may pose to the therapeutic alliance, they should be treated cautiously. On the other hand, any opportunity to retain someone in community based treatment and avoid revocation and custody should be considered. This is an area that warrants greater exploration with stakeholders and the judiciary in Scotland.

5. Integration of harm reduction and moderation approaches / abstinence by gradualism

Practitioners must meet people where they are in the stages of change. For many people entering mandated treatment, this will be a relatively early point in their recovery journey. Consequently, many people in this population may benefit more from a harm reduction or moderation approach than abstinence, especially in the early phases of engagement. There is plenty of literature contesting the relative merits of harm reduction approaches as compared to abstinence – but Tatarsky (2002) rightly points out that in many cases the best approach is both. Integrating harm reduction and moderation approaches may look like:

• Making referrals to needle exchange programmes, safe consumption facilities, methadone maintenance programmes etc
• Delivering education about how to minimise risk when consuming drugs, for example education on safe injecting practices and blood borne viruses
• Providing equipment that makes people safer when using drugs

Miller (2001) notes that some people fear or resist entering treatment because they do not think they will cope with being required to immediately become sober. A gradualist or moderation approach can help to retain these people in treatment as they move through the early stages of developing their readiness to change. McLellan (2003) summarises this approach: "Gradualism seeks to create a continuum in which people who are using alcohol or substances in a dangerous or destructive manner are gradually led through a channel that first seeks to reduce the destructiveness of their use, and then seeks to help them attain a life free of addictive behaviour. The continuum also acts as a safety net in the case of relapse"

Wallace (2019) points out that in order to successfully integrate these approaches, practitioners require a supportive policy and legal context – these approaches need to be understood, accepted and enabled amongst probation or parole officers, judges, social workers, and government agencies.

6. Affective, Behavioural and Coping skills

The integration of psychoanalytic theories and cognitive behavioural therapy in drug treatment has developed into a practice with a very practical emphasis on helping people to acquire emotional, behavioural and cognitive coping skills (Wallace, 1996). Because relapse frequently happens when a person encounters a triggering situation or is challenged by coping with negative emotions or painful affective states (Marlatt and Gordon, 1985), learning new coping skills is essential for this population. However, people in this group also often suffer from an inability to recognise, label or process their feelings, and difficulty regulating their emotional state (Derby, 1992; Rothschild, 1992; Yalisove, 1992;1997). The causative mechanisms of this association are complex and likely to be multi-directional. For example, a person's emotional skills may be limited by past trauma, but limited emotional skills may also make traumatic experiences more likely (due to the social, relational and behavioural impact they have), and may also cause people to experience common setbacks as more traumatic than the general population.

This process can take time, as it requires the person (with the help of their practitioner) to identify the need and trigger, learn new coping responses, practice these in their everyday life, generalise the skills to a variety of situations, and learn to discern when it is best to use different coping strategies. Often, this process may need to be repeated in multiple steps as the person learns first to avoid the most destructive outcomes – for example: a person may respond to certain triggers with aggressive or violent behaviour. Initially, the most adaptive coping mechanism they can manage may be to walk away and sit in silence until they are calm. However, walking away in silence is an avoidant response that is not healthy if it remains the person's only response to common every day frustrations. Over time, once the person has developed confidence in their ability to avoid violent outbursts, the practitioner can then take the person through this process again to help the person acquire a more active coping skill, such as being able to deliver a positive, assertive verbal response (Wallace, 2005).

7. Medication Assisted Treatment (MAT)

MAT involves the use of medications, along with counselling and behavioural therapies, to provide a whole-patient approach to treatment (Abuse, 2013). As reflected in Scotland's recently developed MAT Standards, there is a compelling body of evidence for using opioid-agonist medications to reduce opioid use and retain people in treatment.

Opioid dependence causes the greatest disease burden of all extra-medical drug use (Degenhardt et al, 2019). Access to and retention on Opioid Antagonist Treatment substantially reduces premature mortality. The medical evidence base is well rehearsed elsewhere, and beyond the scope of this report, but the following points warrant noting in relation to optimising effectiveness in the community justice population:

• There can be a number of common barriers to MAT engagement, including attitudes, convenience of daily pharmacy prescribing, and stigma perpetuated by attitudes that see drug dependency as a choice rather than a disease justifying medical treatment.
• MAT's impact both supports, and is supported by, being delivered in conjunction with other interventions, such as the various psycho-social options listed above.
• Heroin assisted treatment can play a valuable role in reducing deaths and crime (Strang et al, 2015), and despite its higher initial costs it has been shown to be cost-effective overall (Byford et al, 2013).
• MAT is only an option for certain types of illegal or criminogenic drugs (mainly opioids, but also benzodiazepines and alcohol). There are no medications known to effectively assist with other drugs of abuse such as stimulants like cocaine, crack cocaine or amphetamines (Degenhardt et al, 2019).

2.6 Feature: Respond to multi-problem clients with an integrated and comprehensive care package

As summarised by Wallace (2019): "Not only are practitioners faced with problems of addiction, but also the following: incarceration; ongoing criminal justice system supervision; performance of risky behaviours; loss of child custody; histories of trauma across the lifespan; engagement in violence; psychiatric co-morbidity; and, a risk of recidivism and relapse to more than one problem behaviour." This reflects a longstanding and well-corroborated evidence base showing a complicated but strong correlation between people who experience mental ill-health and people who use substances, both generally and problematically. For example, studies have found:

• Offenders with substance problems were more likely than others to have increased mental health problems and risk factors for suicide or aggression. (Ruiz et al 2011)
• There is a high incidence of co-occuring substance use and history of trauma and trauma related symptoms (Blanco et al, 2013; Ehlers et al, 2013; Reynolds et al, 2005). Moreover, a person is more likely to escalate to injecting drugs if they have experienced violence or trauma in the past (Fuller et al, 2002; Ompad et al, 2005; Lake et al, 2015). A survey of mental health needs amongst over 250 clients at one Scottish Justice Social Work service found that over 70% had some kind of mental health issues, and that "there is little point in asking solely about mental health without asking about drug/alcohol use and prescribed medication" (Community Justice Scotland, 2021).
• Opioid users typically experience elevated mental health symptoms compared to the general population, including depression, anxiety, and post-traumatic stress (Becker et al, 2008; Fink et al, 2015; Kerridge et al, 2015). Moreover, people with opioid dependence who experienced multiple childhood traumas and/or mental disorders, were less likely to engage in treatment and more likely to have contact with the justice system (Santo et al)

This pattern is borne out in Scotland . Research with community-sentenced people who use drugs is now somewhat out of date, but this population is significantly more similar to the prison population than those who are not involved in the criminal justice system, so the Scottish Government's recent Health Needs Assessment (2022) for the prison population is informative. It reported that: "various respondents noted that mental health needs were common amongst individuals living in prison who experience problems with substances... We heard reports that some individuals are inappropriately remanded to prison if there are no secure hospital beds available or that some people were being placed in prison as a result of a lack of appropriate community and/or psychiatric provision. This is considered as leading to significant levels of vulnerability for these individuals. Respondents were clear in their view that prisons should not be a place someone is sent for their own protection and that Sheriffs are sometimes considered as believing this to be appropriate." The report recommended that there should be "a fully functional and integrated approach to address the consistent overlap between substance use and mental health".

The evidence for integrated mental health and drug treatment is promising to strong:

• A 2019 systematic review of interventions for people who both use drugs and commit offences, with co-occurring mental health problems showed that, in general, the evidence base on these types of interventions is relatively scarce - only 13 studies met the quality standards for inclusion. This may reflect a limited number of programmes in existence with this dual focus for this specific population, but may also be because the complexity of the problems, systems, interventions and ethical considerations involved makes it extremely challenging to conduct randomised controlled trials – the standard for inclusion in the review. Notwithstanding this challenge, from the 13 studies included, the authors found that therapeutic communities and specialised mental health courts may help people reduce substance use and criminal activity.
• Outside of the literature on people involved in the justice system, multiple systematic reviews have found that treatments designed to treat PTSD and Substance Use Disorder at the same time hold promise for reducing symptoms of both (Van Dam et al, 2021; Torchalla et al, 2012; Simpson et al, 2017; Bailey et al, 2019).
• Similarly, Roberts et al (2016) conducted a systematic review and meta-analysis looking at both individual and group psychosocial therapies, which also concluded that trauma-focussed interventions could be delivered effectively alongside substance use treatments. This body of evidence was more fully extended to criminal justice populations in a 2020 systematic review of group interventions for trauma and substance use for women in the justice system, which found that while this is a relatively under-studied area, the literature shows promising results including reductions in substance use and PTSD symptoms over time.
• A systematic narrative review focussed specifically on amphetamine type stimulant users concluded that this group is a highly diverse population, with drug use trajectories shaped by a complex dynamic of individual, social and environmental factors. Tailored, joined up interventions are needed to address overlapping economic, health and social care needs in order to support long term abstinence" (O'Donnell et al, 2018).

It is also important to note Baughman et al's finding regarding the prominence of violence or trauma exposure and co-occurring mental and substance disorders: as decreasing use of mood-altering substances can increase the person's experience of violence- or trauma-related memories. If unaddressed, the associated negative feelings can put the person's programme participation, and continued sobriety, at risk. Overall, the authors' data suggest the need for services that can address these issues as part of the treatment continuum. They argue that mental health providers need to be integrated into the court team and participate in team meetings and court hearings.

Beyond mental health support, people in this population also often have a number of wider social needs. A recent piece published in the Lancet regarding how to minimise drug harms in the UK argued that "interventions need to address drug use more holistically, and recognise the contribution of economic distress and social factors to drug use and harms." Work by Public Health Scotland found that people in the most deprived areas were 18 times as likely to have a drug-related death as those in the least deprived areas, and 8 times more likely to have an alcohol related death or hospital stay (2020). In Community Justice Scotland's annual report on Outcome Activity Across Scotland (2022), "partners reported that service users were presenting with needs linked to alcohol and substance use, physical and mental health, wellbeing, employability, housing and more. Many individuals were experiencing more than one issue concurrently."

The Robertson Trust's report Hard Edges Scotland (2020) highlighted severe and multiple disadvantage in Scotland, with 191,000 people having experience across substance dependency, offending or homelessness in a typical year. The report emphasises the significance and long-lasting impact of childhood harms, such as poverty, mental illness, and homelessness, leading to problems in adulthood. Similarly, the Independent Care Review's series, The Promise Scotland (2020), included an economic model on human costs that showed care experienced adults are one and a half times more likely to experience severe multiple disadvantage, including substance use, homelessness, mental health issues and offending. The Scottish Drugs Forum (SDF) also identifies poverty in Scotland as the root cause of the drug deaths crisis, which has not been seen in other comparable European countries.

The prison needs assessment, mentioned earlier, also found that: "the biggest and most consistent need we heard expressed was housing upon liberation. The importance and benefits of having secure non-hostel/homeless residential status upon release was consistently emphasised, whether maintained or a new tenancy, through family, or via residential rehab… Greatest concern was expressed over those individuals who are released onto the streets, into a hostel, or into a House in Multiple Occupancy [HMO], where they are faced with the prospect of going straight back into a substance using community… A further unmet need that respondents talked about was a desire to feel human, loved, valued, connected, and to have a sense of hope."

2.7 Human Rights Considerations

International guidelines on human rights and drug policy have been developed by experts working with the World Health Organisation, United Nations Development Programme and UNAIDS. These guidelines do not have official standing in Scottish law or policy, but are relevant, reputable and reflect international consensus on good practice. While many of these guidelines are pertinent to the treatment and care of people with substance related problems in the justice system, two are particularly relevant when considering community based treatment orders made by a court. These are:

• If treatment is court mandated, no penalties should attach to failure to complete the treatment.
• Treatment as an alternative to custody must only be offered with informed consent, where medically appropriate and must not be ordered for longer than the applicable custodial sentence.

3. The role of judicial supervision in community drug treatment

The idea of judicially supervising a person's journey through substance use treatment raises many complex issues that are impacted substantially by consideration of what the alternative path for that person might be. There are a number of theoretical mechanisms that may be relevant to considering effectiveness. The literature on these is explored in more detail below, but briefly:

• In favour of judicial supervision:
  • Formal accountability and fear of negative consequences may be effective for a small proportion of people, who otherwise struggle to commit to recovery
  • If processed in a timely way, the experience of judicial supervision may help the person to connect their problems with their substance use, contributing to developing their agentic decision to change.
  • The ability to supervise someone's treatment closely may be the factor that causes a judge to give the person a chance in the community instead of sending them to custody.
• Against judicial supervision:
  • Increased time spent in court and around justice professionals may contribute to strengthening the person's identity as an offender, which is a known criminogenic risk.
  • A number of features of judicial supervision may be harmful to the therapeutic alliance.
  • Judicial supervision (in particular, negative reaction to lapses or mixed messages between court and treatment providers) may trigger resistance or reactance from the person.
  • A number of features of judicial supervision may provoke fear, stress and anxiety, potentially to an existentially threatening level, for the person – which can be a trigger for relapse, recidivism and/or disengagement from the process.
  • The more frequently a person comes before a judge, the more opportunities the court has to send them to custody.

Kearley and Gottfredson (2020) further highlight the tensions that can exist between the aims of justice intervention and those of a public health approach to substance use: "on the one hand, drug use is treated as a crime that must be punished; on the other hand, it is treated as a chronic relapsing disease or behavioural condition that requires ongoing treatment and support. Some scholars view these two approaches as wholly contradictory, others point to research that suggests these distinct mechanisms (sanctions and treatment) may actually complement one another… [in this] perspective, legal actors may put pressure on drug users to seek and remain in treatment, and drug treatment providers may help legal actors by delivering a more effective response to persistent drug use than prison. Of great importance, then, is some clarity regarding the extent to which coerced treatment strategies provide substantial benefits over alternatives, without widening the reach or deepening the intensity of punishment".

Moreover, clear communication between the court and the person being sentenced or supervised is essential if they are to draw a strong causal relationship between their actions and the consequences they face in court. This is a key part of the theory that judicial supervision deters criminal behaviour, as well as potentially contributing to the person connecting their substance use to their problems, and thus moving further in the direction of crystallizing their desire and readiness to change. Festinger et al (2018) note that there can be challenges with communication in the court room. This arises from a number of factors, including that people with substance related problems and offending behaviour may, on average, have had less access to formal education, have a higher prevalence of (potentially undiagnosed) neurodivergences, and have a more chaotic lifestyle than the general population, or even the general population passing through the courts. These factors, and the fact that the person may also be either intoxicated, or withdrawing from the substances they usually depend on, may also mean they experience higher levels of situational stress when appearing in court. All of these issues may make communication, comprehension and memory more challenging. In addition to these general challenges, the person may use drugs on multiple occasions, which may or may not coincide with dates of testing, and there may be delays before results are received, again before discussion with their case worker, and again before their court date. The combination of this disrupted timeline, and the general issues that may impact communication, can make it difficult for the person to develop an understanding of their longitudinal drug use pattern and this pattern's relationship to the consequences they experience in court. This can contribute to the person struggling to understand what is expected of them, or viewing the court's actions as arbitrary, mean-spirited or prejudicial.

Most research on judicial supervision of drug treatment comes from the US, and is almost exclusively rooted in the idea of a drug court, or sometimes more widely a 'problem solving court', which takes a similar approach but a wider remit in terms of the issues that may be addressed. A drug court is not usually a purpose-built physical facility, but rather a specially focussed court session that forms part of the general programme of hearings and sessions that comprise the business before a local court. In "Defining Drug Courts: The Key Components," the typical key components include: the integration of services, reliance on a non-adversarial approach, early entry into treatment, provision of a continuum of services, frequent monitoring, continued judicial involvement, and interdisciplinary coordination (Drug Courts Program Office 1997). However, the ways in which drug courts are implemented, and the populations at whom they are aimed, vary widely.

Before getting into this literature, it is important to remember Nolan's (2009) observation: "embedded within problem-solving courts are cultural assumptions that…when transplanted may significantly challenge or alter the legal cultures of importing countries… Without a deeper understanding of the ongoing dialectic between law and culture, then, importers can underestimate the degree to which these programs carry with them features of a foreign cultural context". Collins argues further that this "produces an assumption of belief in their efficacy based on how they "could" or "should" work if functioning correctly, based on a set of abstract international principles, and results in an assumption that if models do not thoroughly replicate the US model, they are inevitably pre-destined for failure." Collins argues that a country importing court models from others runs the risk of, metaphorically, importing trains that run on the wrong kind of tracks – ultimately they will not connect with and run on the national infrastructure.

This important point notwithstanding, drug courts are now a longstanding intervention with a large, if not entirely consistent, body of research around them, and are the main source of data on how people can be supervised judicially while engaging in drug treatment, and what that experience is like for people.

One way US drug courts can be classified is by the point at which the person receives intervention: pre-adjudication models offer intervention at the pre-charge stage, with charges dismissed on successful graduation, whereas post-adjudication models offer intervention as an alternative to a custodial sentence. Scotland's DTTOs are a post-adjudication model, but it is worth noting that the Problem Solving Approach adopted at Aberdeen Sheriff Court for people with several convictions and multiple complex needs sits somewhere between these two models. It used structured deferred sentences to support people to engage with services to address their needs (typically including substance use), and upon successful completion many participants would be admonished, rather than receiving a community or custodial sentence.

Overall, drug courts show extremely variable results, for example, graduation rates range from 11% (Brewster, 2001) to at least 72% (Mackin et al, 2008) in different individual programmes. Several systematic reviews and meta-analyses have sought to address high level questions about whether drug courts' "work" overall or on average (although the warnings about the concept of "effectiveness", expressed earlier in this report, should also be borne in mind). Work by Lowenkamp suggests that studies generally find effective treatment and interventions coupled with "appropriately balanced surveillance and monitoring" produces the best outcomes (eg, Lowenkamp et al, 2006A; Lowenkamp 2006B; Lowenkamp et al, 2010, Paparozzi and Gendreau, 2005). Trood et al (2021 report that most studies on drug courts report follow ups of 6 months to three years, so it is notable that an unusually long study of Baltimor City Drug Treatment Court resulted in significantly fewer arrests, charges and convictions across a 15 year follow up. The authors suggest this indicates drug courts have the potential to lead to sustained, long term effects on offending even for those with significant criminal records and chronic substance use histories (Kearley and Gottfredson (2020))

However, in perhaps the most comprehensive review and meta-analysis to date, Trood et al (2021) looked at the role of judicial supervision in problem-solving courts, in relation to both recidivism and individual wellbeing outcomes. They found that problem-solving approaches, compared to treatment as usual, demonstrated a significant average reduction in offending, but that the unusually high variation in outcomes across studies meant they "cannot conclude with reasonable certainty that the true effects of problem-solving courts favour treatment, or that analogous results will be found among future studies". They also found that mental health courts were associated with a larger decrease in offending, compared to both drug courts and specialised driving while intoxicated courts.

The authors also report that prior meta-analyses showing meaningful reductions in offending compared to conventional approaches appear to be driven primarily by lower quality studies, and that results are weaker or even non-existent when only the highest quality studies are included (Gutierrez and Bourgon, 2012; Mitchell et al, 2012). Overall, they found that although problem solving court participants appeared to recidivate less when compared to groups who received only a standard court process, this pattern did not hold when compared to groups receiving a standard court process plus treatment. This finding may indicate that the majority of the benefit of specialty courts comes from the treatment itself, and not from the judicial supervision or other court processes.

This raises the important question of what the intervention is being compared to, and what is likely to happen to the person if they do not go through the drug court or mandated treatment process. While the studies above demonstrate mixed results for people in the justice system when compared to the alternative justice response they might face, it is not clear whether that alternative is very similar in these mostly US jurisdictions to what it might be here in Scotland.

The evidence when mandated treatment is compared to voluntary treatment depends significantly on which markers of "success" are used, and the time period in which they are measured. There is evidence that, especially when delivering person-centred support alongside motivational interviewing, mandated treatment can help move people through the phases of change and concurrently reduce harms (Wallace, 2019). However, the causative relationship with any long term benefits is less certain – Streisel's study on the drivers of recovery and desistance over people's 20 year journeys with substances and criminal justice found that for "those who were sentenced to treatment or mandated to attend treatment as part of a criminal justice aspect…even when there were direct legal consequences to not completing treatment, respondents who were not attending treatment programmes out of their own volition did not attain the change that the criminal justice system wanted to see." They often found it easy to remain abstinent during treatment because they "didn't want to go back to jail", but this motivation ended when the order did, and they did not sustain change after discharge.

This finding also raises another point that relates to the purposes of sentencing discussed in the prior section. If a sentence keeps someone abstinent only for the length of the order, is this valuable? On one hand, this will at least be protective of overdose death for the person during this time, but on the other hand, this period of abstinence may also reduce their tolerance and put them at greater risk of overdose death if/when they do lapse. Additionally, there is some evidence that even short-lived periods of abstinence can serve as a useful reference point to help people connect their drug use to their problems and develop an agentic choice to change, but on the other hand, negative experiences with treatment can deter people from seeking help in the future when they are more ready and the treatment may be more likely to be successful (Streisel, 2021).

With high variability and evident potential tensions in the drug court model, can the research help to identify the features that make some approaches more successful than others?

Much of the research is focussed on the importance of frequent contact between judicial officers and court participants, but there is relatively little research on other mechanisms used by judges and problem solving courts, such as pre-court review meetings or specific training for the judicial officer, which may also be equally important to impact (McIvor, 2009; Winick, 2003). However, Trood et al (2021) included the moderators that were available in the literature included in their meta analysis, and found that amongst those studies:

• Programmes with individualised treatment had stronger treatment effects than those with standardised treatment.
• Programmes that included specialised training for court staff were more effective than those that did not
• Courts that required weekly attendance once per week in the initial stages were associated with a stronger reduction in offending behaviour than those with fortnightly hearings in the initial stages. This is consistent with earlier meta-analyses (Mitchell et al, 2012, Sevigny et al, 2013) that found more frequent hearings, especially in the initial stages, is conducive to both drug treatment and reducing recidivism. However, further research is needed to harmonise this with other strong evidence for individualising treatment and dosage of interventions.

The US National Institute of Drug Abuse, drawing on their own extensive research, concluded that the most effective models integrate justice and treatment services, and are characterised by collaboration between the personnel employed in the justice system, and those employed in the health and social support system throughout the screening, planning, treatment and testing, and monitoring processes (NIDA, 2018).

The United Kingdom has had a tiny number of drug courts over recent decades, compared to the estimated 3-4000 in the US (US Department of Justice, 2020), and consequently the evidence from UK studies is sparse.

DTTOs, when first brought in, essentially sought to replicate a drug court intervention, via a national sentencing approach rather than through local court-centred initiatives. Two studies on DTTOs in England and Wales (Eley et al 2002; McSweeney et al, 2007) suggested improvements in participants' drug use and offending. However, it should be noted that the only study to control for other factors affecting retention in treatment (McSweeney et al, 2007), found that people ordered into treatment with a DTTO did not have better retention in treatment than those attending voluntarily.

Research on DTTOs in England and Wales (Powell et al, 2009) found that people had quite different outcomes, depending on whether they were sentenced in Magistrates or Crown Court, and whether they commenced treatment in custody or the community. In the original pilot, revocation rates varied greatly between sites – from 30% to 60% of orders (Turnbull, 2000).

The research on DTTOs in England and Wales also identified key challenges around inter-agency working and availability of treatment (Eley et al, 2002, McSweeney et al, 2007, Turnbull and Webster, 2007). This body of research points to the following as necessary for effective delivery:

• Clear communication between agencies and courts regarding who is suitable for an order
• Clear national standards regarding what is a realistic and acceptable level of drug use whilst on a DTTO, how quickly participants can become drug free, the likelihood of relapse, and how the results of drug screenings should be used
• Reducing delays in court reports, assessments, and processing breach proceedings.

Collins (2019) characterises the implementation approach as challenging: "Dedicated Drug Courts in England and Wales were expected to simultaneously react to and reflect local needs, while implementing a centrally determined, national social service and court programme," and argues that this paradoxical expectation made their eventual removal inevitable: "no level of local enthusiasm for, or belief in, the ideas of therapeutic justice can bridge the fundamental need to secure central government funds and coalesce highly centralised service provision around a new policy innovation"

Similar implementation challenges appear to have been encountered in the small number of English and Welsh dedicated drug courts that have been piloted. A process evaluation of the dedicated drug courts pilot in England and Wales from 2005-2011, implementing the Drug Rehabilitation Requirement community order (which replaced DTTOs in England and Wales), noted the importance of clear national guidance on how the model should be both theoretically and practically implemented, and the fact that success was contingent on central government funding for dedicated roles, which was not generally permanent (Kerr et al, 2011).

While this evaluation did not assess outcomes or impact, it is noteworthy that respondents had conflicting views on whether the dedicated drug court was "more lenient" in terms of either non-custodial sentencing, or interim sanctions for infringement.

The practical resource challenges identified included:

• The dedicated drug courts were supposed to be cost neutral after initial set-up, but some courts found the dedicated drug court encroached on the space and time of other courts. Others "languished with a lack of case work".
• To be effective, all wraparound services would require more resources and support to engage with the dedicated drug court. The pilot evaluation reported that if numbers continued to rise at their present (in 2011) rate, it would be necessary to provide: "more court space and time, a larger pool of magistrates, potential staffing increases at treatment agencies and probation to cope with increased offender caseloads and extra time spent preparing reports and attending court (Kerr et al, 2011).

This literature sits alongside a report published in 2009, reviewing the pilot Glasgow and Fife drug courts, which opened in 2001 and 2002 respectively (Nolan, 2009). This review identified relatively strong support for the drug courts amongst stakeholders, and that sheriffs had found their own specific practices that they felt were helpful, although these could not be assessed for their specific impact – these were practices like beginning each sitting with a "particularly successful individual", so that other participants could see that it was possible to change for the better for others on the same order. Pre-review meetings between the professionals and sheriff were also viewed as facilitating better information sharing and more collaborative decision-making, and were seen as a key distinction between the drug court and a standard DTTO. Relatedly, the dedicated drug court model also meant it was possible to roll all of someone's charges together so the court could respond holistically to the person's full legal situation, and also make it more likely someone would consistently see the same sheriff, compared to a DTTO process in a mainstream court.

Nolan's 2009 evaluation of drug courts found that sheriffs are reluctant to impose interim sanctions, and explicitly maintained court formalities, in contrast to the traditional American approach. Learning from the experience of Irish colleagues, the Scottish drug courts allow the sheriff to attend the pre-court meeting (Collins 2019).

Most funding for the pilots was used to resource the dedicated treatment and testing team for each court. Stakeholders reported that this allowed more contact time with people, including increased home visits and group work – although the extent or impact of this could not be assessed. Some concern was also expressed that if treatment and support available through criminal justice is significantly better than that available through mainstream services and the NHS, this may create an incentive for people to escalate their offending in order to access adequate drug treatment. This appeared to be a greater concern in Fife (where mainstream treatment was less well resourced), than Glasgow (where most people entering drug court were already known to local treatment services). While this specific observation is now substantially out of date, it highlights the importance of local context in terms of population needs and existing infrastructure.

4. Conclusions from the evidence review: fundamental paradoxes of treatment and desistance

As this review has shown, substance use, treatment and recovery, and offending, sentencing and desistance, are all complex phenomena that interact with one another and with many social and economic factors in people's lives. Coupled with legal, political and cultural considerations (such as the stigma many people who use drugs experience, or the arbitrary illegality of some drugs of abuse but not others^[6]), we find a large literature, but few simple answers or consistently effective models for responding to the population of people affected by all these issues at once.

At the very highest level, the evidence seems to suggest that overall and on average, court ordered treatment is less effective than voluntary treatment, but still better for people than custody. Beyond that, the evidence on how best to maximise the potential benefits, and minimise the potential harms, of court ordered drug treatment in response to offending behaviour is growing but remains uncertain.

As Streisel (2021) put it: "the reasons that treatment "worked" for some people were the same reasons that they "didn't work" for others. Even more confounding, the same reasons it "worked" and "didn't work" could occur within the narrative of one respondent… some respondents noted treatment episodes where they disliked a particular modality, but later noted a different episode where this modality worked". Human agency emerges as the distinguishing factor – whether the person had made an agentic choice to change before engaging in the treatment. This finding presents an opportunity for two possible interpretations: optimistically, it might suggest that interventions refocussed on fostering the conditions for agentic change (rather than merely fostering abstinence itself) may hold promise for helping people; pessimistically, removing people's agency by mandating them into support, no matter what it aims to foster, may inherently reduce their opportunity to make a truly agentic choice, which is necessary for lasting recovery.

Moreover, the core of recovery (agentic change), and the core of treatment (the therapeutic alliance), are both in tension with the criminal justice system's focus on compliance and enforcement. While court mandated treatment may recognise the need for support and treatment in order to change behaviour, requiring someone comply with the treatment and support package or face punishment can in fact rupture both the agency and the alliance. This may weaken the potential benefits and reduce the impact of treatment. However, this argument only suggests that mandated treatment will be less effective than voluntary treatment. If the alternative to mandated treatment is even more focussed on compliance and control, such as a prison sentence or an order with multiple onerous requirements, then mandated community-based treatment may still be less harmful.

Finally, compatible policy goals can come into tension when the resources required to deliver them are scarce. For example, the current aims of preventing deaths, getting more people into treatment and reducing waiting time for treatment may all compound one another in terms of resource requirements. This is obviously not to argue against any of these as worthy aims – only to underscore the importance of adequately funding and resourcing services to meet the needs in this space – which the evidence consistently highlights is essential to success.

With all these tensions stipulated, the evidence canvassed in this review suggests that a rough sketch of the most evidence-based community sentencing option for people with substance use problems would be one that:

1. Does not widen the reach or deepen the intensity of punishment.

2. Recognises the harms of prison and the risk of death for people with substance use problems who are sent there, and prioritises keeping people out of prison. This requires that the judiciary:

• are aware of the services offered locally, and adequately informed on them. This is supported by:
  • awareness raising from local providers
  • collaborative working between court staff and practitioners
  • detailed information to accompany recommendations in social work reports
  • a well-resourced and regularly maintained database of information on local services
• trust that these sentences are effective at achieving their purposes. This is supported by:
  • training on substance use and treatment
  • well-resourced services with adequate staff and minimal delay commencing treatment
• accept that abstinence may not be the goal of treatment, and testing results may not reflect a person's level of engagement in treatment or progress through the phases of change
• accept the additional time and work required in the court process to conduct the necessary assessments and planning

3. Recognises that substance dependency is a health condition and should be treated that way. It impairs the control a person has over their thoughts and actions, and recognises the profound difficulty of enduring cravings or withdrawal in order to make progress.

4. Recognises that while traditional models of voluntary treatment begin at the "action" phase, people who are mandated to treatment have several preparatory steps to move through first. Therefore, sentences need to support the person to make an agentic choice to change. Some things that contribute to this are:

• being as consensual as possible while recognising that the alternative criminal justice sanction the person will face makes truly free consent impossible to obtain.
• fostering the conditions necessary for the person to connect their drug use with the problems in their life, and to see their current path as one leading to their "feared self", and alternative paths as leading to a more preferred future self by:
  • ensuring the person sees their treatment as fair and not arbitrary
  • processing through court quickly enough to help the person connect their behaviour with its consequences
  • Communicating clearly to help the person draw a clear connection between behaviour and consequences, and using aids adapted to their needs
  • Motivational interviewing and relapse prevention skills training
  • Accepting that it takes time to safely explore the person's thoughts and feelings to resolve ambivalence and build their confidence and coping skills so they feel able to take on the actions of change
• using a gradualist approach including harm minimisation and moderation to retain the person in treatment as they move through the phases of change at their own pace.

5. Recognises that a strong therapeutic alliance and support system forms the basis of almost all effective drug treatment, and prioritises a strong therapeutic alliance by:

• maximising the person's trust in their practitioner. Something that can help with this is giving them discretion in what they report to the court.
• minimising the intrusion of the court into the therapeutic alliance by:
  • minimising review frequency
  • allowing the person and practitioners to develop their own goals and tasks, rather than these being dictated by the court
  • applying the principles of therapeutic alliance to the court's relationship with the person by:
• ensuring the person sees the same judge each time they appear in court
• providing judges with specialist training on substance use, sub-conscious stigma and the skills of therapeutic alliance building
• integrating drug, mental health and social workers into the court process, for example through pre-review meetings with the judge
• training judges and court staff to:
  • take a compassionate and non-stigmatising approach in the court room and with their remarks,
  • have regard for the very high probability of trauma in the backgrounds of the people in this population, avoiding being "rigid, aloof, tense, uncertain, self-focussed or critical", and instead showing more "dependability, benevolence and responsiveness"
  • have collaborative conversations with the person before them about their progress and goals
  • give positive reinforcement for the person's efforts even when the outcomes being achieved fall short of expectation.

6. Recognises that no single response is appropriate to everyone, and effective responses are based on thorough individualised assessment and targeting, and consequently:

• assesses every person who may warrant it
• uses an assessment that covers:
  • health and substance related issues
  • stage of developing motivation to change
  • learning or communication needs, including screening for previously unidentified neurodivergences that would warrant support and/or treatment, such as Autism Spectrum Disorder (ASD), Attention Deficit/ Hyperactivity Disorder (ADHD), or Dyslexia.
  • Criminogenic risk factors and underlying needs, including wider needs such as shelter, housing security, safety, food, income, employment, meaningful use of time, and social bonds.
  • each person's unique background, and social and economic context. This might lead to incorporating aspects of their cultural background, religion, sexual orientation, gender identity, or family context where these are helpful to strengths-based identity formation, or being sensitive to the diverse and potentially negative experiences some people may attach to these identities.
• Assessment should take place in the community if at all possible.
• Both treatment and level of court supervision should be adapted to the person's risk and need, including:
  • Recommended weekly or fortnightly reviews in the first month, then adjusted based on need and minimised to the extent possible
  • Providing adaptive, but adequate dosages of intervention, specifically:
• Support for a minimum of 18 months
• At the higher ends of community based treatment, ideally 4-5 days per week
  • Recognising that mental illnesses like depression, anxiety, PTSD, paranoia, or hallucinations may not be apparent until the person has been abstinent for at least 4 weeks, by:
• allowing flexibility for responding to emerging issues or diagnoses.
• accepting that this may be a challenging time for compliance as the person copes with these symptoms without substances.
• integrating mental health assessment, treatment and support.
  • Using structured deferred sentences to assess people's needs within the community as they begin to engage with support, so that judicial expectations and the person's treatment and support plan can be flexibly adapted.

7. Recognises the role of social exclusion and economic distress in substance use and offending, and provides an integrated and comprehensive care package addressing multiple needs, including:

• Drug treatment and integrated testing
• Mental health and wellbeing
• Self-care and self-efficacy
• Addressing trauma
• Physical health, including blood borne virus clinics
• Housing
• Safety and violence
• Income and employment
• Social bonds and family
• Meaningful use of time
• Education

8. Provides a range of different types and modes of drug treatment for different needs, including:

• Education
• Cognitive Behavioural Therapy, Relapse Prevention, Social Skills Training,
• Individual drug counselling and/or supportive-expressive psychotherapy
• Community Reinforcement Approach / Contingency Management
• Affective, Behavioural and Coping Skills
• Medication assisted treatment, including agonist, antagonist, heroine assisted, and benzodiazepine prescribing
• Twelve step facilitation
• Gradualist approach accepting "experimental" brief commitments to specific periods of sobriety before expecting a longer term commitment to abstinence
• Harm reduction and moderation education
• Referral to available needle exchanges, safe consumption facilities etc
• Providing safe equipment
• Both individual and group modes of delivery

9. Recognises the significant resources needed to provide a consistent, thorough and high quality service at appropriate dosage, and:

• resources all justice, health and social services adequately
• provides clear national standards and sentencing guidance for what is expected
• fosters collaboration between practitioners and the court through steps like:
  • co-location
  • shared pre-review meetings
  • dedicated coordination roles
  • collaborative screening and assessment
  • joint training and awareness raising
• provides specialised training for court staff and judiciary on the implementation model, its intended benefits, and each person's role in making it successful.