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Institute for Substance Abuse Treatment Evaluation Substance Abuse Treatment Effectiveness in Tennessee 2003–2004 Tennessee Outcomes for Alcohol and Drug Services

Substance Abuse Treatment Effectiveness in Tennessee 2003–2004: Statewide Treatment Outcomes Evaluation

Satish Kedia, Ph.D. with assistance from Heidi Kenaga, Ph.D. Priyanka Jani, M.S. Sharese Willis, M.A.

Institute for Substance Abuse Treatment Evaluation (I-SATE) The University of Memphis in partnership with the

Bureau of Alcohol and Drug Abuse Services Tennessee Department of Health

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Copyright © 2005 by the Institute for Substance Abuse Treatment Evaluation The University of Memphis ISBN: # 0-09718291-6-0

Printing publication number: UOM 85-0405/3.5M

The University of Memphis, a Tennessee Board of Regents institution, is an Equal Opportunity/Affirmative Action University. It is committed to education of a non-racially identifiable student body.

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Institute for Substance Abuse Treatment Evaluation (I-SATE) The University of Memphis 316 Manning Hall Memphis, Tennessee 38152-3390 Phone: (901) 678-1753 Fax: (901) 678-0707 Email: [email protected] www.isate.memphis.edu

Bureau of Alcohol and Drug Abuse Services Tennessee Department of Health William R. Snodgrass Tennessee Tower 26th Floor, 312 Eighth Avenue North Nashville, Tennessee 37247-4401 Phone: (615) 741-1921 Fax: (615) 532-2419 www2.state.tn.us/health/A&D

Tennessee Association of Alcohol and Drug Abuse Services TAADAS Statewide Clearinghouse 1800 Church Street, Suite 100 Nashville, Tennessee 37203 Phone: (615) 780-5901 Fax: (615) 780-5905 www.tnclearinghouse.com Redline Phone: (800) 889-9789

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Special appreciation for their support Phil Bredesen Governor State of Tennessee

Kenneth S. Robinson, MD Commissioner Tennessee Department of Health

Stephanie W. Perry, MD Assistant Commissioner Bureau of Alcohol and Drug Abuse Services

Herb Stone Director, Treatment Services Bureau of Alcohol and Drug Abuse Services

Gwen Shanks Interim Director, Finance and Systems Bureau of Alcohol and Drug Abuse Services

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Table of Contents List of Tables List of Figures List of Maps Acknowledgments EXECUTIVE SUMMARY Preview of Report

viii ix ix x 1 6

CHAPTER 1 Introduction Defining Substance Abuse and Addiction Substance Abuse Trends in the United States Substance Abuse Trends in Tennessee

7 9 10 12

CHAPTER 2 Substance Abuse Treatment Protocols in Tennessee Criteria for Patient Placement Overview of Treatment Modalities Outpatient Intensive Outpatient Halfway House Residential Rehabilitation Detoxification

15 15 16 16 17 17 18 18

CHAPTER 3 Outcomes Evaluation Methodology Research Design Admission Data Follow-up Data and the TOADS Questionnaire Sampling Strategy and Eligible Follow-up Study Population Inclusion Criteria for the Study Population Exclusion Criteria for the Study Population Non-Response Analysis Data Integration and Analysis Limitations of the Study

19 19 19 19 21 22 22 23 25 25

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vi

CHAPTER 4 Substance Abuse Treatment Outcomes Client Demographics Substance Abuse History Treatment Features Accessing Treatment Reasons for Seeking Treatment Continuum and Length of Care Services and Skills Received Level of Treatment Completion Participation in Aftercare and Continuing Recovery Programs Participation in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) Clients’ Overall Perceptions of Treatment Treatment Outcomes and Performance Indicators Alcohol and/or Drug Abuse at Six-month Follow-up Alcohol and/or Drug Abuse within Various Subgroups since Treatment Alcohol and/or Drug Abuse by Treatment Characteristics Quality of Life Measures at Admission and Six-month Follow-up Employment Situation and Usual Occupation Living Arrangement before and after Treatment Marital Status Arrest Record Domestic Violence Involvement Physical and Mental Health at Six-month Follow-up

36 38 38 38 43 46 47 47 50 51 51 54 54

CHAPTER 5 Comparing Clients’ Self-Reports with Collaterals’ Reports Coverage Rate Comparing Levels of Agreement Assessing Nonchance Determining Directionality of Agreement Choosing a Collateral Conclusion

57 57 58 58 61 61 64

CHAPTER 6 National and State Level Trends in Substance Abuse Treatment Effectiveness Substance Abuse Treatment Effectiveness in Various States

65 66

27 27 29 31 31 32 32 33 33 34


CHAPTER 7 Conclusion Summary of Treatment Outcomes Clients’ Perceptions of Treatment The Burden of Untreated Substance Abuse Dollars Well Spent on Substance Abuse Treatment Recommendations

71 71 72 73 76 78

References

83

Tennessee Agencies Funded by the Bureau of Alcohol and Drug Abuse Services

89

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List of Tables 3.1

Non-Response Analysis for Clients Who Consented to Participate

24

4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9

Demographic Characteristics Level of Income Earned in the Year before Follow-up Clients’ Children and Dependents Substance Abuse History Accessing Treatment Continuum of Care Number of Days in Treatment Treatment Features Frequency and Helpfulness of Participation in Aftercare and Continuing Recovery Programs Participation in Aftercare and Continuing Recovery Programs by Subgroup Frequency and Helpfulness of Participation in AA/NA Participation in AA/NA by Subgroup Alcohol and/or Drugs Abused at Admission and Six-month Follow-up Alcohol and/or Drug Abuse Frequency at Admission and Six-month Follow-up Tobacco Use at Six-month Follow-up Abstinence and Recidivism within Various Subgroups at Six-month Follow-up Abstinence and Recidivism by Continuum of Care Abstinence and Recidivism by Number of Days in Treatment Abstinence and Recidivism by Participation in Aftercare and AA/NA Employment Situation and Usual Occupation at Admission and Six-month Follow-up Performance at Work or School at Six-month Follow-up Living Arrangement at Admission and Six-month Follow-up Marital Status at Admission and Six-month Follow-up Recent Arrest Record at Admission and Six-month Follow-up Revoked Driver’s License and Reasons for Arrest Domestic Violence Involvement at Admission and Six-month Follow-up Physical and Mental Health at Six-month Follow-up

28 29 29 30 32 32 33 33

4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27

viii

34 35 36 37 40 43 43 44 46 46 47 49 49 50 51 52 54 55 56


5.1 5.2 5.3 5.4

Demographic Features of Clients at Admission Client – Collateral Agreement and Disagreement Directionality of Disagreement between Clients and Collaterals Collateral Population by Relationship and Contact

59 60 62 63

List of Figures 1.1 1.2

Revenue Sources for Substance Abuse Services in Tennessee Substance Abuse Expenditures by Service Area in Tennessee

8 9

3.1

Number of Telephone Attempts for Completing Interviews

23

4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17

Gender Ethnicity Age Group Child of Substance Abuser Living with a Substance Abuser after Treatment Primary Reason for Being Treated Court Ordered Treatment Level of Treatment Completion Participation in Aftercare and Continuing Recovery Programs Participation in AA/NA Perceived Helpfulness of Treatment Abstinence and Recidivism at Six-month Follow-up Alcohol and/or Drugs Abused at Admission and Six-month Follow-up Abstinence within Subgroups at Six-month Follow-up Change in Clients’ Employment Situation since Treatment Change in Homelessness Change in Arrest Record

27 28 28 30 31 31 32 34 34 36 38 38 42 45 48 50 52

List of Maps 1 2 3

Treatment Helpfulness Ratings (2003–2004) Average Abstinence Rate by Region (2003–2004) Change in Arrests after Treatment (2003–2004)

39 41 53

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Acknowledgments A number of individuals have worked long hours in close collaboration to carry out the many activities required to produce this evaluation report. I would like to convey my greatest appreciation to the Bureau of Alcohol and Drug Abuse Services of the Tennessee Department of Health for their support and provision of funding for the project and express my gratitude to Dr. Stephanie W. Perry, Gwen Shanks, and Herb Stone for their ready assistance and continuous feedback. Further, this report would not be possible without the commitment of those personnel in partnering treatment agencies who secured clients’ consent to participate in the follow-up study.

I am pleased to acknowledge the diligence and hard work of the I-SATE research team in producing this report: interviewers Oletta Tucker, Martha Brown, Felicia Curry, Earlean Jones, Ruby Burton, and Laverne Perkins; assistant to the director Ava Haynes; data assistants Wanda Laird, Les Jarred, and Sowmya Kodimela; data manager Priyanka Jani; statistician George Relyea; research associates Heidi Kenaga and Julie Grady; editorial assistants Linda Sadler and Sharese Willis; production analysts Kavita Kolli and Smitha Dandge; graduate assistants Stephanie Gann, Jennifer Kadrovich, and Malavika Kodur; systems analysts Krishna Rayi and Thirumal Munukuntla; and graphic designer Rick Jurczyk.

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Executive Summary

This report, issued by the Institute for Substance Abuse Treatment Evaluation (I-SATE) at The University of Memphis, measures the effectiveness of substance abuse treatment for individuals in Tennessee who agreed to participate in an outcomes evaluation. These individuals were enrolled during 2003 in publicly funded treatment centers supported by the federal government’s Substance Abuse Prevention and Treatment (SAPT) Block Grant, which provides support to states, territories, and the District of Columbia for the planning, implementation, and evaluation of alcohol and drug abuse treatment and prevention. The Tennessee Department of Health’s Bureau of Alcohol and Drug Abuse Services is the state authority that receives and dispenses SAPT funding to treatment providers in the state. Clients in this assessment participated in five modalities of care: outpatient, intensive outpatient, halfway house, residential rehabilitation, and/or detoxification (detailed in chapter 2). At the time of admission to treatment, facilities’ staff asked clients to voluntarily participate in a follow-up evaluation study and be interviewed after 6 months. Facilities’ staff gathered admission data from consenting clients, and I-SATE interviewers collected follow-up data via telephone 6 months after admission. The eligible follow-up sample comprised 2,697 individuals, almost 80% of whom (n=2,142) completed interviews. A complete discussion of the outcomes evaluation methodology used by I-SATE can be found in chapter 3. What follows is a summary of the 2003–04 report findings, in terms of client demographics, substance abuse history, treatment features, and treatment outcomes, including recidivism rates and quality of life indicators.

•

Slightly less than one third (29.8%) of clients were female vs. 70.2% male. White clients (67.8%) outnumbered those of other ethnicities (31.3% African American and 0.8% Native American or Hispanic). Adult clients were by far the majority, 95.2% vs. those 17 and younger (4.8%).

Executive Summary

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•

Most clients (67.5%) had attended high school, and about one fifth (20.4%) attended college; a small number had attended only middle school (1.9%). In terms of income, during the year before follow-up, 65.7% earned $8,500 or less, 27.1% earned between $8,501 and $25,000, and a few (7.2%) earned more than $25,000.

•

More than half (60.0%) of clients had at least one child, and the majority of these were minors (79.8%). However, 41.6% reported that they had one or more dependents, and a little more than half (58.5%) had no dependents.

•

Nearly two thirds of clients (65.8%) began using substances prior to the age of 17. About the same percentage (67.8%) reported having a family member who abused drugs or alcohol, most commonly a parent (39.4%), a sibling (29.6%), or other relative (32.1%). After treatment, almost all clients (94.7%) were not living with a substance abuser.

•

A little more than a third (33.7%) of clients were being treated for alcohol and drug abuse, a little less than a third (32.2%) for drug abuse only, and about one fifth (23.0%) for alcohol abuse alone. A little over a tenth (11.2%) had received a dual diagnosis, that is, treatment for both mental illness and substance abuse problems.

•

Exactly one third of clients (33.0%) were required to attend treatment by court order. About half (48.7%) had to wait for treatment: 49.2% for 1 to 7 days, 22.6% for 8 to 14 days, 18.5% for a month or more. A little over half (51.5%) had previously been treated for substance abuse.

•

In terms of treatment modalities, a little more than a third (38.9%) received residential treatment, about a fourth (24.6%) received outpatient, about a fifth (20.3%) received detox/residential, and the balance (16.2%) received some combination of modalities.

•

In terms of treatment duration, a 16 to 30 day stay was the most common (32.7%), followed by 91 to 180 days (17.5%) and 31 to 60 days (16.9%); 15.4% of clients stayed two weeks or less. A little over a tenth (10.6%) stayed 61 to 90 days, and 6.9% stayed 181 days or more. The majority of clients (84.4%) received some type of skills training, mainly relapse prevention (94.0%) and coping skills (82.4%). About a fifth (21.8%) participated in cultural competency classes, and slightly less (17.9%) attended vocational skills classes.

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Executive Summary


•

More than three fourths (76.9%) of clients completed all their treatment, and a little more than a tenth (11.8%) finished less than half.

•

About one fifth (26.6%) of clients attended aftercare activities; the majority (70.9%) participated once or twice a week. Most clients (64.9%) found such activities “very helpful,” and another fourth (25.6%), “somewhat helpful.”

•

Two thirds of clients (66.2%) attended Alcoholics Anonymous/Narcotics Anonymous (AA/NA) meetings. Many of these clients (39.8%) went once or twice a week, and roughly another third (32.5%) went several times a week. More than three fourths (75.5%) found meetings “very helpful,” and another fifth (20.2%), “somewhat helpful.”

•

The majority of clients (75.4%) found their treatment “very helpful,” and a little less than a fifth (17.3%) “somewhat helpful.” Only 6.1% described their treatment as “not helpful at all.”

•

A little less than two thirds of clients (65.1%) were abstinent 6 months after admission. The percentage of those who reported abusing alcohol, the most popular substance, declined from 63.3% at admission to 24.2% after treatment, a decrease of 61.7%; those who abused cocaine decreased from 45.1% to 11.0%, a drop of 75.7%; those who abused marijuana decreased from 32.5% to 5.7%, a decrease of 82.5%; and those who abused opiates/narcotics decreased from 16.8% to 4.1%, a 75.6% drop. Even more dramatic declines were seen in the less commonly abused substances: sedatives/hypnotics, from 7.2% to 0.4% (a 94.2% decline), and stimulants/amphetamines, from 6.7% to 0.8% (an 88.2% drop). At follow-up no clients reported abuse of hallucinogens and inhalants.

•

There was a significant decrease in the frequency of abuse as well: 67.2% of clients at admission reported using alcohol or drugs daily, whereas by the time of the followup interview, this percentage dropped to 7.8%, an 88.4% decline. Even those clients who said they abused substances several times a week dropped from 15.5% to 4.9%, a 68.6% decline.

Executive Summary

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•

In terms of abstinence rates across demographic groups, a higher proportion of female clients than male clients (67.7% vs. 64.0%) reported abstinence, and, in a change from previous years, African American clients had lower rates (63.9%) than White clients (65.6%) or those of other ethnicities (72.2%). Youth had higher rates than adult clients (72.8% vs. 64.7%). Educational achievement was not positively correlated with abstinence, as clients with a middle school education reported a higher rate (73.2%) than those who had attended high school (65.6%) or college (63.8%).

•

Among subgroups, the highest abstinence rates were reported by pregnant women (80.0%), adolescents (72.8%), women (67.7%), and those with a prior arrest record (65.8%).

•

In terms of treatment modality, clients enrolled in a combination of detox/outpatient services achieved the highest abstinence rate, 70.6%, with residential/outpatient clients (69.3%) and outpatient clients (68.7%) close behind. Clients with perhaps the most severe levels of addiction, those in detox/residential/outpatient services, reported the lowest rate, 59.6%.

•

As in previous years, abstinence rates went up the longer the client stayed in treatment: for example, 50.0% of those enrolled at a facility 1 to 6 days were no longer abusing substances 6 months after admission, whereas 67.0% of those who were in treatment 31 to 60 days were abstinent and 74.3% of those in treatment 181 days or more.

•

Again, participation in aftercare and AA/NA was positively correlated with abstinence rates; of those reporting abstinence, more than three fourths (76.3%) participated in aftercare activities and a majority (69.9%) participated in AA/NA.

•

Unemployment among clients declined sharply after treatment, from 60.7% at admission to 34.3% at the 6-month follow-up. The percentage of clients who were employed full-time almost tripled, from 15.7% to 44.7%, and those who were employed part-time rose, from 4.3% to 12.7%. Those clients who reported their occupation as “skilled worker” rose slightly from 25.7% to 30.5%, and as “professional” from 6.2% to 10.7%. Two thirds of clients (66.7%) reported that their work or school performance had improved since treatment.

4

Executive Summary


•

Whereas at admission almost half of clients (45.8%) reported living with relatives other than those in their immediate family, by the 6-month follow-up this percentage had dropped to 10.3%. Correspondingly, before treatment only 10.9% lived with their immediate family, but after treatment 50.9% did so. At the 6-month follow-up, only 0.5% of clients reported being homeless, compared with 6.9% at admission.

•

By the 6-month follow-up, only 10.0% of clients had been arrested, compared with over half (55.5%) at admission. The most common reasons for arrest were parole/ probation violation and Driving Under the Influence (12.6% each), followed by major driving violation (8.8%) and disorderly conduct/vagrancy/public intoxication (8.4%).

•

There were downward trends in clients’ involvement in domestic violence, as both perpetrator and victim. At admission, 14.3% of clients had committed such violence, and 18.7% had been the victim; percentages after treatment dropped to 1.2% and 2.7%, respectively.

•

The vast majority of clients (84.2%) said that their physical health had improved since treatment, and almost half described their current status as “excellent” or “very good,” with another third (33.9%) describing it as “good.” But close to half (47.6%) reported that, in the 30 days before the follow-up interview, they had experienced a mental health problem, most commonly serious anxiety or tension (63.3%) or serious depression (60.9%). A little over a fourth (26.3%) had trouble understanding concepts, concentrating, or remembering.

• Like other states, Tennessee has found that treatment is more cost-effective than other alternatives: compare an average annual expenditure of $2,670 to treat each client in a state facility with the estimated $43,000 cost to taxpayers per annum per untreated client.

Executive Summary

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Preview of Report Substance Abuse Treatment Effectiveness in Tennessee 2003–2004: Statewide Treatment Outcomes Evaluation is organized into nine sections: chapter 1 comprises an introduction to those participating agencies whose administrative and financial support have made this outcomes evaluation possible, a statement of the evaluation’s goals, a definition of substance abuse as used in this report, and a brief overview of national and state substance abuse trends; chapter 2 details substance abuse treatment protocols in the state; chapter 3 describes the methodology employed by I-SATE staff to produce this outcomes evaluation; chapter 4 reports on client demographics, treatment features, treatment outcomes and performance indicators, and quality of life measures; chapter 5 offers empirical evidence supporting the use of collaterals (the method employed in this study) to verify client self-report data; chapter 6 examines the economic and social burden of untreated substance abuse in the United States and how various states have found treatment to be more effective than punitive measures such as incarceration; chapter 7 comprises a brief summary of treatment outcomes and clients’ perceptions of treatment, a discussion of the burden that untreated substance abuse represents and the cost-effectiveness of treatment, and policy recommendations derived from the research results; and the last two sections consist of references and a list of those treatment providers funded by the Bureau of Alcohol and Drug Abuse Services. Copies of this report are available at http://www.isate.memphis.edu/Reports

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Executive Summary


Chapter 1

Introduction

Under the 1972 Drug Abuse Office and Treatment Act, the U.S. government first

abuse treatment and prevention. SAPT funds also provide assessment for those

began mandating the collection of data on admissions to federally funded drug abuse

substance abuse clients with concomitant conditions, such as HIV/AIDS, tuberculo-

treatment programs. From 1973 to 1981, federal reports were issued based on data

sis, and Hepatitis B or C; for pregnant women or those with dependent children;

from 1,800 to 2,000 programs, comprising some 200,000 annual admissions. In 1988,

and for adolescents. At present, the SAPT Block Grant constitutes around 40%

the Comprehensive Alcohol Abuse, Drug Abuse, and Mental Health Amendments

(sometimes more) of those public funds used by states for substance abuse preven-

established the Substance Abuse Prevention and Treatment (SAPT) Block Grant

tion and treatment (Substance Abuse and Mental Health Services Administration,

and mandated federal data collection on clients receiving treatment for either alco-

2004c).

hol or drug abuse (Substance Abuse and Mental Health Services Administration, 2000, pp. 3–4). This report, Substance Abuse Treatment Effectiveness in Tennessee 2003–2004: State-

The SAPT Block Grant provides resources for assessment, treatment, and evaluation of substance abuse and related conditions.

wide Treatment Outcomes Evaluation, has its origin in those early initiatives to support substance abuse treatment for all Americans in need of it by providing em-

The Bureau of Alcohol and Drug Abuse Services (hereafter the Bureau), a division of

pirical studies of and documentation for its effectiveness. Currently, the U.S. govern-

the Tennessee Department of Health, is the single state authority that dispenses funds

ment allocates SAPT Block Grants to all 50 states, 8 territories, the District of Co-

allocated by the Substance Abuse and Mental Health Services Administration

lumbia, and certain Native American tribes to help public health professionals plan,

(SAMHSA). The Bureau’s mission is to reduce substance abuse among all residents

implement, and evaluate alcohol and drug

of Tennessee by promoting prevention, re-

Chapter 1 Introduction 7


ducing the incidence of high-risk behaviors through community programs and activities, and ensuring treatment services for all individuals in need. This includes paying for such services for those clients whose

Figure 1.1 Revenue Sources for Substance Abuse Services in Tennessee for Fiscal Year 2003–04 (total budget $44.9 million)

alcohol and drug abuse treatment is not covered by TennCare (the state’s managed

6.7%

care plan for under- or uninsured residents), other health insurance, or personal re-

17.7%

sources. In addition, the Bureau appropriates state and city funds for alcohol and drug abuse services. The budget of the Bureau of Alcohol and Drug Abuse Ser-

75.6%

vices for the fiscal year 2003–04 was $44,922,400. Most (75.6%) of these funds were allocated by the federal government in fiscal year 2003–04; Tennessee received

Federal funds State funds

almost $34 million in SAPT funding. An additional 17.7% came from the state, and 6.7% came from ADAT funds (see Figure

Treatment) funds

1.1). Of the total budget, $32,040,100 (71.3%) was spent on treating substance

Abuse and Mental Health Services Admin-

abuse clients (see Figure 1.2).

istration, 2004a, p. 35). The evaluation research on which this report is based is con-

The Bureau pays for services for indigent clients in Tennessee whose drug and/or alcohol treatment is not covered through insurance or personal resources.

As per the SAPT Block Grant directive, this report aims “to assess and improve, through independent peer review, the quality and appropriateness of treatment services delivered by providers that receive funds from the Block Grant” (Substance

8

ADAT (Alcohol and Drug Abuse

Chapter 1 Introduction

ducted by Tennessee Outcomes for Alcohol and Drug Services (TOADS), under the auspices of the Institute for Substance Abuse Treatment Evaluation (I-SATE). For more than 15 years, I-SATE has evaluated client outcomes across various performance indicators and disseminated the results to a variety of stakeholders, including treatment providers and policymakers. This year-round project is a critical component of the Bureau’s performance-based evaluation system and impacts the development of treatment services and policy decisions concerning alcohol and drug abuse across the state.


Figure 1.2 Substance Abuse Expenditures by Service Area in Tennessee for Fiscal Year 2003–04

3. to identify strengths of the services currently being provided by treatment facilities and discuss areas that need improvement; and

(total budget $44.9 million) 4. to provide a brief analysis of the cost-effectiveness of substance

4.0% 4.6%

abuse treatment.

Defining Substance Abuse and Addiction

20.1%

71.3%

Before discussing the prevalence of substance abuse in the United States, it may be helpful to define terms such as abuse and addiction, which the layperson may re-

For treatment For prevention For administration For training and evaluation

gard as interchangeable. For the public health professional, substance abuse is defined as the intentional use of alcohol and other drugs for pleasure, coping, or selfmedication that results in a pattern of negative consequences in one or more areas of

To fulfill program objectives, this outcomes evaluation has four major goals:

an individual’s life functioning. His or her recurrent use of a substance that results in

1. to assess the overall effectiveness

failure to fulfill major responsibilities, legal problems, risk to self or others, and/or

of treatment through various performance indicators, focusing on the

social or interpersonal problems is indicative of substance abuse. Addiction, how-

nine primary goals of substance abuse treatment in Tennessee (de-

ever, is understood as a primary, chronic, progressive, and relapsing disease charac-

tailed in chapter 2);

terized by craving, loss of control, and denial that results in harm to the individual

2. to measure the effectiveness of treatment for special programs and special populations;

who nonetheless continues to use the substance despite this harm. In this outcomes evaluation report, we use the term abuse as defined above.



10

It is well established that substance abuse and addiction have repercussions on an

terview. The NSDUH report also estimated that one out of seven Americans 12 years

individual’s physical and mental health, productivity, financial stability, and relation-

and older (approximately 33.5 million people) drove under the influence of alco-

ships and may well lead to criminal behavior. Current research indicates that al-

hol at least once in the 12 months before the interview (Substance Abuse and Men-

though substance abuse and addiction have genetic and physiological bases related to

tal Health Services Administration, 2003, pp. 23–24, 28).

changes in the brain, they have strong behavioral and environmental correlates as

Close to 22 million Americans (9.4% of the

well.

total population aged 12 or over) abused or were dependent on drugs and/or alcohol.

Substance Abuse Trends in the United States

Most of these individuals (14.9 million) abused or were dependent on alcohol alone,

The 2002 National Survey on Drug Use and

while 3.9 million abused or were dependent on illicit drugs. Another 3.2 million people

Health (NSDUH), formerly called the National Household Survey on Drug Abuse,

abused or were dependent on some combination of drugs and alcohol (Substance

contains the most comprehensive data to date regarding alcohol and drug abuse

Abuse and Mental Health Services Administration, 2003, p. 4).

trends. According to this report, Americans age 12 and older are using and abusing drugs

According to the NSDUH survey, nearly

and alcohol at alarming rates. In the 30 days prior to the survey, 51.0% of Americans

19.5 million Americans 12 years old and over reported that they had used illicit drugs

(approximately 120 million) at least 12 years of age and older were current alco-

at least once during the 30 days before the survey. Marijuana, with 14.6 million current

hol drinkers (Substance Abuse and Mental Health Services Administration, 2003, p. 23).

users, was the most commonly used drug. Approximately 4.8 million reported that

Fifty-four million of these current drinkers

they used marijuana at least 20 of the 30 days prior to the interview. Two million drug

reported that they had engaged in binge drinking, defined as having five or more

users used cocaine (567,000 of whom used it in crack form); 1.2 million, hallucinogens;

drinks on the same occasion at least once in the 30 days prior to the survey. In addi-

676,000, Ecstasy; and 166,000, heroin (p. 1). Several million others reported non-

tion, 15.9 million reported heavy drinking, defined as having five or more drinks on

medical use of psychotherapeutic drugs: 4.4 million used pain relievers, 1.8 million used

the same occasion on at least five different days in the past 30 days before the in-

tranquilizers, 1.2 million used stimulants, and 0.4 million used sedatives. An esti-



mated 1.9 million people had used OxyContin at least once (p. 1).

distribution patterns. Research staff conducts interviews with four knowledgeable individuals from each city—one ethnographer or epidemiologist, one law enforce-

Estimates are that in 2002 nearly 22 million Americans abused or were dependent on drugs and/or alcohol.

ment official, and two treatment providers (one from a methadone treatment center and one from a nonmethadone treatment center, where available)—in order to develop an in-depth understanding of the local drug situation that can inform

According to the National Center for Health Statistics (2002), the percentage of

policymakers of emerging problems concerning access to specific drugs and the

adults aged 18 years and over who consumed alcohol excessively rose from 9.5%

changing context of their use. More than half of the 78 epidemiologists, ethnogra-

in 2001 to 9.7% in 2002. Young drinkers (18–24 years of age) comprised the larg-

phers, law enforcement officials, and drug treatment providers polled saw no lessen-

est percentage of this group, 18.4% of the total. Those aged 25–44 accounted for

ing in the nation’s drug problem in the spring of 2002, compared with the fall of

12.8%, 45–64 year olds accounted for 6.0%, and those 65 and over accounted for

2001 (Office of National Drug Control Policy, 2002).

2.4% of the total. The study considered alcohol consumption excessive when drink-

Roughly 70% of all respondents described

ers had at least five drinks in one day at least 12 times during the past 12 months.

the drug situation as “very serious,” and about 30% said that it was “somewhat seri-

Americans between 18 and 24 constitute the largest percentage of excessive drinkers.

ous” (p. 1). Sources from 15 cities stated that Ecstasy and other “club drugs” had surfaced as a problem or intensified in the spring of 2002. OxyContin was a similar problem in 14 cities, and methamphetamine use emerged or grew during the same time period.

For more than 10 years, the Office of National Drug Control Policy has published “Pulse Check,” an update on the latest trends in drug use and markets in 20 U.S. cities. The report tracks heroin, crack and powder cocaine, marijuana, and methamphetamine use; drug-related criminal activity; demand for treatment; and changes in supply and

In the spring of 2002, 15 cities reported that Ecstasy, OxyContin, and methamphetamine were becoming a problem.



In terms of drug-related criminal activity, crack and heroin were involved most fre-

maintained the very high levels seen in the past few years. Methamphetamine use de-

quently: for example, crack was implicated in almost 30% of prostitution, gang-related

clined among 8th grade students, but remained steady among students in the up-

incidents, and violent behavior, and in almost 20% of nonviolent crimes and inci-

per grades. Students in all grades showed a fairly steady decline in the use of inhalants,

dences of domestic violence (pp. 4–5). Heroin was linked to approximately 25%

with an especially striking 40% drop among 8th graders since rates peaked in the mid-

of prostitution-related arrests and in slightly lower percentages of gang arrests and vio-

1990s. Only tranquilizers and barbiturates increased in use, and this rise was only evi-

lent/nonviolent crimes. Methamphetamine was the drug most commonly involved in

dent in the 12th grade group (pp. 3–4).

domestic abuse, at a rate of approximately 35% (Office of National Drug Control

Substance Abuse Trends in Tennessee

Policy, 2002, p. 5).

In order to gauge patterns of drug and al-

According to the Office of National Drug Control Policy, methamphetamine is involved in over one third of domestic violence incidents.

Monitoring the Future: National Results on Adolescent Drug Use is a recent study of drug use and attitudes among the nation’s youth (Johnston, O’Malley, & Bachman, 2003). After surveying about 43,700 students in the 8th, 10th, and 12th grades, researchers found that drug use had declined in most categories. For the first time since 1998, Ecstasy was less popular in all three grades, with the annual prevalence dropping 20% (p. 3). Marijuana use was down as well, but only among 10th grade students was this decrease statistically significant. Eighth and 10th grade students reported lower levels of amphetamine use, but 12th grade students

12


cohol use and abuse in Tennessee, in 1998 the Community Health Research Group at the University of Tennessee-Knoxville conducted the Tennessee Health and Lifestyles Survey. The sample size comprised 11,155 adults residing in the state: 4,144 (37%) male and 7,011 (63%) female; 10,289 (92.2%) White, 537 (4.8%) African American, and 329 (2.9%) of other backgrounds (Community Health Research Group, 2000, p. 7). The study population reported using alcohol and marijuana more than any other substance. A considerable percentage (79.5%) had used alcohol at some point during their lifetime. More than half (52.5%) had consumed alcohol within the past 12 months, and 36% had done so within the 30 days prior to the survey (Community Health Research Group, 2000, p. 2). Approximately 29% reported using marijuana at least once


in their lifetime, 5% in the previous 12 months, and 2.6% in the 30 days before the

143, 145, 151). The problem, however, is not restricted to adults. The SAMHSA-spon-

survey. Other drugs used included hallucinogens at a rate of 6%, inhalants at 2%,

sored IMPACT study of substance abuse among Tennessee adolescents, conducted

and heroin at 0.9% (pp. 2–3). Twelve percent of the study population reported that

jointly by Vanderbilt University’s Center for Mental Health Policy, Tennessee Voices

they were addicted to or dependent on heroin, 11.5% to cocaine/crack, 11% to in-

for Children, and the Tennessee Commission on Children and Youth, estimated that

halants, 8% to alcohol, and 8% to marijuana (p. 3).

at least one fifth of the state’s youth (about 106,000) were using or dependent on substances (Heflinger & Flowers, 2002).

Four out of every five Tennessee respondents in a 1998 survey had used alcohol at least once in their lifetime, and three out of every ten had used marijuana.

According to a 2001 survey, one fifth of the state’s youth were using or dependent upon substances.

Survey participants reported lifetime usage

In 2003, I-SATE at The University of Mem-

rates for medically prescribed drugs such as painkillers (60%), tranquilizers (27%),

phis published a brief report outlining substance abuse trends in Tennessee across 5

sedatives (16%), and stimulants (9.5%). Nonmedical use of psychoactive prescrip-

years (1998–2002), based on admissions to publicly funded alcohol and drug abuse

tion drugs was present but not common. Approximately 6.5% said that they had done

treatment facilities throughout the state. I-SATE derived the data from undupli-

so during their lifetime, 1.2% within the past 12 months, and 0.3% within the past

cated clients and their reported abuse of multiple substances (Kedia, 2004b).

30 days (p. 2). I-SATE’s research found that alcohol was According to another recent survey, the 2001 National Household Survey on Drug Abuse

the most commonly abused drug. In 1998, 68.5% of clients admitted to abusing alco-

(NHSDA), sponsored by SAMHSA, 6.5% of residents in Tennessee (302,000) abused or

hol, a percentage that decreased slightly to 62.6% in 2002. Cocaine ranked second

were dependent on alcohol or illicit drugs in the year prior to the survey. About 241,000

among abused substances, and the rate of abuse also steadily declined, from 44.2%

Tennesseans (5.2%) abused or were dependent on alcohol, and 110,000 (2.4%) were

in 1998 to 41.5% in 2002. However, rates for the third most abused substance, mari-

dependent on illicit drugs (Wright, 2003, pp.

juana, remained steady, from 39.7% of cli-



ents admitting abuse in 1998 to 37.5% in 2002.

significant increase in stimulant abuse by pregnant women. In 1998, 3.3% of such cli-

Reflecting

of

ents reported abuse, but by 2002 this figure had shot up to 26.7%. Further, clients

OxyContin and methamphetamine abuse in the state, across the 5 years opiate rates

in both rural and urban areas reported increases in abuse of opiates/narcotics across

doubled from 7.41% to 15.63% and stimulant rates rose from 2.85% to 6.85%. This

the 5 years: for rural clients, 7.9% compared with 17.7%; for urban clients, 7.02%

was true for all demographic groups and subgroups. For example, for males, opiate

compared with 12.31% in 2002. Stimulant abuse also significantly increased for both

rates jumped from 6.32% in 1998 to 14.2% in 2002 and for females, from 9.8% in 1998

groups, for rural clients from 3.93% in 1998 to 9.10% in 2002 and for urban clients from

to 18.8% in 2002. And while only 3% of males were using stimulants in 1998, this

1.91% to 3.33% across the same period.

the

recent

epidemic

number increased to nearly 7% in 2002.

Recent research by I-SATE reveals that rates of opiate abuse doubled from 1998 to 2002, reflecting the epidemic of OxyContin in Tennessee.

Across 5 years, stimulant abuse by pregnant women in Tennessee rose from 3.3% in 1998 to 26.7% in 2002.

I-SATE also found that marijuana abuse was much more popular among youth than adult clients. Nearly 79% of adolescents re-

14

Rates among females nearly tripled, from 3.03% in 1998 to 8.2% in 2002. Opiate

ported using marijuana in 1998. Although that rate steadily decreased over the fol-

abuse also rose for both African Americans and Whites: from 2.3% in 1998 to 3.8% in

lowing 4 years to 59.0% in 2001, by 2002 marijuana abuse went on the rise to 66.9%.

2002 for African Americans, and from 10.1% in 1998 to 20.8% by 2002 for Whites.

Adolescent abuse of stimulants showed a slight increase from 4.1% in 1998 to 5.0%

Perhaps the most startling finding was the

in 2002 (see Kedia, 2004b).



Chapter 2

Substance Abuse Treatment Protocols in Tennessee In this chapter, we provide an overview of the current treatment regimen in Tennessee for helping state residents overcome a substance abuse problem. At present, the pri-

Criteria for Patient Placement As part of the admission protocol, counse-

mary goals of substance abuse treatment in Tennessee include the following:

lors at treatment facilities assess clients using the Addiction Severity Index (ASI)

1. to help clients abstain from or reduce their use of alcohol and/or

and designate their levels of care based on the criteria set forth by the American Society of Addiction Medicine (ASAM). The basis of any treatment plan is to help indi-

drugs; 2. to reduce unlawful activities, arrests, and criminal justice expenditures; 3. to increase employment and produc-

viduals abstain over the long term while also addressing other disorders related to their substance abuse.

tivity; 4. to improve clients’ family and community lives; 5. to enhance clients’ relationships with others; 6. to facilitate clients’ living in a stable

During intake, facility staff assess clients and assign them to a level of care based on criteria set forth by the American Society of Addiction Medicine.

environment; 7. to improve clients’ mental and physical health; 8. to expand clients’ life-management skills to improve their quality of life; and 9. to decrease substance abuse-related costs to society.

To design an individualized approach to treatment, counselors interview each client and occasionally family members. The interviews help the counselor to determine substance abuse problems, physical and mental health conditions that might interfere with treatment, the strength of the client’s support system, and the client’s

Chapter 2 Substance Abuse Treatment Protocols in Tennessee

15


motivation to engage in the treatment pro-

The services provided by staff to each cli-

cess. The counselor and client plan a series of treatment milestones, and treatment con-

ent are periodically reviewed to evaluate the client’s response to treatment and an-

tinues until the client is demonstrably functional.

ticipated outcome. Based on the results of the reviews, a client may be shifted to a

In order to assign the client to the proper

lower or higher level of treatment or discharged from treatment altogether.

level of care, counselors consider the six assessment components established by ASAM. Dimension 1 assesses a client’s substance abuse history to determine probable inten-

Overview of Treatment Modalities

sity of withdrawal symptoms and level of monitoring required during detoxification.

According to the level of care designated, clients were assigned to one of five treat-

Dimension 2 determines whether factors in the client’s medical history might influence

ment modalities: outpatient, intensive outpatient, halfway house, residential rehabili-

treatment. Dimension 3 identifies those psychiatric/psychological issues that might im-

tation, or detoxification. Clients may receive individual therapy or group therapy

pede treatment and thus need to be addressed as part of the client’s substance

involving 6 to 12 clients. If mental health problems (co-occurring disorders) are intertwined with substance abuse challenges,

abuse program. Dimension 4 measures the client’s degree of acceptance of or resistance to treatment. Dimension 5 analyzes the client’s potential for relapse and continued substance use. Finally, Dimension 6 considers elements of the client’s surroundings that might encourage or inhibit the client’s involvement in treatment, such as social environment, family, education level, employment, or legal resources or obliga-

treatment may include a dual-diagnosis approach. Detailed descriptions of the care provided in the various treatment modalities are available in the Bureau’s program requirements (2004) and the ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders (Mee-Lee, Shulman, Fishman, Gastfriend, & Griffith, 2001).

tions.

Outpatient Counselors interview clients in order to determine those factors that may interfere with or aid in their recovery.

Outpatient treatment (ASAM Level I) is for clients who have mild, moderate, or stable medical or psychiatric challenges and strong support systems, as well as a personal impetus to change their substance abuse be-

16



havior. This modality keeps clients in their

ceiving Level I outpatient care. Intensive

own communities while helping them develop strategies to achieve sobriety. Clients

outpatient therapy combines 9 to 19 hours of therapy each week with at least 3 hours

in this level of treatment may also be in transition from more intensive therapy on

of service on days of treatment.

the journey to recovery.

Clients receive outpatient treatment while remaining in their communities.

Clients in intensive outpatient care do not need daily supervision but do require a sound support network and more intensive treatment.

Clients attend therapy less than 9 hours per week and no more than one session per

Halfway House

day. The required length of a session is 50 minutes for an individual therapy session

The halfway house (ASAM Level III.1) is

and 90 minutes for a group session.

appropriate for patients who are stepping down from a more intensive level of residen-

Intensive Outpatient

tial rehabilitation. Halfway house patients need a stable environment offering shelter

For patients who require a higher level of treatment than that offered in regular outpatient care but do not need residential supervision, intensive outpatient care (ASAM Level II) is available. Intensive outpatient care assists clients in their efforts to eliminate the behavioral pattern that led them to addiction. Clients also acquire skills for living independently and becoming functional citizens in their communities. Clients who receive this level of care generally do not have a sound support system, lack personal inclination to alter their substance abuse tendencies, fail to recognize the extent of their existing substance abuse problem, or did not achieve successful results after re-

and daily supervision as they transition back into the community from treatment.

Clients who need a stable, supportive environment continue their recovery in a halfway house.

The main components of halfway house treatment include counseling and lectures on alcohol and drug abuse, both occurring at least once per week. Clients may also receive training in interpersonal and vocational skills, employment assistance, or formal educational planning.


17


Residential Rehabilitation

Detoxification

Clients who are evaluated as high risk are placed in residential rehabilitation. This

Detoxification services are generally provided in a clinically managed or medically

level of treatment provides therapy to clients who may have physical or emotional

monitored environment, depending on the assessed level of withdrawal symptoms. In

problems that pose a major obstacle to treatment, lack the supportive network and

social detoxification (ASAM Level III 2D), clinicians use medication while guiding

environment necessary for positive outcomes, or do not possess the cognitive abili-

clients toward withdrawal. This modality is rendered in a residential facility that ben-

ties to understand their alcohol and/or drug problem. Within the category of residential

efits from 24-hour access to clinical support.

rehabilitation are several ASAM levels: clinically managed medium-intensity treatment, clinically managed high-intensity treatment, and medically monitored treatment. In an attempt to return clients to their communities as functional members, residential rehabilitation offers five counseling sessions and five lectures per week.

Clients undergoing detoxification receive appropriate medication and supervision to aid them in the withdrawal process.

Medically

Clients placed in residential rehabilitation are considered high risk because of physical or emotional problems, lack of social or familial support, or cognitive difficulties that may pose an obstacle to treatment.

monitored

detoxification

(ASAM Level III 7-D) is for patients who need a more extensive treatment regimen, including closer supervision and withdrawal management under a more stringent set of physician-approved policies and monitoring procedures. Just as with clinically monitored detoxification, the medical staff is accessible 24 hours a day. The individual treatment plan for each patient might also include individual, group, and/or family therapy.

18



Chapter 3

Outcomes Evaluation Methodology Research Design

The Insight-CH software has specific modules for alcohol and drug admission and dis-

For this outcomes evaluation, I-SATE used

charge data. These modules allow for entry of a client’s demographic data, as well

a pre- and post-test design. At the time of admission, counselors collected pre-test data from the clients. I-SATE interviewers collected post-test data via telephone 6 months after clients’ admission to the treatment facility.

I-SATE interviewers collected follow-up data 6 months after admission.

as information about his or her economic and occupational circumstances, living arrangement, referrals to treatment, substance abuse history and patterns of abuse, route(s) of administration, arrest record and legal status, physical and mental health, medical history and conditions, and prescribed therapies. This admission data serves as a baseline with which the followup data are compared for the purposes of outcomes evaluation.

Admission Data Alcohol and drug abuse treatment facilities in Tennessee funded by the SAPT

Follow-up Data and the TOADS Questionnaire

Block Grant are required to collect data on clients at the time of intake. Counselors

Using structured questionnaires, I-SATE interviewers gathered follow-up data for

gathered admission data using software called Insight-CH developed by QS Tech-

the outcomes evaluation 6 months after clients were admitted to treatment. Interview-

nologies, Inc., and the Bureau’s information technology division then compiles the

ers attempted to contact clients by telephone to administer the interview. To in-

data into a statewide database.

crease their chances of making contact with each client, interviewers made at least

Chapter 3 Outcomes Evaluation Methodology

19


seven telephone attempts: three during the

tives) who were involved in substance

day, three in the evening, and one over the weekend.

abuse. Several questions pertained to the treatment experience: why they had sought

A project interviewer makes at least seven attempts to contact a client for the follow-up interview.

treatment, and how long they had to wait for treatment, if at all. Interviewers also asked clients which treatment modalities they had received, the length of treatment, whether they had completed treatment, and if they received further treatment else-

The TOADS follow-up questionnaire was developed to meet standards set by the Gov-

where after leaving. Other questions gathered information about any prior alcohol

ernment Performance and Results Act (GPRA); the Center for Substance Abuse

and/or drug abuse treatment. Interviewers also asked clients what type, if any, of spe-

Treatment (CSAT); the Interstate Core Data Items, Treatment Outcomes and Perfor-

cial skills training they had received.

mance Pilot Studies II (TOPPS II) Enhancement; and the SAPT Block Grant. The purpose of the questionnaire was to yield a comprehensive view of the efficacy of publicly funded alcohol and drug abuse treatment. Outcomes performance indicators

Interviewers asked clients about their experiences while in treatment and their prior substance abuse history.

used to measure the results of substance abuse treatment included information about

Clients responded to questions about their

client demographics, economic situation, aspects of treatment, changes in substance

level of involvement with the aftercare services offered by treatment centers or by

abuse patterns, changes in physical and emotional health, and any arrests during the 6

some other organization. Specifically, interviewers asked if and how frequently they

months since admission to a treatment facility.

participated in aftercare, and if so, how helpful they considered such services. I-SATE

Interviewers gathered demographic infor-

staff then asked clients the same questions about their involvement in AA/NA (Alco-

mation during the follow-up interview as well, including age, marital status, current

holics Anonymous or Narcotics Anonymous). In addition, interviewers asked cli-

living arrangement, current employment status, and usual occupation. They also asked

ents about how helpful they found their treatment experience, the reasons why they

clients whether they had any family members (specifically, parents or other rela-

rated it the way they did, and whether they had any suggestions on ways to improve treatment and facilities.

20



I-SATE staff asked clients whether they

their involvement in domestic violence, ei-

had abused alcohol and/or drugs since admission, including the 30 days before the

ther as victim or perpetrator.

follow-up interview, soliciting specific information about which drugs clients abused and their frequency of alcohol or drug abuse. In cases where clients had returned to drug abuse, interviewers documented their reasons for relapse. Interviewers also

Interviewers asked clients whether they had been arrested since treatment and about their involvement in domestic violence.

asked clients who had not returned to substance abuse about the length of time they had been abstinent. Additionally, clients stated whether treatment had resulted in

Finally, the interviewers requested information about clients’ physical and mental

enhanced work or school performance and whether they had been absent from work

health in the 30 days prior to follow-up. One question asked clients if they had used a to-

because of alcohol and drug problems in the 30 days prior to the follow-up interview.

bacco product in the past 30 days and, if so, which one(s).

All the information clients shared about their drug and alcohol abuse since admission enabled I-SATE researchers to determine abstinence and recidivism patterns.

Interviewers asked clients to share information about any behavior involving substance abuse since treatment.

Sampling Strategy and Eligible Follow-up Study Population The follow-up study population was chosen through nonprobability sampling instead of random sampling. Specifically, I-SATE used the consecutive nonprobability sampling method, which “involves recruiting all patients who meet the inclusion and exclu-

Interviewers also asked whether the client had been arrested since treatment, and if

sion criteria as they become available” (Portney & Watkins, 2000, p. 147).

so, how many times. Other questions yielded data about specific charges for

Clients were included in this study only if

which clients had been arrested and the number of arrests per charge; here inter-

they voluntarily consented to participate in the follow-up interview. Since this was

viewers were seeking information about DUI, including the number of times clients

an ongoing study of all those clients who were admitted for treatment during the

had been arrested for DUI since treatment. Clients also responded to inquiries about

2003 calendar year, interviews were conducted between July 1, 2003, and June 30,


21


2004. Because of the ongoing nature of the study, at no one point were all of the interviewees available for random sampling. Also, random sampling may have resulted in some agencies with few participating clients being poorly represented. Therefore, in order to maximize the evaluation results, all clients who consented to participate were included.

All SAPT Block Grant-funded treatment facilities in the state were asked to participate in the TOADS outcomes assessment.

Exclusion Criteria for the Study Population 1. At the time of the follow-up interview, interviewers did not have a valid phone number for the client (e.g., phone number was incorrect, unpublished, or not in service), or 2. The client was institutionalized (e.g., in jail, state custody, a hospital, shelter, or group home), or 3. The client initially agreed but then refused to be interviewed at the time of follow-up contact, or 4. The client was deceased.

To secure a wide spectrum of client participation, all treatment facilities funded by the SAPT Block Grant were requested to seek consent from their clients for this follow-up study. About 9,000 substance abuse clients were treated in Tennessee in 110 treatment facilities operated by 45 primary vendors.

Inclusion Criteria for the Study Population

up study. These clients were recruited while being admitted to residential (58.5%), intensive outpatient (21.1%), halfway house (9.4%), and outpatient (10.9%) modalities. Following current practice in the literature (Gerstein & Johnson, 2000; Flynn, Craddock, Hubbard, Anderson, & Etheridge, 1997; and Flynn, Simpson,

1. The client’s treatment was funded

Anglin, & Hubbard, 2001), the sample size and the interview coverage rates were de-

by the SAPT Block Grant, and

termined for this study in the following way.

2. After the method and purpose of the study was explained by a counselor at the treatment facility, the client voluntarily consented to participate in the follow-up study.

22

During the 2003 calendar year, 5,442 clients consented to participate in the follow-


The eligible follow-up sample coverage rate for the TOADS evaluation study was 79.4%.


A. Clients who consented to participate 5,442 B. Excluded from the sample selection 2,745 Wronga or no telephone number (2,251) Institutionalizedb (287) Continuing in treatment (143) Refused to participatec (50) Deceased (14) C. Eligible follow-up sample 2,697 D. Follow-up interviews completed 2,142 d E. Follow-up interviews not completed 555 F. Eligible follow-up sample coverage rate (D/C)

79.4%

Figure 3.1 Number of Telephone Attempts for Completing Interviews

10.2% 26.6%

38.0% 25.3%

a

Wrong is defined as incorrect, unpublished, or not in service. b Institutionalized is defined as in jail, state custody, a hospital, shelter, or group home. c Refused to participate in the interview while on the phone with an interviewer. d Follow-up interviews could not be completed for a variety of reasons, e.g., some clients did not answer or return any of the interviewers’ calls.

1st attempt (n=569) 2nd attempt (n=541) 3rd, 4th, or 5th attempt (n=814) 6 or more attempts (n=218)

Only 26.6% of the follow-up interviews with clients were completed on the first attempt. While the second attempt resulted in almost one fourth (25.3%) of completed interviews, the greatest (38.0%) success was attained during the third, fourth, or fifth attempts; 10.2% of completed interviews took six or more phone calls (see Figure 3.1).

consented to participate in the study. Staff compared the responses given by the 2,142 clients who completed interviews and the 3,300 who did not (see Table 3.1). Although the two groups appeared to have very similar demographic characteristics and treatment features, statistically there were significant differences between the two groups for six of the ten variables: gender, ethnicity, age group, education level, em-

Non-Response Analysis

ployment status, and recent arrest record. On the remaining four variables (marital

To determine whether there was a bias in sampling those clients who did not respond,

status, child of substance abuser, prior treatment history, and level of function at

I-SATE researchers analyzed data on ten key demographic characteristics and treat-

admission), the differences between the two groups were not statistically significant.

ment features for the clients who initially


23


Table 3.1 Non-Response Analysis for Clients Who Consented to Participate

Variable Gender Male Female Ethnicity White African American Other Missing values Age group Youth Adult Marital Status Never Married Married Separated/divorced/widowed Unknown Education Level Middle school High school College Missing values Employment Status Full-time Part-time Unemployed Student Other Missing values Child of Substance Abuser Yes No Prior Treatment History Yes No Level of Function at Admission Superior Good Poor Recent Arrest Recordb Yes No a

Clients with Complete Interviews (N = 2,142)

Clients Excluded or with Incomplete Interviews (N = 3,300)

%a

%a 0.0050

70.2 29.8

73.7 26.3

67.8 31.3 0.8 0.0

65.9 32.3 1.4 0.4

4.8 95.2

6.8 93.2

45.7 15.5 34.5 4.3

46.5 13.5 34.4 5.6

1.9 67.5 20.4 10.2

2.2 70.4 14.9 12.5

0.0041

0.0020

0.0559

0.0002