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Client Outcomes from Rural Substance AbuseTreatmentMatthew L. Hiller a , Carl G. Leukefeld b , Thomas F. Garrity b , Theodore Godlaski c ,Marlies Schoeneberger d , Michael Townsend e & Karyn Hascal ea Temple University, Department of Criminal Justice , Philadelphia, PAb University of Kentucky, Center on Drug and Alcohol Research, Dept. of BehavioralSciences , Lexington, KYc University of Kentucky, College of Social Work , Lexington, KYd National Development and Research Institute, Inc. , New Yorke Office of Drug Control Policy , Frankfort, KYPublished online: 08 Sep 2011.

To cite this article: Matthew L. Hiller , Carl G. Leukefeld , Thomas F. Garrity , Theodore Godlaski , MarliesSchoeneberger , Michael Townsend & Karyn Hascal (2007) Client Outcomes from Rural Substance Abuse Treatment,Journal of Psychoactive Drugs, 39:1, 59-68, DOI: 10.1080/02791072.2007.10399865

To link to this article: http://dx.doi.org/10.1080/02791072.2007.10399865

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Client Outcomes fro01 Rural

Substance Abuse Treat01entt

Matthew L. Hiller, Ph.D . * ; Carl G. Leukefeld, D.S.W. * * ; Thomas F. Garrity, Ph.D. * * ;

Theodore Godlaski , M.Div. * * * ; Marlies Schoeneberger, Ph.D. * * * * ;

Michael Townsend, M.S.S.W. * * * * * & Karyn Hascal, M.S.W. * * * * *

Abstract- Several national evaluations have been conducted since the late 1 960s that have assessed the effectiveness of publicly-funded substance abuse treatment in the United States. These studies, however, have focused principally on urban-based treatment programs, and it is unclear whether findings from urban programs can be replicated in outcome studies of programs in rural areas. The current study, therefore, examined the treatment outcomes of clients admitted to one of several short­term inpatient or outpatient drug-free treatment agencies in rural Kentucky. Findings showed that treatment was associated with reductions in drug use and criminality during a six-month follow-up interval. Employment status also improved significantly, and health services utilization was reduced. The similarity between the current findings and findings from national outcome studies of urban-based treatment programs is discussed.

Keywords-drug abuse, inpatient, outcomes, outpatient, rural

The National Institute on Drug Abuse has funded three major evaluations of substance abuse treatment services with a national scope in the United States over the past four decades (Aetcher, Tims & Brown I 997). The first, the Drug

tThis study was supported by grant 6URI Tl i613-0 l - 1 from the Center for Substance Abuse Treatment. Special appreciation is expressed to the UK-CDAR project staff (Bridgett Augustino-Kreisler, Patricia Hounshel l , Barbara Patterson, and Marlies Schoeneberger) for their contributions to data collection and data management of this project. Opinions in this document are those of the authors and do not represent the position of the Center for Substance Abuse Treatment or the Substance Abuse and Mental Health Services Administration.

• Assistant Professor, Temple University, Department of Criminal Justice, Philadelphia, PA.

**Chair and Director; Professor, University of Kentucky, Center on Drug and Alcohol Research, Dept of Behavioral Sciences, Lexington, KY.

***Associate Clinical Professor, University of Kentucky, College of Social Work, Lexington, KY.

****Project Director, National Development and Research Institute, Inc., New York.

•••••Former Director, Kentucky Cabinet for Health Services, Division on Substance Abuse; Deputy Executive Director, Office of Drug Control Policy, Frankfort KY.

Please address correspondence and reprint requests to Matthew Hiller, Temple University, Department of Criminal Justice, 5th Aoor, Gladfelter Hall, Philadelphia, PA 1 9 1 22; email: mhiller@temple.edu

Journal of Psychoactive Drugs 59

Abuse Reporting Program (DARP; Simpson & Sells I990, I982; Sells & Simpson I976), collected data on 44,000 treat­ment admissions to 52 treatment agencies between I %9 and 1973. The Treatment Outcome Prospective Study (TOPS ; Hubbard et al . 1989), collected data on I I ,000 admissions to 41 programs between 1979 and 1 98 1 . The most recent outcome study, the Drug Abuse Treatment Outcome Stud­ies (DATOS; Aetcher, Tims & Brown 1 997; Hubbard et al . 1997) collected baseline data on 10,010 clients between 1991 and 1993 in % treatment programs that were based in large metropolitan areas l ike Chicago, New York City, Miami, and New Odeans. These national outcome studies focused primarily on relatively large urban-based treatment programs because this was the best approach for securing a large sample during a relatively short time frame for statisti­cal research comparisons that included longitudinal data for one- and five-year posttreatment intervals (Simpson, Joe & Broome 2002).

To date, studies of substance abuse treatment outcomes have found that, overall, treatment can be effective in reducing

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alcohol and illicit drug use, criminality, and psychosocial problems related to substance abuse and dependence. For example, results of the Drug Abuse Reporting Program have been reported widely by Simpson (Simpson 1997, 1984). In general, findings showed that clients treated in outpatient methadone maintenance, therapeutic community, and out­patient drug-free (ODF) treatment programs demonstrated significant reductions in drug use and criminal behaviors and improved social functioning when treatment was pursued for at least three months; all three of these treatment modalities were superior to simple drug detoxification. The findings of the Treatment Outcome Prospective Study (Hubbard et al. 1989) replicated many of those of the Drug Abuse Report­ing Program. Clients in outpatient methadone maintenance, long-term residential, and outpatient drug-free treatment (ODF) modalities experienced significant improvements in their drug abuse outcomes; regular use of heroin, cocaine, and nonmedical psychotherapeutic drugs declined markedly through three to five years of follow-up after treatment. Treatment effects on marijuana and heavy alcohol use were not as prominent for any treatment modality, a result similar to that of the Drug Abuse Reporting Program. There also were significant reductions in the prevalence of predatory criminal behavior and suicidal ideation for all three treat­ment modalities. However, employment and support were not notably improved after treatment. Data from the Drug Abuse Treatment Outcome Studies are similar to those of the DARP and TOPS. DATOS also is the most relevant of the three national outcome studies to the current investigation because it collected baseline and follow-up data during the 1 990s and because it included an examination of short-term inpatient (STI) programs. Findings from DATOS show that treatment is associated with positive outcomes, including reduced drug use and criminal justice involvement, for each of the major treatment modalities studied (Hubbard et al. 1997).

Rural treatment programs were not targeted for study in these three national outcome studies, and it is unclear whether conclusions for treatment effectiveness based on ur­ban samples translate to rural areas where treatment deli very systems are structured differently to accommodate limited resources, geographical separation and long travel distances, and client population characteristics that can affect the ef­fective delivery of treatment (Warner & Leukefeld 2001 ; Brown, Voskuhl & Lehman 1977). Furthermore, alcohol and drug abusers in rural areas often report l imited access to treatment (Schoeneberger et al. 2006; Clark et al. 2002; Fortney & Booth 2001 ; Leukefeld & Edwards 1999; Metsch

& McCoy 1999; Leukefeld & Godlaski 1997), with most available treatment options paid for through public monies. For example, substance abuse treatment in Kentucky is con­ducted primarily within a network of Comprehensive Mental Health Centers that provide the majority of substance abuse and mental health services to those who need them in the state. Short-term inpatient (STI), a brief but intensive resi-

Journal of Psychoactive Drugs 60

Client Outcomes from Rural Substance Abuse Treatment

dential treatment, and outpatient drug-free (ODF) programs are the two primary modalities used for treating substance abusers within this system.

The current study, therefore, examines outcomes from substance abuse treatment in Kentucky, a rural state. The study was guided by two research objectives. The first ob­jective was to examine the combined outcomes for clients admitted to substance abuse treatment in Kentucky, includ­ing changes in alcohol and drug use, legal status and criminal involvement, employment and support, and health services util ization between baseline and six-month posttreatment follow-up interviews. The second objective was to examine these outcomes by the treatment modalities represented in the sample (i.e., short-term inpatient (STI) and outpatient drug-free (ODF) treatment modalities). These objectives were intended to answer two research questions: what is the overall impact of substance abuse treatment in rural Kentucky, and do outcomes differ by treatment modality? It was expected that outcomes from rural-based treatment would be similar to urban-based treatment and that findings for rural STI and ODF programs would resemble those from urban areas.

METHOD

Sample

Baseline data were collected from 604 clients admitted to publicly-funded treatment in three rural mental health re­gions in Kentucky between November 15, 1 999 and January 3 1 , 200 1 . This included clients admitted to comprehensive care substance abuse treatment programs in Eastern Ken­tucky (n = 206), in South Central Kentucky (n = 165), and Western Kentucky (n = 233). Most clients lived in rural (5 1 %) or very rural (28%) areas of Kentucky. The remaining 2 1 % were treated in a program based in a small city (less than 100,000 population), and lived in or near there. Over half of the participants were admitted to outpatient treatment (5 1 %, three programs); 49% were in short-term inpatient treatment (two programs lasting from 14 to 28 days). As shown in Table 1 , the majority of participants were male (73%), White (91 %), and had been referred to treatment by the criminal justice system (66%). The median age at baseline data collection was 33 years old, 25% were mar­ried, 40% were divorced, separated, or widowed, and 35% had never been married. Fifty-seven percent had graduated from high school, and 7% had a GED. Forty-eight percent reported alcohol as their primary drug problem, 1 6% mari­juana, 1 1 % crack/cocaine, 14% other opiates and synthetics, and 1 1 % other drugs (e.g., amphetamine, methamphetamine, benzodiazepine ).

Procedure The current study was conducted as a part of a Treat­

ment Outcomes and Performance Pilot Studies Enhancement (TOPPS I I) cooperative agreement with the Center for

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TABLE 1 Sample Descriptions

% Male

Race/ethnicity

% African American

% White

% Other

Average age (SD)

Marital status

% Single/never married

% Married

% Divorced/separated/widowed

Education

% High school graduate

% GED

Living anangements

% Independent

% Dependent

% Homeless

Primary drug problem

% Alcohol

% Marijuana

% Crack/cocaine

Substance Abuse Treatment. During the initial phases of this cooperative agreement, a consensus was reached by the principal investigators from each site concerning the types of instrumentation each state should use, the time frames for data instruments (including baseline, discharge, and six-month follow-up interviews), and how data could be combined across states for a final report on interstate data. The data collection procedure described in the next section of this article was implemented according to cooperative guidelines to provide data that could be efficiently collected and combined across sites.

Eligibility criteria for clients to be admitted into the cur­rent study included, ( l ) having been admitted to substance abuse treatment, (2) being at least 1 8 years of age, (3) not being admitted for education purposes only (e.g., DUI education), and (4) not being admitted for mental health or mental retardation treatment only. Dual diagnosis of mental health problems with substance abuse was an acceptable status for inclusion in the study. Following the collection

Journal of Psychoactive Drugs 61

Characteristic Baseline at Baseline Follow-up (N = 604) (N = 558)

73 73

8 8

91 91

33.3 (9.87) 33.3 (9.92)

35 35

25 24

40 41

57 58

7 7

85 85

1 2 12

3 3

48 47

16 17

I I I I

of written, informed consent, researchers conducted the baseline interview in a face-to-face session with each cli­ent. This baseline instrument was comprised primarily of the Addiction Severity Index Lite (ASI- Lite; McLellan et al. 1999, 1992), which was modified to meet the needs of the CSAT cooperative agreement. Demographic and other relevant background information were collected during this interview, as was information for the following six domains: ( l ) alcohol/drug use, (2) legal status, (3) employment/sup­port status, (4) family/social status, (5) medical status and services, and (6) psychiatric status and services utilization. Locator data, including the city and county participants considered their "home base," also were obtained during the baseline interview to facilitate the collection of a six-month post-discharge follow-up interview. Clients were reimbursed $5 for completing a baseline interview.

Clients were again contacted at discharge from treat­ment and given a brief interview that assessed reasons for discharge and client satisfaction with treatment Approximate( y

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six months after treatment discharge, clients were again contacted for a follow-up interview. Like the baseline instru­ment, the six-month follow-up interview contained many of the ASI-Lite items. A total of 558 clients (or 92% of the baseline sample) provided a six-month follow-up interview. Eighty-eight percent of the follow-up interviews were con­ducted by phone, and 1 2% were completed in face-to-face sessions. In addition to the 558 who were interviewed, four other people were deceased at follow-up, one was medically incapacitated, and nine refused to be interviewed again, yielding a total follow-up rate of 95%. As shown in Table 1 , the demographic profile of those completing the follow­up was strikingly similar to the demographic profi le for the baseline interview, suggesting the follow-up sample is an unbiased subset of the baseline sample.

Measures Alcohol and drug use. Alcohol and drug use included

the percentage of people who reported that they had used alcohol or a specific drug as well as the number of days in the previous 30 days they had used that drug (both at baseline and at follow-up). Furthermore, three variables were cre­ated to reflect the percentage of individuals abstinent from alcohol use, from drug use, and from both alcohol and drug use in the previous six months at follow-up.

Legal status and criminality. Three criminal involve­ment variables were common between the baseline and follow-up interviews. The first two represented the client's self-report of arrests they had incurred in the six months and 30 days before the baseline and follow-up interviews. The third measure included self-reports of being incarcerated either in a prison or a jail in the preceding 30 days.

Employment and support. Infonnation for employment and living arrangements were coded into dichotomous vari­ables, including employed (0 = no, 1 = yes) in the previous six months. Individuals who were not in the workforce because they were disabled, students, or homemakers were coded as a 1 on this variable, so comparisons were made in terms of the percentage that were unemployed at baseline and at follow-up. Similar comparisons were made on the percentage that reported they had been paid for work in the preceding 30 days, and the percentage that had independent and dependent (including homeless) l iving arrangements.

Health and mental health services. Variables for health and mental health focused primarily on services utiliza­tion. Two measures reflected whether the client had been hospitalized overnight or had been to the emergency room for treatment (0 = no, I = yes) in the previous six months. Physical health also was assessed with the question: "How many days have you experienced medical problems in the past 30 days." Finally, mental health services use was based on a measure that indicated whether the client had been treated overnight in a hospital for psychiatric problems (0 = no, I = yes).

Journal of Psychoactive Drugs 62

Client Outcomes from Rural Substance Abuse Treatment

Statistical Analysis Because they were col lected on both baseline and

follow-up interviews and thus were directly comparable, only matched variables from the basel ine and follow-up interviews were examined for change over time. Data were analyzed for the first research objective using a series of McNemar's chi square tests for testing for change in pro­portions over time (for dichotomously-scored data) and in a series of non-independent measures t-tests (for continu­ously-scaled variables). This approach allowed us to test for change from baseline to follow-up on the primary outcome variables. For example, a statistically significant McNemar's chi square test indicated that the proportion of clients report­ing a behavior (e.g. , percent who had used alcohol in the preceding 30 days) had changed from baseline to fol low-up. Similarly, the non-independent measures t-tests showed when statistically significant change occurred in average reported behavior scores (e.g .. number of days in the past 30 during which alcohol had been used) from baseline to follow-up. Both the chi-square and t-test analyses examined the data as a within-subjects design, directly contrasting each client's behavior at follow-up with what they had reported on an equivalent measure taken at baseline, and making each client their own control for comparison. Because the first objective was to examine overall treatment outcomes, we aggregated finding across treatment modalities. How­ever, modality was considered in the second set of analyses perfonned to examine outcomes separately for short-term inpatient (STI) and outpatient drug-free (ODF) programs. Outcomes were analyzed in a series of repeated measures analysis of variance (ANOVA) tests with time (i.e., baseline to follow-up) as the within subject's factor and treatment modality (ODF versus STI) as the between subjects (or group) factor. Main effects are summarized for time (T) and for group (G), and the time by group interaction tenn (TxG) is noted when it reached statistical significance (p < .05). A main effect for time is interpreted as a statistically significant change over time in the outcome measure, a main effect for group indicates that on average one group scored significantly higher than the other on the outcome measures, and a time by group interaction shows that one group changed at a significantly greater rate than the other. That is, one group had a significantly larger change score than the other group in the comparison.

RESULTS

Overall Impact of Treatment

Alcohol and drug use. Outcomes for alcohol and drug use are presented in Table 2. Treatment appeared to be re­lated to a marked reduction in alcohol and drug use between baseline and follow-up intervals. For example, the propor­tion of the sample reporting they had drunk alcohol to the point of being intoxicated dropped from 27% at baseline to

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TABLE 2 Alcohol and Illicit Drug Use, Criminal Justice Involvement, Employment and Support, and Health Services

Utilization Outcomes: Overall Change from Baseline to Follow-up (N = 558)

Alcohol use (past 30 days) % Any alcohol use Average number of days of alcohol use % Any alcohol use to intoxication***

Average number of days of alcohol use to intoxication*

Illicit drug use Cocaine (past 30 days)

% Any cocaine use***

Average number of days of cocaine use***

Marijuana (past 30 days)

% Any marijuana use***

Average number of days of marijuana use*

Sedatives (past 30 days) % Any sedative use Average number of days of sedative use

Other opiates (past 30 days) % Any other opiates use*

Average number of days of other opiate use Amphetamine (past 30 days)

% Any amphetamine use*

Average number of days of amphetamine use**

Hallucinogens (past 30 days) % Any liallucmogen use Average number of days of hallucinogen use

Multiple drug use (past 30 days) % Any multiple drug use*

Average number of days of multiple drug use

Legal status and criminal involvement Arrested past six months

% Arrested***

Average number of times arrested***

Arrested past 30 days % Arrested*

Average number of times arrested Incarcerated past 30 days

% Incarcerated*

Average number of days incarcerated

Employment and support % Unemployed past six months**

% Paid for work in past 30 days**

Average number of days paid for work in past 30 days % Independent living % Dependent living**

Health and mental health services % Hospitalized in past six months % Visited emergency room in past six months***

% Psychiatric hospitalization past six months Average number of days ill in past 30 days**

*p < .05 **p < .01 ••• < .001

Journal of Psychoactive Drugs 63

Baseline

35 3 . 1

27 2. 1

10 .8

25 2.8

15 2.3

1 8 2.7

5 .2

I .05

23 2.6

50 .7

9 . I

22 3.6

25 43

7.7 85 15

1 2 34

6 4.0

Outcome Six-Month Follow Up

30 2.4

18 1 .4

3 .2

16 1 .9

1 3 2.2

14 2.2

3 .03

I .02

16 2.0

23 .3

6 .01

17 3.5

1 6 54 1 0.5 77 23

I I 24

4 5.4

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18% at follow-up [x2(n = 556) = 1 3.60, p < .00 1 ], as did the average number of days during which they had drunk to intoxication [t (555) = -2 .5 1 , p < .05].

In terms of illicit drug use, changes from baseline to follow-up were most pronounced for cocaine, marijuana, and use of multiple drugs. Significantly fewer clients reported cocaine use in the 30 days before the follow-up up interview [x2(n = 557) = 2 1 .32, p < .001 ], and the average number of days cocaine had been used dropped similarly [t (556) = -4. 1 9, p < .001 ]. A smaller proportion of clients were using marijuana at follow-up when compared to baseline measures [x2(n = 557) = 21 .32, p < .001 ], and a statistically significant drop in the average number of days used was evident [t (556) = -2.44, p < .05] . Finally, a significantly smaller proportion of clients reported multiple use of drugs at follow-up than at baseline [x2(n = 55 1 ) = 6.97, p < . 0 1 ] .

Legal status and criminality. Clients also reported significantly less involvement in the criminal justice system at follow-up (see Table 2). For example, 50% of the sample had been arrested in the six months before baseline, but only 23% reported they had been arrested during the six months before the follow-up interview [x2(n = 555) = 92.89, p < .001 ] , which led to significantly fewer arrests reported at follow-up [t (556) = -6.75, p < .001] . Reductions in the percentage arrested (9% versus 6%) and in the percentage incarcerated (22% versus 17%) in the previous 30 days were modest.

Employment and support. Overall, findings showed that treatment was associated with improved employment status at follow-up, including fewer clients who were un­employed [x2(n = 556) = l6.24, p < .00 1 ] , more who were paid for working at a job [x2(n = 558) = 2 1 .88, p < .001 ] , and significantly more days worked for pay [ 1 0.5 versus 7.7 at baseline, t (557) = 6.03, p < . 00 1 ] . However, as shown in Table 2, a significantly larger proportion of clients reported they were in dependent living arrangements at follow-up [x2(n = 556) = 1 6.24, p < .001 ] .

Health and mental health services. Findings for health services use following treatment were mixed (see Table 2). Significantly fewer clients had been to the emergency room at follow-up (24%) when compared to the baseline measure [34%, (n = 555) = I8.65,p < .00 I ]. However, clients reported a significantly larger average number of sick days at follow­up [5.4 versus 4.0 at baseline, t (555) = 3.08 , p < .0 1 ] .

Treatment Modality and Outcomes Findings for comparison of client outcomes by treat­

ment modality (described more fully below) generally showed that STI clients presented to treatment at baseline with more serious alcohol and drug use problems, greater involvement in the criminal justice system, higher rates of unemployment and more recent use of health services, in­cluding overnight hospital stays and visits to the emergency room. Also, findings showed that outcomes six months after treatment were more posit ive for STI clients, possibly

Journal of Psychoactive Drugs 64

Client Outcomes from Rural Substance Abuse Treatment

because they had greater room for improvement (that is, more problems at intake) than those in ODF.

Alcohol and drug use. As noted previously, alcohol and drug use decreased over time, but analyses shown in Table 3 indicated that clients in short-term inpatient (STI) treatment had more serious initial involvement with alcohol than those in outpatient drug-free (ODF) treatment lFgroup( I , 556) = I I .24,p < .O I ], and they showed significantly greater reductions in alcohol use [Finteraction{ l , 556) = 7.26, p < .00 I ] and use of alcohol to intoxication in the past 30 days

[Finteraction( l , 554) = 15.23, p < .OOI ] . Similarly, cl ients in STI treatment reported greater overall use of cocaine, marijuana, sedatives, amphetamines, and multiple drugs, and significantly greater reductions in the use of these drugs over time. For example, STI clients reported an average of 4.6 days of multiple drug use in the last 30 days on the baseline interview, which fell to an average of I .8 days at the follow­up interview. Multiple drug use increased among those in ODF treatment from an average of .5 days to 2.2 day in the past 30 [Finteraction{ l , 549) = 39.94, p < .OOI ] . There were no statistically significant between-modality differences in the proportion of clients who were abstinent from alcohol, drugs, or both alcohol and drugs at follow-up. For example, 39% of those who received ODF treatment and 35% of the STI clients reported they had abstained from both drugs and alcohol in the previous six months.

Legal status and criminality. Marked reductions in criminal justice involvement were evident, and analysis of criminal justice involvement revealed two significant main effects for time, three for modality, and three time by modal­ity interactions (see Table 3).

· More specifically, clients in

STI treatment showed significantly greater reductions in the proportion arrested in the previous six months [Finteraction< I , 553) = 4.66, p < .05], percent incarcerated in the prior 30 days

[Finteraction{ l , 553) = 17.58, p < .OO I ] , and the number of days incarcerated [Finteraction( l , 553) = 1 3.69, p < . 0 1 ] .

Employment and support. As shown in Table 3, STI clients were significantly less likely to be unemployed at fol­low-up than they were at baseline [Finteraction< 1 , 554) = 5.09, p < .05] , and reported a significant increase in the number of days they were paid for work [Finteraction< I , 553) = 24.24, p < .OO I ] . However, significantly more were in dependent living arrangements at six-month follow-up (25%) than at baseline (7%) [Finteraction( I , 555) = 25.09, p < .05] .

Health and mental health services. Health services uti l izations dropped significantly more over time in the STI group (see Table 3), including overnight hospital stays

[Finteraction( I , 556) = 5.58, p < .05 ] and visits to the emer­gency room [Finteraction( l , 553) = 8.2 I , p < .05] in the past six months.

DISCUSSION

Findings from the current study suggest that rural sub­stance abuse treatment programs have a positive impact on

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Hiller et al.

their clients' li ves, especially in terms of alcohol and drug abuse, criminal involvement, and employment outcomes. Within subjects comparisons that used each client's baseline behavior as a control showed that alcohol use to intoxica­tion, cocaine, marijuana, and use of multiple drugs dropped markedly from baseline to follow-up. Similarly, a much smaller percentage of the clients reported they had been ar­rested in the preceding six months, dropping from 50% of the sample at baseline to 23% at follow-up. A significantly smal ler percentage of clients were unemployed at follow­up, and overall , clients reported significantly more days in which they were paid for work. Health services util ization also decreased from baseline to fol low-up, including fewer who had been to the emergency room in the previous six months.

Analyses of outcomes by type of treatment modality (i.e. , outpatient drug-free and short-term inpatient) showed that clients placed in short-term inpatient (STI) had more serious problems at treatment entry with alcohol and drug use, the criminal justice system, employment and support, and greater use of health services. Consistent with findings reported for urban-based STI programs that participated in the DATOS project (Hubbard et al . 1 997; Broome, Simpson & Joe 2002), clients in STI in rural areas showed positive outcomes from this brief but intensive treatment modality. Clients in STI showed reduced use of alcohol, cocaine, mari­juana, sedatives, other opiates, and multiple drugs during a six-month post-discharge follow-up interval. S imilarly, a dramatic decrease (i .e., 60% to 27%) in the percentage of clients reporting they had been arrested i n the previous six months was evident. Employment and support outcomes were positive, with significant reductions the number of cli­ents unemployed at follow-up (28% to 15% ), and significant increases in the number who reported being paid for work in the past 30 days (34% to 55%). Fewer of the clients in STI reported subsequent use of health services, including overnight hospital stays and visits to the emergency room.

Although improvement in treatment outcomes was less dramatic for the ODF programs (perhaps because they presented to treatment with fewer problems initially and thus had a more limited range that they could improve), clients benefited from treatment in this modali ty as well. In analyses not presented here in tabular form, ODF clients showed sig­nificantly less involvement in the criminal justice system at follow-up ( 19%) than at baseline ( 40% ). Fewer ODF clients were unemployed at follow-up than at baseline, and fewer were treated i n the emergency room in the preceding six months. Paradoxically, a significant increase in the use of other opiates was found for those in ODF, with an average of 1 .8 days at baseline and three days out of the past 30 days at follow-up. Oxycontin emerged as a drug of abuse in central and eastern Kentucky during the time interval examined in the current study, and the increase in other opiate use at follow-up was l imited to the Eastern and South Central Re­gions covered in the study; the Western region saw no such

Journal of Psychoactive Drugs 66

Client Outcomes from Rural Substance Abuse Treatment

increase. When considered together, these findings suggest that clients involved in substance abuse treatment in eastern and central Kentucky were vulnerable to the regional shift in drug abuse patterns that occurred throughout those parts of the state.

As hypothesized, outcomes from rural treatment pro­grams were comparable to findings for urban programs in the three national outcomes studies. Like findings from DARP, TOPS, and DATOS, alcohol and drug use decreased significantly over time in the current study, as did criminal invol vement. Employment rates increased significantly. Although rural programs must operate in settings with many barriers to treatment entry, including distance and lack of public transportation and chronic poverty, these programs affect the outcomes of their clients in a manner similar to programs in larger cities. Also l ike urban programs, rural treatment centers currently are being modified under the pressure of reduced government funding for treatment, man­aged care, and continuing unmet need for services (Rivers, Komaroff & Kibort 1 999). Therefore, continued monitor­ing of program outcomes nested within changing services delivery systems is needed.

Two findings emerged in the current study that seem to require additional consideration. The first, the results that showed significantly more clients at follow-up were in a dependent l iving arrangement, suggests that more needs to be done in rural treatment programs to fi nd adequate living arrangements for their clients as they move back into and be­gin to function again in their communities. This represents a significant challenge for rural treatment programs, however, because opportunities for subsidized housing are l imited in the areas these programs serve. The second finding, clients' reporting more sick days at follow-up, appears inconsistent with findings that fewer medical services were used at fol­low-up. It is unclear whether this indicates that people were more l ikely to be i l l and not seek medical care, or whether this represents an artifactual finding resulting from how the question was asked. Interviewers were instructed to include common il lness (like having a common cold or influenza) as well as chronic i l lnesses (including cirrhosis of the l iver) in the answers to this question. Perhaps different findings would have emerged if acute and chronic health problem questions had been asked separately. Alternatively, it may be that when clients enter recovery that they are more readily able to attend to their health and other activities, thus leading to the report of more i l lness days.

Limitations to the current study include factors associ­ated with relying on self-reported information and telephone interviews at follow-up. Findings and generalizations from the current data are l imited because self-reported data were the only outcome indicators available for analysis. Although this methodological approach is similar to that typically used in the substance abuse treatment effectiveness studies, inclusion of a biological assay (e.g., urine or hair specimen) for testing for recent drug use would have allowed for the

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determination of how valid self-reports were in the current study. Self-reported data in drug abuse treatment studies, however, have been consistently found to be both valid and reliable indicators of posttreatment performance (Fletcher, Tims & Brown 1 997). It also should be acknowledged that fol low-up data was collected primarily through a telephone interview (88%, 1 2% were collected face-to-face), which could have led to a bias in the fol low-up interview rates of clients in very rural areas with limited telephone coverage. However, every effort was made to contact and interview all cl ients at fol low-up, including those in very rural areas. For cl ients without a phone, interviewers traveled to their home and conducted a face-to-face interview. With 93% of the baseline clients interviewed, and 95% located, it seems unl ikely that very rural clients were underrepresented in the fol low-up interviews completed.

Statements about the effectiveness of rural-based sub­stance abuse treatment also are necessarily limited for the current study because clients were not randomly assigned to treatment, and a nontreatment control group was not used. Instead, a within subjects design was used that compared each individual's behavior at follow-up (approximately six months after treatment discharge) with what they reported on the baseline interview at treatment entry. Although this approach allows for the analysis of change over time, it i s unclear whether cl ients improved because they were in treatment or because of some other unmeasured factor. Ideally, a controlled experimental design should have been used where each client was randomly assigned to ODF, STI, or a nontreatment comparison group, but these types of efficacy studies are rare in the substance abuse treatment l iterature because of the ethical and conceptual issues this experimental approach raises in field-based settings.

To help compensate for the lack of experimental control in the current study, future analysis of this data set will use multivariate modeling to address additional variables that

Client Outcomes from Rural Substance Abuse Treatment

could act as potential predictors of treatment outcomes. These analyses will examine the relative impact of several client background factors shown to be related to treatment outcomes in DARP, TOPS, and DATOS and other outcome evaluations of substance user treatment, including gender (Chatham et al . 1 999), age (Joe, Simpson & Broome 1999), subsequent treatment in the community (Broome, Simpson & Joe 2002), and problem severity level (Simpson et al. 1 999; Woody et al . 1984). Length of treatment stay and the intensity of service contact (e.g., number of services contacts) also will be examined in relation to outcomes. Longer length of stay and the number of services contacts frequently are reported as consistent predictors of better outcomes among clients in urban-based treatment programs (Simpson, Joe & Brown 1 997; Howard et al. 1 996; Condelli & Hubbard 1 994; De Leon 1984; Simpson 198 1). Examining the mosaic of treatment outcomes in a more complex and multivariate manner that considers both client background factors and treatment-level variables will allow us to deter­mine whether these factors show the same relationship to outcomes from rural-based treatment.

Based on the findings of this study from Kentucky, rural practitioners should note that outcomes from their programs may parallel findings from national evaluations that focus primarily on urban settings. Rural programs may have a positive impact on their clients' l ives, possibly influencing clients to reduce alcohol and drug use, criminality, and health services utilization. Even in economically deprived regions, these programs may help clients become employed. However, the current study is only the first look at a complex dataset for determining correlates of treatment outcome from rural treatment programs. Additional study is needed to ex­amine client factors and treatment events and their relation to outcomes. It is expected that these more complex analyses will yield valuable information for program planning and treatment services delivery.

REFERENCES

Broome, K.M.; Simpson, D.O. & Joe, G.W. 2002. The role of social support following short-term inpatient treatment. American Journal on the Addictions I I : 57-65.

Brown, B.S. ; Voskuhl, T.C. & Lehman, PE. 1 977. Comparisons of drug abuse clients in urban and rural settings. American Journal of Drug and Alcohol Abuse 4 (4): 445-54.

Chatham, L.R. ; Hiller, M.L. ; Rowan-Szal, G.A.; Joe, G.W. & Simpson, D.O. 1999. Gender differences at admission and follow-up in a sample of methadone maintenance clients. Substance Use and Misuse 38 (4): 1 137-65.

Clark, J .J . ; Leukefeld, C. G. ; Godlaski, T.; Brown, C. ; Garrity, T. & Hays, L. 2002. Developing, implementing, and evaluating a treatment protocol for rural substance abusers. Journal of Rural Health 18 (3): 396-406.

Condelli, W.S . & Hubbard, R.L. 1994. Relationship between time spent in treatment and outcomes from therapeutic community treatment. Journal of Substance Abuse Treatment I I : 25-33.

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De Leon, G . 1984. The Therapeutic Community: Study of Effectiveness. NIDA Research Monograph, DHHS Publication No. ADM 84- 1286. Rockville, MD: National Institute on Drug Abuse.

Fletcher, B.W.; lims, F.M. & Brown, B.S. 1997. Drug abuse treatment outcome study (DATOS): Treatment evaluation research in the United States. Psychology of Addictive Behaviors I I : 2 16-29.

Fortney, J. & Booth, B.M. 200 I . Access to substance abuse services in rural areas. Recent Developments in Alcoholism 15 : 177-97.

Howard, K.l. ; Moras, K.; Brill, PL.,; Martinovich, Z. & Lutz, W. 1996. Evaluation of psychotherapy: Efficacy, effectiveness, and patient progress. American Psychologist 5 1 : I 059-64.

Hubbard, R.L. ; Craddock, S.G. ; Flynn, P.M. ; Anderson, J. & Etheridge, R.M. 1997. Overview of ! -year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors I I (4): 26 1 -78.

Hubbard, R.L.; Marsden, M.E.; Rachal , J .V. ; Harwood, H.J . ; Cavanaugh, E.R. & Ginzburg, H.M. 1989. Drug Abuse Treatment: A National

Volume 39 ( 1 ), March 2007

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Hiller et al.

Study of Effectiveness Chapel Hill, NC: University of North Carolina Press.

Joe, G.W.; Simpson, D.O. & Broome, K.M. 1999. Retention and patient engagement models for different treatment modalities in DATOS. Drug and Alcohol Dependence 57: 1 13-25.

Leukefeld, C.G. & Edwards, R.W. 1999. Recommendations to bridge rural/urban drug-use(r) research and practice. Substance Use and Misuse 34 (4-5): 785-93.

Leukefeld, C. G. & Godlask.i, T. 1997. Perceptions of rural addictions and related HIV. Substance Use and Misuse 3 1 ( I ): 83-88.

McLellan, A.T.; Cacciola, J . ; Carise, D. & Coyne, T.H. 1999. Addiction Severity lnde.x Lite-CF: Clinica/ffraining Version. Philadelphia, PA: University of Pennsylvania.

McLellan, A.T.; Kushner, H.; Metzger, D.; Peters, R.; Smith, I.; Grissom, G.; Pettinati, H. & Argeriou, M. 1 992. The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment 9: 199-2 13.

Metsch, L.R. & McCoy, C. B. 1999. Drug treatment experiences: Rural and urban comparisons. Substance Use and Misuse 34 (4-5): 763-84.

Rivers, J.E.; Komaroff, E. & Kibort, A.C. 1999. Access to health and human services for drug users: An urban/rural community systems perspective. Substance Use and Misuse 34 (4-5): 707-25.

Schoeneberger, M.L.; Leukefeld, C.G.; Hiller, M.L. & Godlask.i, T. 2006. Substance abuse among rural and very rural substance abusers at treatment entry. American Journal of Drug and Alcohol Abuse 32: 87- 1 10.

Sells, S.B. & Simpson, D.O. (Eds.) 1 976. The Effectiveness of Drug Abuse Treatment: Vol. 3. Further Studies of Drug Users, Treatment Typowgies, and Assessment of Outcomes During Treatment in the DARP. Cambridge, MA: Ballinger.

Simpson, D.O. 1997. Effectiveness of drug abuse treatment: A review of research from field settings. In: J.A. Egertson; D.M. Fox & A. I.

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Leshner (Eds.) Treating Drug Abusers Effectively. Cambridge, MA: Blackwell Publishers of North America.

Simpson, D.O. 1 984. National treatment system evaluation based on the Drug Abuse Reporting Program (DARP) follow-up research. In: F.M. lims & J.P. Ludford (Eds.) Drug Abuse Treatment Evaluation: Strategies, Progress Prospects. NIDA Research Monograph Series 5 1 , DHHS No. ADM 84-1329. Washington, DC: U.S. Government Printing Office.

Simpson, D.O. 1 98 1 . Treatment for drug abuse: Follow-up outcomes and length of time spent Archives of General Psychiatry 38: 875-80.

Simpson, D.O. & Sells, S.B. (Eds.) 1990. Opioid Addiction and Treatment: A 12-Year Follow-up Malabar, FL: Krieger. .

Simpson, D.O. & Sells, S.B. 1982. Effectiveness of treatment for drug abuse: An overview of the DARP research program. Advance in Alcohol Substance Abuse 2 1 : 7-29.

Simpson, D.O.; Joe, G.W. & Broome, K.M. 2002. A national 5-year follow-up of treatment outcomes for cocaine dependence. Archives of General Psychiatry 59: 538-44.

Simpson, D.O., Joe. G.W. & Brown, B.S. 1997. Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors I I : 294-307.

Simpson, D.O.; Joe, G.W.; Aetcher, B.W.; Hubbard, R.L. & Anglin. M.D. 1999. A national evaluation of treatment outcomes for cocaine dependence. Archives of General Psychiatry 56: 507- 14.

Warner, B.D. & Leukefeld, C. G. 200 I. Rural-urban differences in substance use and treatment utilization among prisoners. American Journal of Drug and Alcohol Abuse 27: 265-80.

Woody, G.E.; McLellan, A.T.; Lubarsky, L.; O'Brien, C.P. ; Blaine, J . ; Fox, S. ; Herman, I. & Beck, A.T. 1984. Severity of psychiatric symptoms as a predictor of benefits for psychotherapy: The Veterans Administration-Penn study. American Journal of Psychiatry 141 : 1 172-77.

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