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RESEARCH AND PRACTICE |
The authors are affiliated with the Neuropsychiatric Institute’s Integrated Substance Abuse Programs at the University of California, Los Angeles.
Correspondence: Requests for reprints can be sent to Elizabeth Evans, UCLA Integrated Substance Abuse Programs, 1640 South Sepulveda Blvd, Suite 200, Los Angeles, CA 90025 (e-mail: laevans{at}ucla.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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Objectives. We examined differences in substance abuse treatment outcomes between American Indians and their non–American Indian counterparts in California, during 2000 to 2002.
Methods. A total of 368 American Indians and a matched sample of 368 non–American Indians from 39 substance abuse treatment programs in 13 California counties were assessed at multiple time points. Records on arrests, driving while under the influence of alcohol or drugs, and mental health care were obtained 1 year before and 1 year after treatment entry. Differences in pretreatment characteristics, services received, treatment satisfaction, treatment completion and retention, and outcomes were examined.
Results. Pretreatment problems were similarly severe among American Indians and non–American Indians. About half in both groups either completed treatment or stayed in treatment more than 90 days; American Indians in residential care had significantly shorter treatment retention. American Indians received fewer individual sessions and out-of-program services, especially for alcohol abuse, but were nevertheless generally satisfied with their treatment. Both groups improved after treatment, with American Indians demonstrating greater reductions in arrests than non–American Indians.
Conclusion. American Indians benefit from substance abuse treatment programs, although the type and intensity of services offered could be improved.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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Although the patterns and treatment implications2–4 of American Indian alcohol use have been well documented, posttreatment outcome studies are few, and results have been mixed.5 Westermeyer’s6 10-year follow-up of 45 hospitalized American Indians found that only 7 improved, whereas Shore and von Fumetti’s7 4-year follow-up of 642 American Indian patients who received out-patient and residential care reported that slightly more than one quarter demonstrated clear improvement. Walker et al.8 tracked an urban American Indian sample up to 2 years posttreatment and documented better outcomes among patients in outpatient care. Several other studies that followed American Indian patients for shorter time periods9–11 found improvements such as decreases in alcohol consumption, adverse consequences, and social and legal problems. Other American Indian treatment research has focused on culturally infused interventions12,13 and adolescent substance use and prevention strategies.14–18 Very few studies have examined how American Indian adults entering treatment for alcohol and drug problems fare over time and if they do as well as other groups.
California is in a unique position to contribute to the research on American Indians. About 4.1 million people in the United States are American Indian/Alaska Native (1.5% of all Americans) and California has the largest American Indian population with 627562 individuals.19 Almost 6000 American Indians (accounting for more than 8000 admissions) annually receive substance abuse treatment in California. The present study capitalizes on the comprehensive data collected from patients in 39 treatment facilities that participated in the California Treatment Outcome Project (CalTOP). Specifically, we address 2 key research questions: (1) Aside from race/ ethnicity, are American Indians different from non–American Indians at treatment entry on general characteristics and problem severity? and (2) How do substance abuse treatment outcomes differ among American Indians and non–American Indians? Given the current literature on the need for culturally appropriate services20,21 and substance abuse severity among some American Indian populations, we hypothesized that compared with other patients, American Indians would present more severe problems, particularly with alcohol; leave treatment earlier; and demonstrate less favorable outcomes at follow-up.
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Study Design |
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TOPABSTRACTINTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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Patients participating in CalTOP were assessed at admission, and a subset was interviewed 3 and 9 months postadmission. Administrative records were obtained for the entire admission sample covering at least 12 months pre- and postadmission. The follow-up rates for the 3- and 9-month interviews were 90% and 78%, respectively. (See Hser et al.22 for details.)
There were 368 American Indians treated in 39 CalTOP programs (21 outpatient, 14 residential, 4 narcotic replacement), mostly in El Dorado County (32.9%), followed by San Diego (14.5%), Alameda (11.9%), San Joaquin (10.6%), and Kern (7.5%) counties. Less than one quarter entered programs located in the 8 remaining CalTOP counties.
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Participants |
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TOPABSTRACTINTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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The 9-month follow-up rate was 70% among American Indians and 65% among non–American Indians. Attrition analysis of subjects who did and did not complete the follow-up interview revealed no significant differences in age, gender, education, treatment modality, employment status, living circumstances, legal situation, or primary drug use.
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Treatment Programs |
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TOPABSTRACTINTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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Patient Assessment and Follow-up Procedures |
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TOPABSTRACTINTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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All patients were assessed at admission and discharge, and their administrative records were obtained. Subsets were interviewed 3- and 9-months postadmission. Treatment staff conducted informed consent and an in-person assessment with entering adult patients as part of the normal administrative process. Telephone follow-up interviews were conducted by UCLA-trained interviewers (representing Asian, Hispanic, and White racial/ethnic backgrounds). Each interview lasted approximately 30 minutes; responses were entered into a computer and checked for internal consistency; and patients were paid $10 for the first interview and $15 for the second.
Official records on arrests, driving while under the influence of alcohol or drugs (DUI), and mental health care were obtained from the California Department of Justice, the California Department of Motor Vehicles, and the California Department of Mental Health.
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Instruments and Measures |
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TOPABSTRACTINTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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Treatment retention was based on treatment records reported to the state database, and was defined as the number of days between program admission and discharge. For those without discharge records, we calculated length of stay from admission to the last day receiving services.
Treatment satisfaction was indicated by 3 measures at the 3-month follow-up that assessed patients’ satisfaction with the program (7 items), services (12 items), and counseling relationships (3 items).26 Satisfaction levels were rated with a 1-to-5 Likert scale, with higher scores indicating greater satisfaction, and a mean score for each of the 3 domains was calculated.
Services received was measured with the Treatment Services Review,27 which gathered information on the number of professional services and discussion or counseling sessions that were received in each of the 7 ASI domains. Service intensity is the sum of the number of times that a patient received services (either in program or out of program through referrals) in the first 3 months of treatment.
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Statistical Analysis |
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TOPABSTRACTINTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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2 tests for categorical variables and t tests for continuous variables (e.g., age, years of education, and ASI composite scores). Posttreatment outcome differences were examined with 3 types of analyses. We used paired t tests to assess whether changes in ASI composite scores from admission to follow-up were significantly different from zero. Next we applied analysis of covariance to examine the interaction between the group variable (American Indians vs control individuals) and ASI composite scores. Statistical significances on main and interaction effects were examined with F tests.
Finally, we applied logistic regression analysis to examine the occurrence of arrest and mental health services utilization after admission. Main covariates in each logistic model included group type (American Indians vs controls) and occurrence of an arrest or mental health services utilization before admission. Other controlling covariates included demographics, legal status, treatment modality, primary drug, and admission ASI composite scores. Statistical significance on odds ratios for each covariate was evaluated by Wald 2 test. All differences presented are significant at P < .05, unless noted otherwise.
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RESULTS |
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TOPABSTRACTINTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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), more American Indians received residential care (49.7% vs 30.5%; P < .05), fewer were employed (25.2% vs 33.4%; P < .05), and more reported alcohol as the primary drug problem (44.6% vs 27.4%; P < .05), using alcohol to intoxication before treatment (32.3% vs 24.8%; P < .05), and experiencing more alcohol-related problems (52.6% vs 38.1%; P < .05).
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). The only exceptions are that employment at admission was significantly lower among American Indians than among non–American Indians (25.2% vs 33.6%; P < .05) and more American Indian patients had children younger than 18 years (67.5% vs 58.2%; P < .05). The 2 groups were also similar in alcohol use and problems during the month before admission and in the 7 ASI severity scores.
Treatment Retention
American Indians stayed more days in outpatient drug-free (non-methadone) treatment (mean = 132 days, SD= 123 vs mean = 121 days, SD= 121; means not significantly different) and fewer days in residential care (mean = 46 days, SD= 52 vs mean = 66 days, SD=91; means significantly different at <.01). About half of patients in both groups either stayed for 90 days or more or completed treatment (53.0% for American Indians and 53.8% for non–American Indians; not significantly different).
Treatment Satisfaction and Services Received
Table 2 shows that patients in both groups were similarly satisfied with their treatment program, counselor, and services received. The total mean number of services received was also equivalent (mean = 165.0 services, SD= 139.6 for American Indians vs mean = 182.0 services, SD= 191.1 for non–American Indians). Patients in both groups primarily received services related to use of drugs (mean= 75.1 services, SD= 53.3 vs mean = 78.4 services, SD= 96.8) and alcohol (mean = 55.8 services, SD= 64.8 vs mean = 71.3 services, SD= 100.1), some services dealing with mental illness (mean = 18.0 services, SD= 47.4 vs mean = 12.6 services, SD= 21.2), and much fewer services addressing medical problems, family conflicts, legal issues, or employment. None of these group differences was significantly different.
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Given the significant differences found between the 2 groups in terms of treatment retention and service intensity, we conducted regression analyses to examine whether service intensity affected treatment retention and if the interaction of service intensity and American Indian ethnicity impacted retention (data not shown). After we controlled for occurrence of previous arrests, DUIs, and mental health services utilization, the interaction of American Indian ethnicity and service intensity was significant for both individual and group sessions. Although service intensity was not related to retention for non–American Indians, increased service intensity for either individual or group services was positively related to treatment retention among American Indians in residential care. Although treatment retention in residential care was shorter for American Indians, increasing the number of individual sessions by 1 increased the stay in residential care by 1.4 more days for American Indians than for non–American Indians. Similarly, increasing the number of group sessions by 1 increased retention by 0.98 more days for American Indians than for non–American Indians.
Treatment Outcomes
ASI composite scores.
Changes after treatment admission are succinctly summarized by the ASI composite scores and, as shown in Table 3, patients in both groups improved in all but 1 of the areas measured (improvement in the medical domain was not statistically significant). The analysis of covariance test on ASI composite scores at follow-up found no significant differences between American Indians and non–American Indians when we controlled for ASI scores at admission.
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Arrests.
In the year before treatment admission, 36.9% of American Indians and 42.1% of non–American Indians had been arrested. Arrests decreased for both groups during the 12 months after treatment admission (22.2% for American Indians and 33.4% for non–American Indians). The percent of American Indians arrested after admission demonstrated a reduction rate of 14.7%, whereas the reduction rate among non–American Indians was 8.7% (data not shown). Table 4 shows how the odds of being arrested varied across several characteristics. American Indians were significantly less likely to be arrested after admission. Arrests were less likely to occur among older patients and those in residential treatment. Patient characteristics that increased the likelihood of arrest were prior arrest history, being male, homelessness, use of illegal drugs (cocaine, heroin, amphetamine, or marijuana) rather than alcohol, and severe drug or family problems.
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About 7% of individuals in both groups had been arrested for a DUI in the year before treatment admission, but in the year after treatment admission American Indians had about half the number of DUI arrests as non–American Indians (1.8 % vs 4.5%), although this difference was not statistically significant. Logistic regression showed that men were 3.9 times more likely to be arrested for a DUI than were women (Table 4).
Mental health services utilization. About 17% of patients in both groups received mental health services in the year before treatment admission; this increased by 3.8% for both groups in the year following admission. Logistic regression analysis showed that mental health services utilization after admission was significantly correlated with services utilization before admission, placement in non-residential substance abuse treatment, and medical or psychiatric illness.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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The pattern of improvements observed in our sample contrasted with previous studies on longitudinal treatment outcomes among American Indians. Our results, however, are consistent with those observed among the overall CalTOP sample22 and among samples reported on by other general studies.28–31 Although direct comparisons are precluded by pretreatment differences, the improvements among American Indians are similar to changes observed among the overall CalTOP sample. For example, the overall sample and American Indians demonstrated significant reductions in problem severity in all 7 ASI domains at follow-up (with the exception that the reduction in medical problems for American Indians was not statistically significant). Similarly, like the overall sample, American Indians showed decreases in the occurrence of DUIs and arrests and an increase in utilization of mental health services 1 year after treatment.
Although lacking program- and cultural-specific information, the present study provided some measures of treatment process. Our hypothesis that American Indians would leave treatment earlier was partially supported. About half of patients in both groups stayed in treatment for the amount of time needed to maximize the benefits of treatment. Both groups also received comparable services and were generally satisfied with the treatment program, counselor, and services. However, American Indians treated in residential programs had significantly shorter retention than non–American Indians. American Indians also received fewer individual counseling sessions. Finally, despite greater unemployment among American Indians before treatment admission, they did not receive more services for employment problems; employment services were minimal for both groups. Attention to these discrepancies may facilitate greater improvement in outcomes for both groups, and particularly for the American Indians.
Importantly, our study demonstrated that greater service intensity (for both individual and group services) was critical for increasing treatment retention among American Indians in residential care. Other studies have also indicated that greater service intensity and treatment satisfaction are positively related to either treatment completion or longer retention, which, in turn, has been related to favorable treatment outcomes.26 This principle, in conjunction with our findings, suggests that American Indians would benefit from a more intense level of services that cover not just substance abuse but other problems as well.
Implications for our findings need to be discussed within the context of a few limitations. For example, the agencies participating in CalTOP were not randomly selected and alcohol-only programs were excluded. It is therefore possible that the observed patterns are not generalizable to other programs that do not provide similar services. Also, the reliability and validity of self-reported information is uncertain. In addition, administrative data were drawn only from records maintained by the State of California, and so events that may have occurred in other states were not studied. Furthermore, insufficient treatment program information was gathered, limiting our ability to identify or investigate culturally specific components of treatment. Finally, American Indians are a heterogeneous population with differences among tribal groups. Although patients self-identified as American Indian, their involvement with American Indian cultures was not ascertained.
Although our analysis was limited to the information that had already been gathered by CalTOP, data were collected in real-world settings using standardized procedures and instruments, permitting comparisons across diverse groups and thus presenting a unique opportunity to assess relevant issues among American Indians. National reports show that American Indian populations suffer more from substance abuse and related health consequences compared with other racial/ethnic groups.1,32 Moreover, American Indians have limited access to quality health care33 and, along with other minorities, are more likely to underutilize or be disconnected from regular sources of care and the health care system overall.34,35 Thus, it is important to understand how American Indians are impacted by the substance abuse treatment services that they utilize.
Our study represents the first to document the health, social, economic, and legal outcomes for American Indians served by diverse substance abuse treatment programs in several California counties. It is encouraging that American Indians in our sample decreased their rates of drug and alcohol use and made improvements in other areas impacted by substance abuse. These nonspecialized substance abuse treatment programs were able to address the needs of their American Indian patients, although the type and intensity of services offered could be improved. Further examination is needed to understand how factors such as culture, ethnicity, geography, and acculturation within mainstream American society affect American Indians’ responses to treatment.
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Acknowledgments |
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Human Participant Protection
Study protocols and informed consent procedures were approved by 2 human subjects protection committees—at the University of California Los Angeles and the State of California Health and Human Services Agency—and a federal Certificate of Confidentiality was obtained to further safeguard data.
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Footnotes |
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Contributors
E. Evans supervised data collection and analyses, wrote the sections on study design and results, and assisted with the literature review. S.E. Spear suggested the topic, led the literature review, and assisted with interpretation of data. Y.-C. Huang conducted and summarized statistical analyses. Y.-I. Hser conceptualized the study and provided guidance with statistical analyses and interpretation of results.
Accepted for publication April 1, 2005.
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References |
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TOPABSTRACTINTRODUCTIONStudy DesignParticipantsTreatment ProgramsPatient Assessment and Follow-up...Instruments and MeasuresStatistical AnalysisRESULTSDISCUSSIONReferences |
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2. May PA, Gossage P. New data on the epidemiology of adult drinking and substance use among American Indians of the northern states: male and female data on prevalence, patterns, and consequences. Am Indian Alsk Native Ment Health Res. 2001;10:1–26.
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7. Shore JH, von Fumetti B. Three alcohol programs for American Indians. Am J Psychiatry. 1972;128: 1450–1454.
8. Walker RD, Benjamin GA, Kivlahan D, Silk-Walker P. American Indian alcohol misuse and treatment outcome. In: Spiegler D, Tate D, Aitken S, Christian C, eds. Alcohol use among US ethnic minorities. Proceedings of a conference on the epidemiology of alcohol use and abuse among ethnic minority groups. Washington, DC: US Government Printing Office; 1989:301–311. NIAAA research monograph 18, DHHS publication ADM 89–1435.
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26. Hser YI, Evans E, Huang D, Anglin DM. Relationship between drug treatment services, retention, and outcomes. Psychiatr Serv. 2004;55:767–774.
27. McLellan AT, Alterman AI, Cacciola J, Metzger D, O’Brien CP. A new measure of substance abuse treatment. Initial studies of the treatment services review. J Nerv Ment Dis. 1992;180:101–110.[ISI][Medline]
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33. Scott BS. Indian health service continues to provide for millions: Medicare and Medicaid work hard to keep up. In: Closing the Gap: Working toward our Goal—Eliminating Racial and Ethnic Disparities in Health. Washington, DC: Office of Minority Health, US Dept of Health and Human Services; 2003:14. Available at: http://www.omhrc.gov/OMH/sidebar/archivedctg.htm. Accessed September 20, 2004.
34. Collins KS, Hughes DL, Doty MM, Ives BL, Edwards JN, Tenney K, for The Commonwealth Fund 2001 Health Care Quality Survey. Diverse communities, common concerns: assessing health care quality for minority Americans; 2002. Available at: http://www.cmwf.org/programs/minority/collins_diversecommunities_523.pdf. Accessed September 20, 2004.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
