The first 90 days following release from jail: Findings from the Recovery Management Checkups for Women Offenders (RMCWO) experiment

Abstract

Objectives

(1) To examine the impact of monthly Recovery Management Checkups (RMC) vs. control in the first 90 days post-release from jail on receipt of community-based substance abuse treatment, and (2) To explore the impact of RMC, treatment, and abstinence on HIV risk behaviors and recidivism.

Methods

Of the 480 women randomized, 100% completed the intake and release interviews, and over 90% completed the 30-, 60-, and 90-day post-release interviews. Of the 915 times women assigned to RMC were interviewed (at release, 30, 69 and 90 days post release), 885 (97%) times they attended linkage meetings, 429 (47%) times they were identified as in need of substance abuse treatment, 271 (30%) times they agreed to go to treatment, 149 (16%) times they showed to the treatment intake, and 48 (5%) times they stayed in treatment at least two weeks.

Results

During the 90 days following release from jail, women in the RMC condition (vs. control) were significantly more likely to return to treatment sooner and to participate in substance abuse treatment. Women who received any treatment were significantly more likely than those who did not to be abstinent from any alcohol or other drugs. Those who were abstinent were significantly more likely to avoid HIV risk behaviors and recidivism.

Conclusions

These results demonstrate the feasibility of conducting monthly Recovery Management Checkups with women offenders post-release and provide support for the effectiveness of using RMC to successfully link women offenders to treatment.

Introduction

From 2000 to 2010 about half of incarcerated women were held in local jails and the number of women in local jails has increased by 30% (Minton, 2011). Because most are incarcerated for only a few weeks or months, they also represent the majority of women offenders re-entering the community. Consistent with the reasons for their arrests, 70% of women entering jail in 2002 reported using alcohol or other drugs weekly in the month before their arrest (Adams et al., 2011, Bureau of Justice Statistics, 2005). Women offenders with substance use disorders often suffer from a host of co-occurring conditions (e.g., medical, psychiatric, socioeconomic) that contribute to high relapse and recidivism rates (Adams et al., 2011, Guydish et al., 2011). These women are more likely than other women offenders and women living in the community to live below the poverty line, have no high school degree or GED, be homeless, be single parents, have custodial issues, engage in HIV related risk behaviors, have histories of victimization and its corresponding trauma, experience higher rates of serious mental illness, and have family histories of substance use disorders (Wellisch et al., 1993, Schilling et al., 1994, Singer et al., 1995, Jordon et al., 1996, Teplin et al., 1996, Peters and Hills, 1997, Veysey, 1997, Henderson, 1998, General Accounting Office, 1999, Langan and Pelissier, 2001, Reif et al., 2001, Bloom et al., 2002, Fazel and Danesh, 2002, Abram et al., 2003, Bloom et al., 2004, Belenko et al., 2004, Adams et al., 2011, Guydish et al., 2011).

The literature suggests that within this vulnerable population, the majority engage in a range of activities that put them at high risk of relapse and either contracting or spreading HIV, with over 90% being sexually active (over half unprotected), 40–55% engaging with multiple sexual partners, 30–50% trading sex for drugs, food, housing or money, and 18–33% injecting drugs prior to incarceration (Adams et al., 2011, Baseman et al., 1999, Belenko et al., 2004, Bond and Semaan, 1996, El-Bassel et al., 1996, Grella et al., 2000, Grella et al., 2005, Guydish et al., 2011, Jordon et al., 1996, Magura et al., 1993, McClelland et al., 2002, Teplin et al., 1996, Wellisch et al., 1993, Wellisch et al., 1996). These circumstances leave women offenders twice as likely to have HIV/AIDS than male offenders and over 7 times more likely than women in the community (Center for Disease Control and Prevention, 2004, Maruschak, 2004). They also constitute a high-risk group vulnerable to relapse to substance use, HIV, and re-incarceration upon re-entry into the community.

Although dominated by studies with male offenders, several studies show that post-release participation in community-based treatment can sustain and often improve upon post-release outcomes (Harrison and Martin, 2003, Prendergast and Wexler, 2004, Wexler et al., 2004). Unfortunately, while a third of jail-based programs refer women to community-based treatment, only about 1 in 4 programs assist the women in contacting community-based treatment (Taxman et al., 2007). Moreover, the vast array of competing needs women face upon re-entry into the community often devastates and prevents the women from successfully accessing and staying in community-based treatment, resulting in high relapse rates and poor outcomes. For women offenders, when the need for successful linkages and retention in community-based treatment is met, post-release recovery is more likely to be sustained. In one study, Guydish et al. (2011) randomly assigned women to probation case management or to standard probation in an attempt to increase post-release treatment participation and reduce relapse and recidivism. There were no significant differences between groups and it was concluded that more treatment was likely needed to achieve successful outcomes.

While it is necessary to link women offenders to community-based treatment upon release and increase retention rates, these strategies alone are likely not sufficient to support the women's long-term recovery process. A growing body of evidence demonstrates that addiction is often a chronic condition, requiring multiple episodes of care over several years before achieving stable recovery, particularly when accompanied by multiple co-occurring conditions much like the conditions common in the women offender population. To manage other chronic conditions, general public health models utilize ongoing monitoring and early re-intervention techniques to alleviate symptoms, restore physical and psychosocial functioning, and improve social relationships and quality of life (Nicassio and Smith, 1995, Rotter et al., 1998). Drawing on experience from the health care field and responding to calls in the addiction field to shift treatment toward a chronic care model (Dennis and Scott, 2007, Dennis and Scott, 2012, McLellan et al., 2000, Weisner et al., 2004), Scott and colleagues developed and tested a Recovery Management Checkup Model (RMC) designed to manage recovery over time (Dennis et al., 2003a, Dennis et al., 2003b, Dennis et al., 2003c, Dennis and Scott, 2012, Scott and Dennis, 2003, Scott and Dennis, 2009, Scott and Dennis, 2011, Scott et al., 2005a). The theory underlying this work is that long-term monitoring through regular checkups and early re-intervention will facilitate early detection of relapse, reduce the time to treatment re-entry; and consequently, improve long-term outcomes. This approach does not rely on participants to identify their symptoms and return to treatment. Instead, these checkups are pro-active and include quarterly assessments and personalized feedback for participants on the status of their condition. Research personnel used Motivational Interviewing (MI) techniques to involve participants in the decision-making process about their care, and help participants resolve their ambivalence about substance use to help move toward a commitment to change by actively participating in treatment or some other type of recovery support. The Recovery Management Check-up (RMC) model relies on treatment linkage, engagement, and retention protocols to help participants secure the care they need over extended periods of time. This model addresses the chronic nature of addiction and incorporates the following components known to facilitate and sustain long-term recovery: (a) sustained client engagement, (b) quarterly monitoring and linkage to treatment, (c) removing obstacles to treatment admission and recovery, (d) enhancing treatment retention and completion, (e) teaching participants the skills needed to actively self-manage their condition, and (f) pro-actively resolving ambivalence about use and abstinence.

RMC has been tested in two clinical trials involving 894 men and women presenting to community-based treatment. Most reported lifetime involvement with the criminal justice system (75% and 83% respectively) and many reported involvement with the criminal justice system in the 90 days before intake (33% and 45% respectively). In the first trial, participants received quarterly checkups for two years (Dennis et al., 2003a, Dennis et al., 2003b, Dennis et al., 2003c, Scott et al., 2005a, Scott et al., 2005b); and in the second, participants received checkups quarterly for four years (Scott and Dennis, 2009, Scott and Dennis, 2011). Results demonstrated that RMC participants were significantly more likely than those in the control condition to receive any treatment and returned to treatment sooner. The size of these effects increased over time. After two years of quarterly checkups, RMC participants in both experiments also reported significantly more days of abstinence and fewer past-month symptoms of abuse/dependence (Scott and Dennis, 2009, Scott and Dennis, 2011).

Given the effectiveness of RMC on successfully linking to and retaining individuals in community-based treatment, it was hypothesized that RMC would provide a viable option for linking women offenders released from jail to community-based treatment. However, given the higher potential for relapse and recidivism during the 90 days post-release, checkups were scheduled for 30, 60, and 90 days post-release and quarterly thereafter. In addition, the high rates of HIV risk in the female offender population clearly highlight the need to expand the previously tested RMC model to include an HIV intervention component. To that end, a gender-specific HIV intervention was added to the existing RMC model.

This article reports the results from the first 90 days of a third clinical trial in which 480 women offenders were randomly assigned to either the RMC condition or a control group upon release from one of the largest single site jails in the U.S. Women participated in checkups at 30, 60, and 90 days post-release. The objectives of this experiment were to examine the impact of monthly Recovery Management Checkups (vs. control) in the first 90 days post-release from jail on receipt of community-based substance abuse treatment, and to explore the impact of RMC, treatment, and abstinence on HIV risk behaviors and recidivism.