Drug and Alcohol Dependence 217 (2020) 108396
Available online 12 November 2020
0376-8716/© 2020 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
The predictability of the Addiction Severity Index criminal justice
assessment instrument and future imprisonment: A Swedish registry study with a national sample of adults with risky substance use
Robert Grahn *, Mojgan Padyab
Department of Social Work, Umeå University, Sweden
A R T I C L E I N F O Keywords:
Addiction Severity Index Substance use disorder Register-based study Imprisonment Sweden
A B S T R A C T
Objective: In Sweden, social workers uses the Addiction Severity Index (ASI) as their main assessment tool when assessing individuals with risky substance use (RSU) or substance use disorder. The aim of this study is to identify among individuals with RSU, the associations of ASI Composite Scores (CSs) with future imprisonment con- trolling for age, education level and gender.
Method: Baseline ASI-data was merged with national registry data on prison sentences (2003–2016). Cox regression was used to estimate the associations between CSs for alcohol, drugs other than alcohol, legal, family and social relationships, employment, mental- and physical health and future imprisonment for adults (n = 14,914) assessed for RSU.
Results: The regression showed that all ASI CSs, age, education level and gender were significantly associated with imprisonment post ASI base-line assessment. The variables with the strongest association with imprison- ment were ASI legal CS, followed by ASI drugs other than alcohol CS, ASI employment CS and being a male. ASI legal score showed the strongest association with imprisonment, with a 6 time increase in likelihood of imprisonment.
Discussion: Given the findings in this study, the strong significant association between ASI legal CS and future imprisonment, it seems as that the ASI-assessment instrument is a reliable and trustworthy assessment tool to use in clinical work. This should motivate social workers and other clinical health professionals to use and rely on the ASI assessment in their intervention planning for clients with RSU, to hopefully reduce future imprisonment and improve their social situation.
1. Introduction
There exists a clear linkage between risky substance use, addiction and criminality (Bennett and Holloway, 2009; Boden et al., 2013;
Bukten et al., 2011; Dietze et al., 2013; Fazel et al., 2006; Fridell et al., 2008). Even though previous research has demonstrated the role of risky substance use and the association with criminality (Bennett and Hollo- way, 2009; Boden et al., 2012; Dietze et al., 2013; Fazel et al., 2006;
Larney and Martire, 2010; Stewart et al., 2000; Walter et al., 2011), limited research exists regarding the capacity of the ASI assessment in- strument as a tool to predict the likelihood of future imprisonment for clients assessed for risky substance use.
Hence, the study presented here, using Swedish registry data both from the national Addiction Severity Index database and the Swedish
National Council for Crime Prevention, aims to identify among adult individuals all assessed for risky substance use, the associations of the Addiction Severity Index Composite Scores (CSs) with future imprison- ment controlling for age, level of education and gender.
2. Background
2.1. ASI as an assessment tool
The Addiction Severity Index is a semi-structured assessment in- strument with a multi-dimensional perspective on substance use severity and addiction, which includes of assessments of addiction related health and social problems (McLellan et al., 2006). One of the main contribu- tions of the ASI-assessment interview is its broad perspective on
* Corresponding author at: Department of Social Work, Umeå University, Biblioteksgr¨and 4, Umeå, 90187, Sweden.
E-mail address: robert.grahn@umu.se (R. Grahn).
Contents lists available at ScienceDirect
Drug and Alcohol Dependence
journal homepage: www.elsevier.com/locate/drugalcdep
https://doi.org/10.1016/j.drugalcdep.2020.108396
Received 26 June 2020; Received in revised form 23 October 2020; Accepted 27 October 2020
substance use severity and these related domains (Nystr¨om et al., 2010).
Problem severity in the associated domains besides alcohol and drugs other than alcohol, include the legal-criminal justice domain, the family and social relationships domain, employment and self-support domain, the medical domain and the mental health domain (McLellan et al., 2006). To note, the ASI and its psychometric properties have been tested extensively on different population and in different countries (Hendriks et al., 1989; Lundgren et al., 2014; Weisner et al., 2000; M¨akel¨a, 2004;
Nystr¨om et al., 2010; Padyab et al., 2018; Pankow et al., 2012). Further, the World Health Organization recommends use of ASI as an assessment and follow-up tool when working with individuals with risky substance use or substance use disorder (United Nations Office on Drugs and Cri- me/World Health Organization, 2017).
2.2. The usefulness of ASI as an assessment tool for criminality
There has been limited research on the use of ASI as an assessment tool for criminality and criminal risk behaviors. However, there exist some research on the subject, and one study from US used the ASI to examine the influence of criminal justice referral on the outcome of treatment for alcohol and drug severity (DeFulio et al., 2013). A Swedish study used the ASI to assess substance use severity for incarcerated in- dividuals to predict future mortality (Håkansson and Berglund, 2013), and a second Swedish study focused on risk factors for prisoners on criminal recidivism using the ASI-interview as baseline data (Håkansson and Berglund, 2012). A third Swedish study examined the roll of psy- chosocial vulnerability using ASI as assessment tool on the association with imprisonment (Grahn et al., 2019). However, none of these studies have had the focus on if or how the ASI-interview assessment predicts future imprisonment for adults with risky substance use.
Hence, the manuscript presented here contributes new knowledge on the usefulness of the ASI-assessment instrument and it’s predictability on future imprisonment.
3. Aim
The study’s aim was to examine the associations between the ASI composite scores regarding level of severity in the legal criminal justice domains as well as in the additional ASI domains including alcohol and drugs other than alcohol domain, the family and social relationships domain, employment and self-support domain, the medical domain and the mental health domain and future imprisonment for clients with risky substance use. The study also controlled for age, level of education and gender.
4. Methods 4.1. Study sample
The present study included 14,914 adults (18 years of age and older) all assessed for risky substance use in 65 Swedish municipalities be- tween 2003 and 2016. All clients were interviewed and assessed by social workers by using the ASI assessment interview instrument (McLellan et al., 1992). In Sweden, social workers at Swedish municipal social services require an education and certification to use the ASI in- strument as a tool when assessing clients with risky substance use. ASI as an assessment instrument is not a diagnostic tool, and social workers in Sweden does not diagnose clients, they assess for severity and needs regarding risky substance use. It is through the Swedish municipal social services system the majority of assessments for individuals with risky substance use take place, where ASI is the most common assessment tool. Individuals either seek out for help voluntarily or are referred due to risky substance use to the social services. The Swedish municipal social services provide a range of interventions to support individuals with a risky substance use, such as outpatient treatment, financial sup- port, housing support, brief interventions, inpatient treatment, referral
to health care and employment services.
4.2. Data-bases
In the present study, data from the Swedish criminal justice registry from The Swedish National Council for Crime Prevention was combined with baseline data from ASI collected by social workers at the municipal social services. Through data from the Swedish criminal justice registry we have access to data regarding number of imprisonments and dates for imprisonments. All individuals in the database include those who have already received their verdict. It does not include anyone who is under investigation or pending their sentence. The study received Institutional Review Board ethics approval from both the National Board of Health and Welfare (NBHW), the Regional Ethical Review Board at Umeå University and the Ethical Review Board at University of Denver.
4.3. Independent variables
ASI Composite Scores: Each CS is the sum of answers to selected questions within each ASI functional domain. The intention has been to give equal weighting to all selected questions within a CS for each functional domain. We have adjusted each CS by the answer range of each individual question and the total number of objects in the CS, each question is then divided by its maximum value and by the number of questions in the CS. These results are then summed to give a CS. When we calculated the CS, we used the procedure recommended by the de- velopers of ASI (McGahan et al., 1986). The more severity the clients assess they have in different domain, the higher their scores will be.
Within each problem domain in the ASI interview, the CS gives a general measure of the client’s situation.
Addiction severity was measured through two ASI Composite Scores one for Alcohol and one for Drugs other than alcohol. Both these CS measured the client’s self-reported level of use, how bothered the client felt by problems derived from alcohol and/or drug use other than alcohol in the past 30 days, and how important the client felt it was to get help to address those problems.
The legal CS focused on questions regarding client’s involvement with the criminal justice system, how bothered they have been about their illegal activities in the past 30 days and the importance to get help with their legal issues. The mental health CS measured client’s self-report about a range of psychiatric symptoms, importance of getting help for these symptoms and how bothered the client was by these symptoms and the number of days the client reported being bothered by these symp- toms, all during the past 30 days. The medical health CS measured by both the number of days of health problems and the client’s experience of being bothered by their issues in the past 30 days and the importance to get help with their health concerns. The family and social relationships CS was measured by the client’s self-estimated satisfaction with marital status, relationships with others, and how bothered the client was by their family and social situation and the client’s report on needs regarding these questions. The employment CS captures the ability to get to work (access to car), number of days worked in the past 30 days and amount of money earned during this period.
Age, was measured by a continuous variable and was reported at ASI baseline. Level of education was also measured by a continuous variable, and reported at baseline, based on number of years of education. The gender variable was a dichotomous variable and divided into male and female.
4.4. Dependent variable
The dependent variable, future imprisonment, was defined as if a person was sentenced to prison any time after their ASI-baseline inter- view (yes or no).
4.5. Statistical analysis
Univariate descriptive methods were used to describe the study sample. Bivariate analysis examined, by using chi-square and t-tests, the relationship between each independent variable and Post-ASI assess- ment interview. To examine if Addiction Severity Index Composite Scores were associated with Post-ASI imprisonment, we used Cox pro- portional hazards regression modelling to estimate adjusted hazard ra- tios (HR) with 95 % confidence intervals. Variables significant at bivariate level were included in two different multivariate Cox propor- tional hazard models, crude and adjusted. In the analysis, clients were followed to the date of the first imprisonment or the latest date they were alive (December 31, 2016), which were possible since we had access to mortality register data for all individuals in the study sample.
All analyses were performed using STATA version 15.1.
5. Results
The study sample consisted of 14,914 clients assessed for risky sub- stance use, of which 2,169 (15 %) had been sentenced to prison Post-ASI assessment interview. The sample had a mean age of 38.9 ± 13.6 years and consisted of 10,574 (71 %) males. Table 1 describes the study sample with respect to all variables included in this study.
5.1. Bi-variate results
The bi-variate statistical results showed that all variables were significantly associated with imprisonment Post-ASI assessment. The ASI CSs for drugs other than alcohol, legal, family and social relations, and employment were all significantly and positively associated with having at least one imprisonment Post-ASI baseline. ASI-CS for alcohol, mental health and medical health were significantly and negatively associated with having at least one imprisonment Post-ASI assessment interview (Table 2). Also, age (younger), level of education (lower) and gender (male) were significantly associated with Post-ASI imprisonment.
The result from the bivariate Cox proportional hazard regression model found that the strongest hazard ration for future imprisonment post ASI-assessment was the ASI Legal CS (HR = 14.0, 95 % CI:
12.08− 16.22, p < 0.001). In model 1 which included all the ASI CSs, the ASI Legal CS was followed by the ASI CSs for drugs other than alcohol, employment and family and social relations. We found that younger clients had higher likelihood of future imprisonment (HR = .97, 95 % CI; 0.96− 0.97, p < 0.001). The result from the bi-variate analysis also showed that male clients were about three times more likely to end up in prison (Table 3, Model 1) compared to women.
5.2. Multi-variate results
The results from the multivariate analysis showed that after con- trolling for all significant variables at the bi-variate in model 2, young age, male gender as well as ASI CSs for drug other than alcohol, legal, family and employment all had a positive significant relationship with future imprisonment, with the AS Legal CS as the strongest predictor followed by the ASI CSs for employment as the second strongest pre- dictor of future imprisonment. The ASI-CS for Legal had the strongest ASI-CS hazard ratio for future imprisonment (HR = 6.12, 95 % CI:
4.88− 7.67, p < 0.001), and every change in the CS was associated with a 6 times higher likelihood of imprisonment post ASI-assessment. Those with higher ASI-CSs for employment, drugs other than alcohol and family and social relations (HR = 2.92; HR = 1.92; HR = 1.4, respec- tively, p < 0.001) were more likely to be sentenced to prison post ASI- assessment (Table 3, Model 2).
The result from the multivariate analysis confirmed the main find- ings from the bi-variate results, that younger age, male gender, lower educational level as well as ASI CSs for drug other than alcohol, legal, family and employment all still had a positive significant relationship with imprisonment Post-ASI assessment. However, the multivariate analysis after controlling for all variables in the model showed a lower magnitude of the association between Post-ASI imprisonment and ASI- CS for Legal, employment and male gender. The Hazard ratio for ASI CS for Legal decreased from HR = 14.0 in the crude model to HR = 6.12 in the adjusted model (Table 3). Similar pattern was found for ASI CS for employment where a decreased hazard ratio was observed from HR = 6.0 to HR = 2.92, for drugs other than alcohol with a decreased Table 1
Univariate description statistics: Factors associated with imprisonment post ASI- baseline (n = 14 914).
n % or Mean (SD)
Age (Years) 14 914 38.9 (13.6)
Education (Years) 14 314 11.3 (2.8)
Gender 14 914
Male 10 574 71 %
Female 4 304 29%
ASI Composite Scores
Alcohol 12 923 0.34 (0.29)
Drugs other than alcohol 11 833 0.13 (0.14)
Legal 13 266 0.13 (0.22)
Mental health 13 332 0.37 (0.27)
Medical health 14 492 0.36 (0.34)
Family and social relations 13 694 0.26 (0.23)
Employment 12 916 0.77 (0.29)
Table 2
Bivariate association between baseline ASI Composite Scores and subsequent imprisonment (n = 14 914) post baseline % or Mean ± SD.
Imprisonment
-No Imprisonment
-Yes P-value
Age 39.7 ± 13.9 34.5 ± 11.4 p < 0.001
Education (Mean ± SD) 11.4 ± 2.8 10.4 ± 2.5 p < 0.001
Male % 81.9 18.1 p < 0.001
ASI Composite Scores (Mean
±SD)
Alcohol 0.35 ± 0.30 0.27 ± 0.29 p < 0.001
Drugs other than alcohol 0.12 ± 0.14 0.18 ± 0.15 p < 0.001
Legal 0.10 ± 0.20 0.29 ± 0.28 p < 0.001
Mental health 0.37 ± 0.27 0.34 ± 0.27 p < 0.001
Medical health 0.36 ± 0.34 0.33 ± 0.34 p < 0.01 Family and social relations 0.26 ± 0.23 0.27 ± 0.24 p < 0.01
Employment 0.76 ± 0.29 0.88 ± 0.22 p < 0.001
Table 3
Cox proportional hazard regression for association between baseline ASI Com- posite Scores and subsequent imprisonment post baseline (n = 2 169).
HR (95 % Cl) Model 1
(Crude) HR (95 % Cl) Model 2
(Adjusted)
Age .97 (.96− .97)*** .99 (.98− .99)***
Education .88 (.87− .90)*** .92 (.90− .94)***
Male 3.36 (2.95− 3.84)*** 3.22 (2.68− 3.88)***
ASI Composite Scores
Alcohol .41 (.34− .48)*** .76 (.62− .94)*
Drugs other than
alcohol 13.48 (10.14− 17.92)*** 1.93 (1.23− 3.02)**
Legal 14.0 (12.08− 16.22)*** 6.12 (4.88− 7.67)***
Mental health .82 (.70− .97)* .48 (.37− .61)***
Medical health .85 (.76− .97)* .82 (.69− .98)*
Family and social
relations 1.49 (1.23− 1.80)*** 1.39 (1.06− 1.84)*
Employment 6.0 (4.82− 7.36)*** 2.92 (2.24− 3.81)***
* p < 0.05.
** p < 0.01.
*** p < 0.001.
hazard ratio from HR = 13.48 to HR = 1.93, and for male gender with a decreased hazard ratio from HR = 3.36 to HR = 3.22. To note the multi- variate model explained 44 % of the variation in the dependent variable, which is high for registry, real-world research studies.
6. Discussion
This study aimed to identify, for a sample of 14,914 adults all assessed for risky substance use, the associations between the ASI CSs regarding level of severity in different associated functional domains (Alcohol CS, Drugs other than alcohol CS, legal CS, mental health CS, medical health CS, family and social relationships CS and employment CS) controlling for age, education level and gender on the likelihood of future imprisonment.
The multivariate model evidenced that both all ASI composite scores, age, education level and gender were significantly associated with imprisonment Post-ASI baseline assessment. The variables with the strongest association with imprisonment were the ASI legal composite score, followed by the ASI drugs other than alcohol composite score, the ASI composite score for employment, being a male and the ASI com- posite score for family and social relationship. Specifically, in the study the ASI legal score was associated with a 6 time (HR = 6.12) increase in likelihood of imprisonment. Given the lack of prior research regarding predictability between the ASI CS legal score and future criminality, this should be considered a new finding. To note, one reason the Swedish ASI assessments are such solid predictor may be due to ongoing national training and research conducted with implementing ASI nationwide.
An important factor revealed by the results of this study, is that the ASI CS for drug use other than alcohol was associated with almost a two- fold increased risk (HR = 1.93) of future imprisonment. A reason for this result may most likely be related to the Swedish policy regarding use of drugs other than alcohol. Specifically, use of drugs other than alcohol are criminalized in Sweden (SOU, 2011:35) it may therefor be strongly related to other criminal acts such as theft, burglary and violence which in turn may lead to imprisonment. This can in itself be considered a problem as these individuals most likely are in need of treatment due to their risky substance use behavior, and those needs may not be met by the criminal justice system. Therefor, it is important to use the criminal justice system as an opportunity to provide treatment to prisoners with addiction. Regarding the higher ASI CS for family and social relations in this study, it’s also important to offer clients in prisons treatment that have a focus on the client’s family and social network, as those most likely are important persons that can support clients to reduce their drug use or stay abstinent from drugs. To note, previous research that has shown that positive family relationships and a strong social network support client with risky substance use to stay abstinent as much as five years after completed addiction treatment (Trocchio et al., 2013).
As expected, the present study shows that men, in comparison to women, run more than three times (HR = 3.22) increased risk of imprisonment Post-ASI assessment. Previous studies confirm this result, that men are more involved in criminal acts such as theft and violence to a much greater extent than women (Gjeruldsen et al., 2004; Storbj¨ork, 2011). This can be understood and is strongly associated with the related lifestyle for individuals with risky substance use.
The higher score for ASI CS for employment and increased likelihood of future imprisonment (HR = 2.92) can be interpreted as individuals with substance use severity with less problem with their employment are in a less vulnerable social situation and, to a lesser extent, is dependent on criminal acts to cope with their life situation.
The strong association of ASI legal CS for future imprisonment is a key finding of this study. The result still remains that after controlling for all variables significant at bi-variate level, the ASI legal CS remained the strongest variable predicting future imprisonment. One implication of this is that ASI legal CS seems to be reliable and useful for social worker in assessing risk for future criminality regarding clients who are in need of support or interventions through the municipal social services in
Sweden. This is a positive result since the predictability of ASI CS for legal problems have not been as widely studied as many of the other composite scores (Calsyn et al., 2004; Padyab et al., 2018; Lundgren et al., 2019)
7. Conclusions
Given the result in this study, the strong significant association be- tween ASI legal CS and future imprisonment, suggest that this measure is a trustworthy assessment of criminal activity that can be used in clinical work with clients with risky substance use. Second our findings indicate that social workers in Sweden conducting the ASI- assessments in a proper manner. Given that both the Swedish national and local gov- ernment funds education and ongoing training for social workers using the ASI as a baseline assessment tool, this should be expected and not come as a surprise. Instead, this should motivate the social workers to use and rely on the ASI baseline assessment, and to use it in their planning for providing appropriate interventions for their clients to reduce their likelihood of engaging in criminal activity and resulting imprisonment.
8. Limitations
Registry data always come with a range of limitations such as vari- ation in assessment capacity and missing data. This study is fortunate in that those who conduct ASI assessments receive high quality and ongoing training in interview data collection to ensure accurate data and, of note, there was very little missing data in the data set used for analyses. Second, it is important to note that in using these large data- bases, we do not focus on predicting the significance of the total model even though we noted this significance in the results section.
Further, the reader should note that this study is based self-reported data regarding severity in different domains such as alcohol and drugs other than alcohol, legal, family and social relationships, employment and self-support, medical and mental health, level of education and gender since ASI is a self-assessment tool and based on self-reported answers. However, a large number of studies about addiction and risky substance use are based on self-reported data. The aim for this study was to examine the associations between the ASI CSs regarding level of severity in different associated functional domains (Alcohol CS, Drugs other than alcohol CS, legal CS, mental health CS, medical health CS, family and social relationships CS and employment CS) controlling for age, education level and gender on the likelihood of future impris- onment for a sample of 14,914 adults all assessed for risky substance use.
Another limitation in this study is data from the Swedish criminal justice registry we have access to does not contain information of reason for imprisonment.
Role of funding sources
This study was funded by a grant from the Swedish Research Council for Health, Working Life and welfare (Grant no. 2016-07213). The Swedish Research Council for Health, Working Life and welfare had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
Contributors
Authors A and B designed the study. Author A conducted the liter- ature search and provided the summaries of previous research studies.
Author A and B conducted the statistical analysis. Author A wrote the first draft of the manuscript and both authors contributed to and have approved the final manuscript.
Declaration of Competing Interest
The authors report no financial relationships with commercial interests.
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