treatment instead of punishment_2011

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Communicating the Principle of “Treatment Instead of Punishment” in Hungary on the Basis of an Examination of

the Patients at a Drug Out-patient Clinic

Journal: Drugs: Education, Prevention & Policy

Manuscript ID: CDEP-2010-0005.R1

Manuscript Type: Original papers

Keywords: Addiction, Crime prevention, Drug education and prevention

URL: http:/mc.manuscriptcentral.com/cdep Email: [email protected]

Drugs: Education, Prevention & Policy

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Communicating the Principle of “Treatment Instead of Punishment” in Hungary on the

Basis of an Examination of the Patients at a Drug Outpatient Clinic

Abstract

Aims: Drug use is an indictable offence in Hungary, but there is an opportunity to suspend the

criminal proceedings if a small quantity of drugs is involved. However, the principle of "treatment

instead of punishment" (TIP) is heavily disputed in the professional literature. The present study

addresses the impact of the legal implementation of TIP on the practices of an institution that treats

drug patients.

Methods: Data was analysed on the basis of Addiction Severity Index (ASI) interviews conducted with

individuals (n=628) who applied for treatment at a Budapest drug outpatient clinic between 2001

and 2005. The ASI of individuals who chose TIP was compared with that of other drug patients using

cluster analysis and a two-sample statistical t-test.

Findings: After 2003, when the criminal law changed, the share of participants in TIP increased from

24% to 72.6%. Approximately half the sample required treatment but did not have any problems.

From 2003, the share of patients "without problems" who chose TIP was high (60%).

Conclusions: A modification of the TIP framework is justified for Hungary’s criminal administration

policy, which should consider the severity of the condition of the person utilizing the service in

connection with drug use.

Keywords: treatment instead of punishment, quasi compulsory treatment, Addiction Severity Index

(ASI), outpatient treatment

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Introduction

The treatment of drug users in lieu of punishment is a heavily discussed and disputed issue in the

international literature (Wild et al., 2001; Wild et al., 2002). In the European Union, the term “quasi

compulsory” treatment (QCT) is generally used (Fisher et al., 2002) in relation to the treatment of

criminals who committed offences other than drug offences. Treatment instead of punishment (TIP)

for drug users is incorporated into the various institutional systems of the individual countries,

relating to both the judicial and therapeutic systems (Fisher et al., 2002; Lévay, 2006; National

Institute on Drug Abuse, 2006; Soulet et al., 2006; Stevens et al., 2003; Stevens et al., 2006). The

present study examines one facet of the situation in Hungary: how the principle of TIP is

communicated in Hungarian drug policies, or more precisely, its criminal policies. We examined the

practices of an institute engaged in the treatment of drug patients in the context of whether the

patients being treated on the basis of TIP are genuinely drug patients in need of treatment and if,

from another point of view, this legal option is reaching the target groups in need of treatment (i.e.

drug users that have a severe need of treatment). Stated more clearly, we evaluated whether the

latest amendment, in 2003, to the regulatory enforcement of TIP has had any perceivable effect on

the number of patients at the treatment institute. Also, we investigated whether the assumption

that the drug users affected by the legal implementation of TIP, in the context of its jurisdiction in

criminal matters, are those whose problems require only short-term treatment, or do not particularly

require treatment, is correct.

Treatment Instead of Punishment in Hungary

Drug users in Hungary are treated primarily in health care institutions. In 2006, 23% of patients

receiving treatment for the first time (1,304 of a total 5,673 persons) received in-patient treatment,

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22% (1,247/5,673) received treatment at outpatient centres specializing in addiction, and 50.3%

(2,856/5,673) received treatment at outpatient centres specializing in drug use. Blue Point Drug

Counselling and Outpatient Centre, where we performed our work, is considered to be part of the

latter outpatient centre group. At the centres specializing in drug use, an effort is made to integrate

the patients’ medical and psychological treatment, whereas the other centres primarily provide

medical treatment. About 200 drug users are treated annually at residential, primarily therapeutic,

community-type institutions outside the health care system. In 2006, 853 outpatient clients

participated in methadone maintenance treatment. Treatment institutions are financed by the

National Health Fund regardless of their legal status (health care or non-governmental

organizations). The funding basically follows the number of treated clients; if they have fewer clients

they receive less money. Treatment institutions receive the same amount money for TIP and non-TIP

clients. In “education-prevention” TIP services, which are described below, clients are financed by

another government fund, so treatment institutions who deal with these kinds of clients receive

extra financing.

In 2004, 260 treatment institutions were involved in providing TIP; however, 15 institutions treated

85% of the TIP clients (Vitrai et al., 2009).

In Hungary, the punishment for consumption-type criminal offences involving small quantities of

drugs (Penal Code: Article 282 of Act IV of 1978) is a 2-year prison sentence. These offences include

the possession and holding of drugs for personal use and the conveyance of drugs without intention

to distribute. The discovery of drug residuals in an individual’s urine is enough for the person to be

prosecuted. Neither the police nor the public prosecutors are authorised to halt prosecution, even,

for example, due to a low degree of social risk, contrary to the practice in several countries of the

European Union (European Legal Data Base on Drugs, EMCDDA). The same legal rules apply for

marijuana as for other drugs, which is also contrary to the practice in several countries of the

European Union (EMCDDA). In Hungary, 89.8% of the criminal procedures concerning drug problems

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in 2006 (6,734 cases) (Felvinczi et al., 2007) were initiated against drug users (demand side:

manufacturing, growing, possession, conveyance, and importing for personal use and involving small

quantities). The possibility of applying TIP in the case of drug offences involving small quantities was

established by an amendment to the Penal Code in 1993, which was later changed by an amendment

in 1998, and again by an amendment in 2003 (Lévay, 2006). Before 1993, the punishment for drug

offences was a suspended sentence, probation, or a fine, regardless of the type of drug (438 cases

between 1990 and 1993). In 1998, the Parliament wanted to make the legislation stricter so that only

drug users who were addicted could choose TIP. In 2003 a significant change occurred; the pool of

offenders eligible for TIP was increased considerably through legislation, including not only drug

addicts, but also recreational users, regardless of the type of drug. The goal of this change in

legislation was to reduce the punishment of recreational users and re-establish the earlier, “more

tolerant” legislation. The Hungarian drug laws have continued to not differentiate between drugs. At

present, three types of TIP programmes are available: a) the treatment of drug addicts, b) the so-

called other treatment of drug users, and c) prevention and educational services for recreational

users (regardless of the type of drug) to prevent the development of severe drug use (Joint Decree

No. 26/2003 (V. 16.) ESZCSM-GYISM). The first two types of programmes refer to the treatment of

drug users in severe need of treatment and may only be performed at health institutions, whereas

the latter may also be provided by accredited prevention institutions. Recreational or regular drug

users who cannot be diagnosed as addicts and whose psychological state does not justify treatment

have access to a prevention education service after completing usage examinations, including

addiction severity index (ASI). The procedure followed in all three programmes is the same: subjects

have to make use of the service (in one of the three forms) continuously for 6 months, for at least 2

hours every 2 weeks. Neither the specialists providing the treatment nor the education-prevention

services have the opportunity to change this time frame based on a patient’s condition or change in

condition. According to the national report to the EMCDDA (National Drug Focal Point, 2008) in 2007,

2,381 persons began TIP and 1,488 completed a programme that year (568 persons (24%) had not

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completed TIP or discontinued the programme). TIP can be voluntarily chosen and, in practice,

essentially everyone chooses it. If a person does not choose TIP or does not fulfil its requirements,

then they stand before the drug user’s court where a fine, suspended sentence, or probation can be

imposed. A prison term cannot be imposed in these cases.

Persons Choosing Treatment Instead of Punishment in the Hungarian Health Service

The number of drug users choosing TIP hardly changed between 2001 and 2002 (703 and 751

individuals, respectively) (Elekes et al., 2006). A very considerable increase (212%) occurred in 2003

following the amendment of the Penal Code, but since that time the number of persons being

prosecuted who choose TIP has increased at a lower rate. In 2002, the ratio of TIP patients among

new clients at treatment centres (beginning the treatment that year) was 16%, in 2003, 2004, 2005,

and 2006 this ratio was 39%, 56%, 57%, and 70%, respectively. (Elekes et al., 2006; Felvinczi et al.,

2007).

Figure 1. Number of individuals in treatment as an alternative to criminal proceedings

from 2002-2006 according to the primary drug used.

Behind the abrupt increase starting in 2003, a 417% increase in cannabis users was observed among

TIP patients (Fig. 1) (Felvinczi et al., 2007). At the same time, in 2005, the number of opiate users

among patients participating in TIP decreased significantly (64%) compared to the previous year

(Elekes et al., 2006). The percentage of TIP patients participating in the education-prevention service

at a national level in 2004 was 36%, and 39% in 2005 (Elekes et al., 2006). Importantly, Hungarian law

does not make a distinction between drugs.

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Our research took place at a non-governmental organization in Budapest, the Blue Point Drug

Counselling and Outpatient Centre, which is a treatment institute that operates as a

foundation. Blue Point has been receiving drug-use patients since 1996. In Budapest, which

has 2 million inhabitants and is the capital of Hungary (10 million inhabitants nationwide),

there are three drug outpatient clinics with a substantial number of patients, Blue Point being

one of them. In 2006, 393 drug users being treated for the first time came to Blue Point. The

centre is the third busiest in Hungary, and it operates in an abstinence-oriented approach.

Clients come voluntarily from the whole country, but mostly from the capital, or they can be

referred by TIP. The centre has an obligation to provide any kind of drug services for the

inhabitants where the clinic is located.

In the assessment phase, the patient ASI is calculated and, after a psychiatric examination, their

treatment plan devised. This examination consists of cognitive-behavioural oriented counselling

performed by social workers, because there are no counsellors in Hungary, and is supplemented by

pharmacotherapy when necessary. In more severe cases, psychotherapy emphasising cognitive tools

is performed by a psychiatrist or psychologist. In Hungary, only these two types of experts can

perform psychotherapy. This approach provides an opportunity to integrate medical and

psychological treatment within the institute. The self-help groups are not included due to their small

numbers; Narcotics Anonymous has 200-300 members throughout the country.

Methods

Subjects

The analysis was carried out on the basis of the ASI data for patients who applied for

treatment at the Blue Point Drug Counselling and Outpatient Centre in Budapest between

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2001 and 2005. The data from 628 subjects were analysed. Patients suited for the education-

prevention service were forwarded to prevention services by the outpatient clinic and were not

treated to a significant extent at the clinic.

ASI questionnaires were not filled out by patients:

• younger than 16 years old. According to the ASI manual, the questionnaire works

properly with persons older than 18 years. Out of the total 1,019 new patients

registered at the outpatient clinic during the period between 1 January 2001 and 31

December 2005, 42 were under 16 years of age (4%), and the age of 38 patients (4%)

was not known. Thus, 8% of the total new clients choosing TIP did not fill out the ASI

questionnaire.

• not ready to take the interview in the opinion of the interviewers or did not understand

the majority of questions. This group of patients may have had more needs or been

more problematic.

Table 1. Number of patients who chose treatment instead of punishment (TIP) and number of

patients with a completed addiction severity index (ASI) interview at the outpatient clinic

from 2001-2005.

The highest number people failed to take the ASI interview in 2002 and 2005, with only 57%

and 58% doing so, respectively. These lower rates can mostly be explained by the reasons

described above (age, illiteracy, or the patient was forwarded to another institution). The

lower figure seen in 2004 can also be attributed to the fact that the outpatient clinic was

moved to its current location that year, resulting in many clients not being able to find the

clinic and, thus, failing to take the interview.

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Measuring Tool

The ASI was developed by McLellan et al. in 1980 (McLellan et al., 1980) and was last changed in

1992 as the fifth edition (McLellan et al., 1992). EuropASI (Kokkevi & Hartgers, 1995) is an adapted

version of the fifth edition of ASI, which was endorsed in Hungary by two research groups

independently (Gerevich et al., 2001, 2005; Rácz et al., 2002). The ASI questionnaire plays an

important role not only in the identification of the patients’ medical profile and need for treatment,

and furthermore the severity of their illness, but also in understanding the background factors

influencing their licit and illicit drug use from the point of view of both diagnosis and research.

The international application of the various versions of ASI to drug users for both clinical and

research purposes has a history extending more than two decades (Argeriou et al., 1994; Chawarski

et al., 2006; Hodgins & El-Guebaly, 1992; Kaminer & Frances, 1991; Joyner et al., 1996; Rounsaville et

al., 1991; Stevens et al., 2006). This measurement tool is not only used for assessing the condition of

the patients, but also for evaluating their treatment programme (Alterman et al., 1994; Cacciola,

1997; Wiese, 1995).

Data Collection

The interviews of new patients who entered treatment between January 2001 and December 2005

were carried out by trained social workers. The social workers took part in a 3-day training

programme. On the first two days, the social workers familiarized themselves with the composition

and encoding system of the ASI through the aid of case briefs and role playing, following the training

recommendations of the developers of the ASI (http://www.tresearch.org/training/asi_train.htm).

On the third day of training, which was held at a later time, the social workers analysed the trial ASIs

that had been given in the meantime. The ASI interview was given in the second session of the

assessment process; the first session was an assessment interview. After recording the interviews,

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http://www.tresearch.org/training/asi_train.htm

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the questionnaires were entered into a Statistical Programme for Social Sciences (SPSS) database. No

follow-up ASI interviews were done after the completion of the treatment.

Variables and Methods Applied in the Analysis

During the course of the analysis, we measured severity as it related to different problem areas, with

the composite score index calculated according to international practice (McGahan et al., 1984). The

composite score is an objective index relating to a given dimension of the client's state of health,

which is the result of a mathematical summation of certain answers connected to the given problem

areas. In the case of employment and legal status, we deviated from the original formula in the

calculation of the composite scores because certain variables did not appear to function properly in

the domestic context in the course of the EuropASI validation (Rácz et al., 2002). We produced the

legal status index from the questionnaire by leaving out the variable and established employment

status by choosing the variable group that best correlated with the severity evaluation given by the

interviewer and, at the same time, possessed the greatest internal consistency through the

introduction of three new variables. Each of the objective indices calculated for the different areas

resulted in a continuous variable falling between 0 and 1, where 0 represents a lack of problems and

1 represents problems of maximum severity.

When creating the composite scores for employment and legal status, we made slight changes

to the original formula, which can be explained by the fact that the Hungarian-endorsed

EuropASI does not contain all of the variables that were, according to the protocol,

established to create the composite scores, but, as noted during the validation process, some

variables were not relevant in the Hungarian context. In the case of legal status, the following

variable was left out of the Hungarian version of the EuropASI: “How many days in the past 30

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did you engage in illegal activities for profit?” The reliability index of the remaining four variables

used to create the composite score for legal status reached the necessary statistical level.

Regarding employment status, only two of the variables necessary to create the composite score

were included in the Hungarian version of the EuropASI: “How many days did you work during the

past 30 days?” and “Do you have a valid driver’s license?” The reliability index created from these

two variables turned out to be low; therefore, they could not be used for the composite scores. In

this situation, we decided to test employment status variables that best correlated with the severity

rating and had the highest internal consistency.

Following the test, the following variables were chosen to be included in the composite scores for

employment status:

1. How many days did you work during the past 30 days?

2. How many days did you experience employment/unemployment problems in the past 30 days?

3. How troubled or bothered have you been by these employment problems in the past 30 days?

4. How important to you is counselling for these employment problems now?

Results

Table 2. Sociodemographic and drug usage characteristics of patients choosing treatment

instead of punishment (TIP) and those admitted for other reasons at the outpatient clinic

between 2001 and 2005.

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Table 2 contains the sociodemographic and substance abuse characteristics of persons who chose

TIP and those admitted for other reasons at the outpatient clinic. A chi-square test was used to

compare differences in Table 2. Three-quarters of the clients who entered treatment between 2001

and 2005 were men. Among the patients, persons between 20 and 24 years of age were over-

represented. A large percentage of the patients had secondary school degrees, and in regards to

their employment status, they either worked full-time jobs or attended university. The vast majority

of the patients had never been married. By the patients’ own accounts, no drug problem could be

established for nearly a quarter of the sample. In the remaining cases, cannabis, heroin, and

amphetamine usage caused the primary drug problem. Nearly one-third of the sample did not have a

continuous history of drug use; that is, they had used drugs only once or occasionally. At the same

time, though, nearly 30% of the other patients had a history of drug abuse encompassing more than

3 years. Slightly more than half of the sample entered TIP during the period examined. Notably, in

certain categories (sex, age group, education level, and primary drug problem), significant differences

were found between persons choosing TIP and those admitted for other reasons. Individuals

choosing TIP tended to be men aged between the ages of 20 and 24 years who had not finished their

trade school or college training and had no history of drug use. Also, patients attending TIP seemed

to have no primary drug problem. No considerable difference was found between the two subgroups

in regards to employment status.

Ratio of TIP Patients Before and After 2003

The percentage of persons receiving TIP in the outpatient clinic significantly increased from 24%

before 2003 to 72.6% after 2003 (chi-quadrate=119.58; p=0.00; Fig. 2).

Figure 2. Change in the number of treatment instead of punishment (TIP) participants in the period

examined.

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The regulations set by the Hungarian Ministry of Health and Social Affairs (26/2003 (V. 16)) define

three different categories for TIP:

1. Treated instead of punished for some other reason

2. Admitted within the framework of the TIP programme

3. Education-prevention services

We used these official categories in the analysis. The third category is not included because

the Blue Point Drug Centre does not provide this kind of service, it only refers patients for it.

Drug centres decide what kind of TIP is necessary for a certain patient through the

preliminary assessment based on the ASI interview.

Comparison of the Health Status of TIP Patients and Patients Treated for Other Reasons

Figure 3. Composite scores of patients registered within the framework of the TIP programme from

2001-2005.

Figure 4. Composite scores of patients treated for other reasons instead of punishment from 2001-

2005.

The composite score for medical status and drug use was lower for patients receiving TIP than

persons treated for other reasons during the period examined. The composite score for employment

status was also lower for patients receiving TIP than the others. The composite score for legal status

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was greater for persons receiving TIP than others until 2003, which is also due to the judicial process.

Regarding family status and psychiatric state, the patients receiving TIP had more favourable indexes

than those treated for other reasons. Taken together, the results show that patients who received

TIP had more favourable values than those treated for other reasons, and among those receiving TIP,

the patients who entered treatment after 2003 can be characterised as having less severe problems

in numerous severity categories (Figs. 3 and 4). Although a slight increase was seen in medical status

and alcohol use values after 2003, they were still below or just over 0.2, which, according to the

EuropASI manual, can be regarded as a low figure (the scale for the composite score ranges from 0 to

1, where 1 represents that the problem is great and treatment is definitely necessary).

Using the composite scores, we made a cluster analysis, which allowed us to clearly differentiate the

patient groups with different characteristics.

Group 1: “serious problems”, 19% of total sample. These patients had more significant employment

problems than the others and can be characterised by both psychiatric and drug problems.

Group 2: “less serious problems”, 18% of total sample. These patients had significant problems in the

areas of law and employment, but lower composite scores for other aspects.

Group 3: “without problems”, 50% of total sample. These patients had, on average, low composite

scores in all aspects.

Group 4: 12% of total sample. The main characteristic of these patients is that they have a major

health problem in addition to mid-level employment and psychiatric problems.

On the basis of the cluster analysis, half of the total sample quite clearly did not have

problems requiring treatment. However, there was no need or point in making comparisons to

other groups to reach this conclusion because the assessment tool (EuropASI) was developed

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to assess treatment needs and problems in a standardised way, independent of the target group

(ordinary persons, addicts, etc.) to which it is applied. On the other hand, this conclusion is

also based on the value range of the composite score.

Figure 5. Proportion of cluster groups per year. The third group represents the group without

problems as explained in the Results section.

Finally, we examined the manner in which the proportion of the group without problems changed

between 2001 and 2005 compared to persons receiving TIP and those treated for other reasons. In

each year from 2001 to 2005, we found a significantly higher proportion of patients “without

problems” receiving TIP. However, in 2004, the increase was not significant. Starting in 2003, the

proportion increased dramatically (28%) among those receiving TIP, and in all three years after

(2003, 2004, 2005), the proportion was above 60%. Beginning in 2003, the proportion of patients

without problems increased not only among those receiving TIP, but also among other patients.

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Discussion

In Hungary, the option of TIP for drug users was established by an amendment of the Criminal Code

in 1993 (Lévay, 2006). A significant change also took place in 2003 (compared to the earlier laws in

force between 1999-2003, when only drug addicts could choose TIP), when the legislature

considerably extended the range of persons who could receive TIP. At present, three types of

punishment alternatives exist: treatment of drug addicts, so-called alternative care for treating drug

users, and the education-prevention service. We examined the consequences of these legal

regulations on the basis of the ASI compiled for the patients of a Budapest (metropolitan) outpatient

drug clinic. The selection of the sample was limited to one institution, and therefore is in no way

representative of the national treatment institutes. However, the characteristics of the sample (ratio

of drugs used, age, and sex) were similar to the national data that has been gathered (Felvinczi &

Nyírády és Portörő, 2007; Vitrai et al., 2009). The analysis based on the ASI was also necessary

because the National Statistical Data Collection Programme (OSAP, see note 1) does not provide

reliable data concerning the number of those treated due to drug problems.

On the basis of the ASI composite scores for the patients registered between 2001 and 2005 at the

drug outpatient clinic, we found a clear effect of the 2003 amendment to the regulatory

enforcement of TIP, resulting in a considerable proportion of the persons receiving TIP being

comprised of patients with slight problems or without problems. We also noted that patients without

problems who were able to take advantage of the education-prevention service were referred by the

outpatient clinic; therefore, their treatment did not take place at the clinic, though an ASI was

calculated for them. Due to this arrangement, only a negligible number of patients with severe

health problems were taken to the outpatient clinic on the basis of TIP. From the experience we

gained in the treatment institute, TIP as applied through the legal system primarily reaches drug

users who do not require treatment (e.g., people who tried marijuana and are without problems, as

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well as occasional users) and who do not need health care for either drug use or other problems

(e.g., health or psychiatric problems).

At the level of drug policy, the findings mean that the implementation of TIP has not reached drug

users who have severe dependencies, this goal was not changed by the 2003 legislation, but only

that, on average, the TIP group after 2003 has not had severe problems. Patients without problems

receiving TIP unnecessarily occupy a great portion of the capacity of the health care system; because

of extra financing for the education-prevention service for TIP drug users without problems,

treatment institutions keep them for the obligatory 6 months. No data is available regarding whether

these patients block entry into treatment. We can only assume that the drug agencies become

complacent waiting for TIP patients rather than providing easier access and availability to

problematic drug users through their programmes. The 6-month treatment period valid for all three

forms of TIP is not justified for a considerable number of cases. When determining the duration and

frequency of treatment, psychiatric and forensic analyses of the patient’s condition should also be

taken into consideration.

In Hungary, experience has shown us the possible consequences of applying legal regulations without

making distinctions; the law mainly affects drug users who do not have problems, as they are the

ones who take advantage of the TIP option. This conclusion means that, in the treatment institutions

(in-patient and outpatient clinics), drug users who do not have problems or who may be

characterised as having only slight problems tend to be the majority of those in treatment. At the

same time, drug abusers with more severe problems do not receive this kind of treatment. The

reason for the extensive application of TIP is that drug abuse (and possessing drugs for one's own

use) is a strictly prosecuted crime in Hungary with a prison term of up to two years. In the case of

users, the legal implementation of TIP is designed to compensate for the fact that this punishment is

avoided, particularly for recreational drug users who do not have severe problems. This is the

advantage of the law, but it mostly compels drug users who do not have problems to take part in

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treatment or education-prevention programmes to avoid punishment. In reality, drug users do not

avoid criminal proceedings, they can only choose treatment (or an education-prevention

programme) instead of prosecution with the consent of the public prosecutor, or earlier during the

investigation period; however, criminal proceedings are still initiated against them in these cases.

Another possible alternative could be medical treatment as a social control mechanism for

“recreational” drug users who do not have problems. The effect of the wide ranging application of

this approach at the level of drug policy would not necessarily lead to the expected results, the

suppression of this type of substance abuse. The utilization of this kind of social control could easily

be counterproductive, as it could push drug users without problems towards the patterns of more

serious drug abuse. At the same time, warnings have been given, primarily by Frank Furedi (e.g.,

Furedi, 2006), about the dangers of treatment agencies or even patient-initiated medical treatment

(for the effects related to medical treatment see Conrad, 2005; McBride et al., 2009; Metz and

Herzig, 2007; Rose, 2007).

On the basis of our observations, we propose the alteration of either the legal implementation of TIP

or the decriminalisation of drug use (personal use and possession). In our opinion, both

modifications, particularly the latter, would result in the treatment of a larger share of the

problematic drug users instead of the unproblematic ones, and the criminalisation and medical

treatment of drug users without problems can be avoided. We surmise that the availability and

access to treatment centres will increase for non-TIP drug users and, furthermore, that the criminal

justice system would be able to pay greater attention to the more problematic drug users. We think

this approach would free up capacity at treatment institutes, which could be used for programmes

designed for treating problematic drug users, even though we did not find any data suggesting that

the current TIP patients are blocking the entry of others into treatment. The principle of TIP in the

context of Hungarian criminal law has become flawed, with 90% of criminal proceedings now

initiated against drug use offenders (Felvinczi et al., 2007). Currently in Hungary, the first proposal

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(the alteration of TIP) is more realistic than the second option (decriminalisation), which still leaves a

question about the effectiveness of QCT options for problematic drug users in Hungary.

The observations we made during the course of our research on the legal procedures related to drug

users and drug addicts, who also commit other offences, can be placed in a wider scope. At the same

time, we noted that, in Hungary, drug users who have not committed other crimes also end up in TIP.

Numerous methodological problems have been brought up by Perry et al. (2008) in studies on the

effectiveness of drug treatment programmes for drug-using offenders in the courts. However,

according to the authors’ summary, interventions for drug-using offenders under the care of the

criminal justice system can be effective (Perry et al., 2008). Numerous other examinations

corroborate the authors’ conclusions (Cooper, 2003; Freeman, 2003; Krebs et al., 2007; Roll et al.,

2005; Turner et al., 2002; Kelly et al., 2005; Marlowe et al., 2005). The fact that the criminal justice

system can serve as a point of contact is an important aspect that has been recognized for a long

time (Leukefeld et al., 1998).

Patients sent to treatment by the justice system have better substance abuse and other

characteristics at the time of admittance compared to non-mandated patients entering through the

justice system and patients not involved in the justice system. In addition, these patients show more

significant improvement at the completion of treatment than the other two groups (Kelly et al.,

2005). At the same time, the “drug court” model has been criticised. For example, California’s voter-

initiated Proposition 36 (Prop 36) has been referring drug offenders to community-based drug

treatment. In the case of these patients, drop-outs (that is, those for whom the treatment “did not

work”) were more criminally involved and had more severe substance abuse problems (Evans &

Hser, 2009). Further examples that drug users in worse condition do not perform as well are

available (e.g., Roll et al., 2005 for intravenous users; Marinelly-Casaey et al., 2008 for frequent

methamphetamine users), and the model unnecessarily broadens the range of those included to

those for whom it is not justified, called the “net widening” effect (Bowers, 2008; Draine et al., 2005;

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Harrison & Scarpitti, 2002; Kelly et al., 2005). Others bring attention to the effects of “iatrogenesis”,

which the legal approach produces among low intensity users who enter high intensity programmes,

and at high cost (Marlowe, 2006). Certain authors also consider the “drug court” in its current form

to be “contraindicated” (Bowers, 2008) because addicts in worse condition (or even anyone who can

already be called an addict), as well as various minorities, perform much more poorly, thereby

remaining in the criminal justice system for an unforeseeable period of time. Many envision the

future of the “drug court” movement as not only affecting criminal justice or the development of

treatment approaches, but also connected with drug policies (e.g., Bowers, 2008). As we mentioned,

the QCT model has been introduced in Europe. A study carried out in five European countries

revealed that “QCT can be a valuable route into treatment for some people who are having problems

with drug use but are not willing or able to enter treatment without a ‘push’ from the criminal justice

system” (Stevens et al., 2006, p. 208). QCT clients are drug offenders, not “simple” drug abusers.

Stevens et al. (2005) summarized their literature review published in French, German, Dutch, and

Italian and compared it to reviews of the English literature, “Some common points have been found,

such as the consistent correlation of dependent drug use and criminal behaviour, and the existence

of studies that show that coerced treatment can have a similar outcome to voluntary treatment.

However, the study has shown a greater range of outcomes, with more reports of negative results of

QCT, than is found by reviewing only the English literature” (Stevens et al., 2005, p. 277). The authors

also concluded that “policy and practical decisions are being made in the absence of conclusive

evidence on which to base them” (Stevens et al., 2007, p. 276). Certainly this is the point our study

wanted to emphasize.

Our own observations of the “drug court” model are not directly comparable to these observations;

however, elements also appeared in our examinations that cause the “drug court” model to be

criticised, whereas the positive aspects of it are not observed due to the Hungarian legal system.

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Limits of the Research

Our research was based on local data and, at present, no analysis is similar to it based on national

data, which would have been a more complex study of clients receiving TIP. The primary reason is

that, in spite of the professional protocol (Pszichiátriai Szakmai Kollegium [Psychiatric Professional

College], 1998), the ASI measuring tool is only seldom used by drug outpatient clinics in Hungary

(Gerevich et al., 2005). In addition, the restricted data collected by the OSAP (sociodemographic and

substance abuse characteristics) do not enable a complex analysis similar to the one presented in this

study. The sample of Blue Point patients is not representative, but the characteristics of the sample

mirror those in the national data (Felvinczi et al., 2007). The lower rates of response, particularly for

2002 and 2005, can be explained by several factors, such as many clients being under the age of 16,

illiterate, or not ready to be interviewed, and in addition, a number of patients who qualified for the

education-prevention service were referred to other prevention services.

In addition, as described in the Methods section of this study, the smaller figure seen in 2004

can also be attributed to the fact that the outpatient clinic moved to its current location,

resulting in many clients not being able to find the clinic and failing to arrive at the interview.

Acknowledgement

The study was supported, in part, by the Ministry of Social Affairs. The authors’ declaration of

interest: the first and third author work at the institution where the study was done.

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Note

1. The National Statistical Data Collection Programme (OSAP) has been applied by drug

treatment centres in Hungary since 1996. Data collection questionnaires have to be filled out

by the centres at the end of each year. This means that only aggregated data could be

collected concerning the individual centres, which made the filtering of duplicates

impossible. Data collection regulation was not effective (Felvinczi et al., 2007). From 2006,

this type of data collection was replaced by a Treatment Demand Indicator (TDI) that met the

EMCDDA norms.

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Figure 1

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Figure 2

TIP for some other reasons

Entered in the framework of TIP”

Total

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Figure 3

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Figure 4

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Figure 5

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List of artworks



from 2001-2005.

Year Number choosing

TIP

Number with ASI

interview

%

2001 112 72 64

2002 199 113 57

2003 275 183 67

2004 192 114 60

2005 250 146 58

Total 1028 628 61

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Table 2. Sociodemographic and drug usage characteristics of patients choosing treatment instead of

punishment (TIP) and those admitted for other reasons at the outpatient clinic between 2001 and

2005.

Total

Number of patients

attending TIP

Number of

patients

admitted for

other reasons Total 628 344 247

Sex** Column% Column%

Male 482 84.6% 70.4%

Female 111 11.0% 24.3%

No data 35 4.4% 5.3%

Age**

≤19 years 188 24.4% 36.0%

20-24 years 266 48.5% 36.0%

≥25 years 161 26.5% 27.1%

No data 13 0.6% 0.8%

Educational level**

Less than 8 years of elementary school 124 21.5% 18.2%

8 years of elementary school 160 20.6% 30.4%

Unfinished trade school, training college 77 16.9% 7.3%

Trade school, training college 77 13.4% 11.7%

Unfinished gymnasium, specialised secondary school 35 5.2% 6.9%

Gymnasium, specialised secondary school 117 18.0% 19.4%

Unfinished academy, university 4 1.2% 0.0%

Academy, university 18 2.3% 4.0%

No data 16 0.9% 2.0%

Employment status

Full-time 230 39.5% 35.2%

Part-time 67 9.3% 12.1%

University student 235 34.9% 40.9%

In military service 7 1.2% 1.2%

Unemployed or housewife 57 10.8% 7.3%

Lives in a controlled environment 4 1.2% 0.0%

No data 26 3.2% 3.2%

Family status**

Never married 560 94.8% 87.4%

Married 17 1.5% 4.0%

Remarried 1 0.3% 0.0%

Lives separately 2 0.0% 0.8%

Divorced 12 0.9% 3.6%

No data 26 2.6% 4.0%

Primary drug problem**

No problems 160 39.2% 7.7%

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Heroin 56 6.7% 12.1%

Amphetamine 95 12.5% 18.6%

Cannabis 157 21.2% 32.8%

Several drugs 63 7.3% 11.3%

Other (alcohol, medicines, cocaine, etc.) 97 13.1% 17.4%

Length of drug career

No drug career 153 29.7% 17.4%

0-2 years 171 21.8% 33.2%

3-4 years 122 16.9% 23.9%

≥ 5 years 136 21.2% 22.3%

No data 46 10.5% 3.2%

Participation in TIP

Reached in the framework of TIP 344

Reached for other reasons 247

No data 37

*p<0.05, **p<0.01

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from 2001-2005.

Table 2. Sociodemographic and drug usage characteristics of patients choosing treatment

instead of punishment (TIP) and those admitted for other reasons at the outpatient clinic

between 2001 and 2005.

Figure 1. Number of individuals in treatment as an alternative to criminal proceedings from

2002-2006 according to the primary drug used.

Figure 2. Change in the number of treatment instead of punishment (TIP) participants in the

period examined.

Figure 3. Composite scores of patients registered within the framework of the TIP programme

from 2001-2005.

Figure 4. Composite scores of patients treated for other reasons instead of punishment from

2001-2005.

Figure 5. Proportion of cluster groups per year. The third group represents the group without

problems as explained in the Results section.

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Abstract

Aims: Drug use is an indictable offence in Hungary, but there is an opportunity to suspend the

criminal proceedings if a small quantity of drugs is involved. However, the principle of

"treatment instead of punishment" (TIP) is heavily disputed in the professional literature. The

present study addresses the impact of the legal implementation of TIP on the practices of an

institution that treats drug patients.

Methods: Data was analysed on the basis of Addiction Severity Index (ASI) interviews

conducted with individuals (n=628) who applied for treatment at a Budapest drug outpatient

clinic between 2001 and 2005. The ASI of individuals who chose TIP was compared with that

of other drug patients using cluster analysis and a two-sample statistical t-test.

Findings: After 2003, when the criminal law changed, the share of participants in TIP

increased from 24% to 72.6%. Approximately half the sample required treatment but did not

have any problems. From 2003, the share of patients "without problems" who chose TIP was

high (60%).

Conclusions: A modification of the TIP framework is justified for Hungary’s criminal

administration policy, which should consider the severity of the condition of the person

utilizing the service in connection with drug use.

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1

Reviewer: 1

Comments to the Author

This paper has something to offer the debate around TIP and the on-going problems and effects surrounding quasi-compulsary treatment. The authors

clearly hold some strong opinions about this and are basing much of their work on a mixture of empirical research and personal and professional experiences.

Equally, it is interesting and informative to see a perspective from Eastern Europe.

However, that said, I have a few problems with the paper, mostly in terms of structure, but also in places with content. Specifically I would like the structure to be tighter. I like the way that you attempt to inform the

reader about the past and current Hungarian policy but the manner in which you do this needs some revision as, in its current form, it detracts from the

overall message. perhaps a specific section which details the Hungarian model?

See Treatment Instead of Punishment in Hungary and Persons Choosing Treatment Instead of

Punishment in the Hungarian Health Service sections.

Replacing from p. 8 to p. 5:

“Drug users in Hungary are treated primarily in health care institutions. In 2006, 23% of

patients receiving treatment for the first time (1,304 of a total 5,673 persons) received in-

patient treatment, 22% (1,247/5,673) received treatment at outpatient centres specializing in

addiction, and 50.3% (2,856/5,673) received treatment at outpatient centres specializing in

drug use. Blue Point Drug Counselling and Outpatient Centre, where we performed our work,

is considered to be part of the latter outpatient centre group. At the centres specializing in

drug use, an effort is made to integrate the patients’ medical and psychological treatment,

whereas the other centres primarily provide medical treatment. About 200 drug users are

treated annually at residential, primarily therapeutic, community-type institutions outside the

health care system. In 2006, 853 outpatient clients participated in methadone maintenance

treatment. Treatment institutions are financed by the National Health Fund regardless of their

legal status (health care or non-governmental organizations). The funding basically follows

the number of treated clients; if they have fewer clients they receive less money. Treatment

institutions receive the same amount money for TIP and non-TIP clients. In “education-

prevention” TIP services, which are described below, clients are financed by another

government fund, so treatment institutions who deal with these kinds of clients receive extra

financing.

In 2004, 260 treatment institutions were involved in providing TIP; however, 15 institutions

treated 85% of the TIP clients (Vitrai et al., 2009).”

I would also like to see a re-write of the introduction which I found to be confusing - in short I didn't really know what your paper intended to do.

Our goal was to evaluate whether we treat those who are in need of treatment (by the measure

of TIP) or treat drug users who do not need treatment (because of TIP), in case TIP is

ineffective or does not reach its target group (i.e. drug users in a “severe” state and in need of

treatment).

In terms of content, you make some good points in your discussion but some of your conclusions are not based on evidence but on 'feelings' and assumptions,

especially when discussing the impact of TIP on the wider service provision. You are probably correct in these assertions but it might be useful to back

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2

those assertions with reference to other countries' experiences on the effect

of quasi-compulsory treatment regimes. There is a body of literature out there which you might like to examine and perhaps refer to.

Reply: p. 21-22

As we mentioned, the QCT model was introduced in Europe. A study carried out in five

European countries revealed that “QCT can be a valuable route into treatment for some

people who are having problems with drug use but are not willing or able to enter treatment

without a ‘push’ from the criminal justice system” (Stevens et al., 2006, p. 208). QCT clients

are drug offenders, not “simple” drug abusers. Stevens et al. (2005) summarized their

literature review published in French, German, Dutch, and Italian and compared it to reviews

in the English literature, “Some common points have been found, such as the consistent

correlation of dependent drug use and criminal behaviour, and the existence of studies that

show that coerced treatment can have a similar outcome to voluntary treatment. However, the

study has shown a greater range of outcomes, with more reports of negative results of QCT,

than is found by reviewing only the English literature” (Stevens et al., 2005, p. 277). The

authors also concluded that “policy and practical decisions are being made in the absence of

conclusive evidence on which to base them” (Stevens et al., 2007, p. 276). Certainly, this is

the point our study wanted to emphasize. Reviewer: 2

Comments to the Author

This is article gives investigates an aspect of Hungarian drug policy, which is relevant also for other countries, and more specifically it gives

interesting insights into (unintended) consequences of a drug policy that let drug users choose between being criminals or patients (or individuals in need

of re-socialization). The suggested changes and additions are:

1. First of all the language needs a brush up. At times the text is difficult to read. This is particularly a problem page 3 lines 29-51 where the study is presented.

2. There is need of some information about how the screening procedures at

the clinic work. Because one question the reader is left with is why some drug users are transferred to prevention education and why some drug users,

who according to the research do not have problems that need treatment, are kept at the clinic?

In Hungary there is no “screening” as it used in, for example, the U.S. We can

state only this on p. 8: “In the assessment phase, the patient ASI is calculated and, after a psychiatric examination, their treatment plan devised.” and “The centre has an obligation to provide any kind of drug

services for the inhabitants where the clinic is located.”

3. Related to the point above, there is need for some information about possible incentives to keep drug users with no problems at the clinic. Are

there economic incentives? How does the clinic get its funding? What difference would it make for the clinic to have fewer clients?

Do we find similar results in public clinics?

A citation was added on p. 18:

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3

“However, the characteristics of the sample (ratio of drugs used, age, and

sex) were similar to the national data that has been gathered (Felvinczi & Nyírády és Portörő, 2007; Vitrai et al., 2009).”

In other words, suggesting some other possible explanations than the clinic

becoming ‘complacent’ (p19).

p.5

Treatment institutions are financed by the National Health Fund regardless of their legal status

(health care or non-governmental organizations). The funding basically follows the number of

treated clients; if they have fewer clients they receive less money. Treatment institutions

receive the same amount money for TIP and non-TIP clients. In “education-prevention” TIP

services, which are described below, clients are financed by another government fund, so

treatment institutions who deal with these kinds of clients receive extra financing.

p. 18 “…because of extra financing for the education-prevention service for TIP drug users without problems, treatment institutions keep them for the obligatory 6 months.”

Also p. 5.

“Treatment institutions receive the same amount money for TIP and non-TIP clients. In

“education-prevention” TIP services, which are described below, clients are financed by

another government fund, so treatment institutions who deal with these kinds of clients

receive extra financing.”

4. Related to point 3 above, it would be nice with some estimate of how many drug users in need of treatment who go without treatment. Probably such

assessments exist. There is no such estimation.

5. At page 14 it is a bit difficult to understand the distinction between

categories 1 and 2. It becomes clear when you read the text, but I think the categories should be clearly defined here. It is probably a matter of

expression.

p 15-16 added: Group 1: “serious problems”.

Group 2: “less serious problems”. It would also improve the text to get a little more to know about how non-tip

patients are recruited and how high/low-threshold the clinic is.

p. 8

“In 2006, 393 drug users being treated for the first time came to Blue Point. The centre is the

third busiest in Hungary, and it operates in an abstinence-oriented approach. Clients come

voluntarily from the whole country, but mostly from the capital, or they can be referred by

TIP.”

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treatment instead of punishment_2011

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