# Effectiveness of legally mandated non-custodial drug and alcohol treatment orders for improved health, well-being, global functioning and quality of life: a systematic review and meta-analysis

## TL;DR

This study reviews whether legally mandated non-prison drug and alcohol treatment programs improve health and well-being compared to usual care, finding insufficient evidence to conclude effectiveness.

## Contribution

The study provides a systematic review and meta-analysis of legally mandated non-custodial treatment orders in criminal justice systems.

## Key findings

- No significant differences were found in drug screenings, depression, or adverse events between treatment and control groups.
- Evidence for the effectiveness of treatment orders is very low due to poor reporting and limited data.
- Future high-quality randomized controlled trials are needed to assess treatment effectiveness.

## Abstract

Adults in the criminal justice system are disproportionately more likely to use alcohol and drugs compared to the general population. Legally mandated alcohol and drug treatment orders have been proposed as an alternative to prison. However, little is known about how treatment orders affect the health and well-being of this population.

A systematic review and meta-analysis. We searched 14 electronic databases (last searched November 2023) for studies comparing adults in legally mandated non-custodial drug and alcohol treatment orders to those receiving mandatory treatment orders or usual care. Global functioning, quality of life, drug or alcohol use measures, dependence severity, depression/anxiety outcomes, family member/significant other outcomes, and adverse events were selected based on a minimum core outcome set. We performed a meta-analysis using mean differences and risk ratios with 95% confidence intervals. We assessed the certainty of the evidence using GRADE. Equity-related factors were mapped to the PROGRESS-plus framework. People with lived experience provided input throughout the review process.

From 6917 records, 11 studies involving 4643 individuals (70% men; seven randomised controlled trials (RCTs)) met the eligibility criteria. All studies were conducted in high-income countries and involved drug and alcohol courts. The main outcomes of global functioning and quality of life were not reported. Poor reporting limited the meta-analysis. There were no differences between the groups receiving the intervention and those in the control group regarding number of positive drug screenings (MD -0.80, 95% CI -3.60 to 2.00, 10 participants, p = 0.58); depression (RR 0.93, 95% CI 0.78 to 1.10, 1533 participants, p = 0.38); or serious adverse events (RR 0.33, 95% CI 0.02 to 6.65, 10 participants, p = 0.47). We judged the evidence as very-low. The equity criteria most frequently reported were age, sex and race/ethnicity.

The evidence is insufficient to draw judgements about the effectiveness of treatment orders for health and well-being. We found no evidence relating to global functioning, quality of life, anxiety, and outcomes specific to family members or significant others. High-quality RCTs are urgently needed. Future studies should involve people with lived experience in the design and conduct of new trials.

Study protocol registration.

The protocol for this study was registered on PROSPERO: CRD42023484923.

The online version contains supplementary material available at 10.1186/s40352-025-00354-4.