Evaluating racial disparity in referral source and successful completion of substance abuse treatment

Addictive Behaviors 48 (2015) 25–29

Contents lists available at ScienceDirect

Addictive Behaviors

Evaluating racial disparity in referral source and successful completion of substance abuse treatment Ethan Sahker a,b, Maisha N. Toussaint c, Marizen Ramirez d, Saba R. Ali b, Stephan Arndt a,e,f,⁎ a

Iowa Consortium for Substance Abuse Research and Evaluation, 100 MTP4, University of Iowa, Iowa City, IA 52245-5000, USA Department of Psychological and Quantitative Foundations, Counseling Psychology Program, College of Education, University of Iowa, 361 Lindquist Center, Iowa City, IA 52242, USA Department of Epidemiology, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA d Department of Occupational and Environmental Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, 100 CPHB, Iowa City, IA 52242, USA e Department of Psychiatry, Carver College of Medicine, University of Iowa, 451 Newton Road, 200 Medicine Administration Building, Iowa City, IA 52242, USA f Department of Biostatistics, College of Public Health, University of Iowa, 145 N. Riverside Drive, 100 CPHB, Iowa City, IA 52242, USA b c

H I G H L I G H T S • • • •

Race moderates the difference between referral and successful treatment completion. Employment referral is associated with greater completion for Black clients. Criminal justice referral is associated with greater completion for White clients. Multicultural considerations may improve successful treatment completion.

a r t i c l e

i n f o

Available online 18 April 2015 Keywords: Health disparity Race Referral source Substance abuse Treatment outcomes

a b s t r a c t Health disparity is a significant problem in the United States, and particularly for substance abuse treatment programs. A better understanding of racial differences in treatment pathways associated with successful treatment completion is needed to reduce the existing health disparities. Referral source is a strong predictor of treatment success and most research on health disparities has focused on the criminal justice referrals. However, little research has examined other types of referral sources, and the interaction with race. The current study sought to compare the effect of referral sources on national substance abuse successful treatment completion rates between Black clients (n = 324,625) and White clients (n = 1,060,444) by examining the interaction of race on referral source and successful treatment completion. Race significantly moderated the difference between referral source and successful treatment completion (Wald χ2 = 1477.73, df = 6, p b 0.0001). Employment referral was associated with the greatest percentage of successful treatment completion for Black clients. Criminal justice referral was associated with the greatest percentage of successful treatment completion for White clients. Results from the present study support a reevaluation of incentives leading to successful treatment completion with a multicultural perspective. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction Health disparity is a significant problem in the United States and a growing problem for substance abuse treatment programs. For instance, Whites are nearly two times more likely to exhibit and report substance dependence within the past year than Blacks (Arndt, Vélez, Segre, & Clayton, 2010). Once clients are placed in treatment, Blacks are two times less likely to complete substance abuse treatment than Whites (Arndt, Acion, & White, 2013; Bluthenthal, Jacobson, & Robinson, ⁎ Corresponding author at: 100 MTP4, University of Iowa, Iowa City, IA 52245-5000, USA. Tel.: +1 319 335 4488; fax: +1 319 335 4484. E-mail address: [email protected] (S. Arndt).

http://dx.doi.org/10.1016/j.addbeh.2015.04.006 0306-4603/© 2015 Elsevier Ltd. All rights reserved.

2007; Guerrero et al., 2013; Saloner & Lê Cook, 2013). The pathways to, and barriers against, treatment services may account for racial and ethnic disparities (Schmidt, Greenfield, & Mulia, 2006). For example, minorities experience more barriers to care, as well as poorer quality of care (Schmidt et al., 2006; Wells, Klap, Koike, & Sherbourne, 2001). A better understanding of treatment pathways associated with racial groups' successful treatment completion is important in order to reduce the existing racial disparity in treatment outcomes and improve programming (Burlew et al., 2011; Guerrero & Andrews, 2011; Guerrero et al., 2013; Mulvaney-Day, DeAngelo, Chen, Cook, & Alegría, 2012). Referral source as a pathway to treatment is a strong indicator of successful treatment completion (Arndt et al., 2013; Atkinson, Misra, Ryan, & Turner, 2003). For example, clients referred through employers

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and criminal justice pathways are associated with the highest percentage of successful treatment completion, while self-referrals and healthcare referrals are associated with the lowest percentage of successful treatment completion (Arndt et al., 2013). A substantive body of research on referral sources within the criminal justice system exists due to the large volume of offenders in treatment (Defulio et al., 2013). Court appointed referrals are associated with the highest treatment completion rates (Atkinson et al., 2003; Defulio et al., 2013; Guerrero et al., 2013). However, racial and ethnic differences appear to occur in treatment and referral source. In one study in Oklahoma, Native Americans, Blacks, and Hispanics were associated with differential positive outcomes compared to Whites in both criminal justice and healthcare referral sources (Acevedo et al., 2013). These findings have strong implications for differential treatment completion among racial groups, but little research has specifically evaluated how different types of referral sources are associated with successful treatment completion among racial groups. A number of internal and external factors that differ by race/ethnicity may be associated with successful treatment completion. Coercion is one factor involved in the high rates of successful treatment completion among clients referred by criminal justice sources (Defulio et al., 2013; Wild, Cunningham, & Ryan, 2006; Wild, Newton-Taylor, & Alletto, 1998). In the criminal justice setting, the coercive incentive would be incarceration as punishment. However, Wild et al. (2006) suggest that coercion may be a factor in other referral sources based on client perceptions of coercive incentive. Other coercive incentives may be threat of job loss or health complications as negative consequences. Furthermore, cultural perceptions of coercive incentive may differ, thus, affecting treatment outcomes (Arfken, Said, & Owens, 2012). Differences among successful treatment completion due to referral source may be moderated by racial differences. While most of the treatment research on health disparities has focused on the criminal justice system, little research has examined other types of referral patterns in the nonincarcerated population. Successful treatment completion is a clinically utile outcome measure predicting longer-term outcomes such as criminal involvement and treatment readmission (Evans, Li, & Hser, 2009; Garnick, Lee, Horgan, & Acevedo, 2009; Zarkin, Dunlap, Bray, & Wechsberg, 2002). Successful treatment completion rates can be used to assess national and state-level systems (Alterman, Langenbucher, & Morrison, 2001; Garnick et al., 2009). The current study seeks to compare the effect of referral sources on substance abuse successful treatment completion rates between Blacks and Whites. First, we evaluated demographic and treatment variables' predictive of successful treatment completion to be used as covariates. Then, we examined the interaction between race and referral source on successful treatment completion. We hypothesize that the referral sources may differ in successful treatment completion for the Black and White groups.

medication assisted opioid therapy (e.g., methadone) were included (n = 7,071,833), as this is often an ongoing, lifetime treatment that may misrepresent treatment retention rates. TEDS-D includes all admissions/discharges rather than individuals. We selected only those records where the client indicated that he or she had no prior treatment in a drug or alcohol program (n = 2,519,308). By only including admissions with no prior treatment history, we ensure a non-duplicative group of individuals admitted and discharged from treatment for the first time. We also restricted the data to records reported from non-intensive outpatient and ambulatory intensive outpatient settings (n = 1,678,472), which excluded brief or acute intervention data from in-patient and detoxification settings. Only clients identifying as White non-Hispanic (n = 1,060,444) or Black (n = 324,625) were included for racial disparity comparisons. The final inclusion criteria resulted in 1,385,069 observations. Because these data represent de-identified existing public information there was no informed consent and the University of Iowa Human Subjects Office, Institutional Review Board exempted this study.

2. Methods

Treatment characteristics used in this study were referral source, number of substances, primary problem substance, and age at first use (of primary problem substance). Referral source included the seven categories of individual/self-referral, alcohol/drug abuse agency, healthcare professional, school, employer/EAP, other community referral, and criminal justice agency. Primary problem substance (i.e., alcohol, marijuana, cocaine, heroin, and methamphetamine) was recorded on admission self-reports. Age at First Use refers to the clients' first experience with their primary problem substance. In addition, several drug categories were collapsed for analysis due to low percentages. Non-prescription methadone and opiates and synthetics were collapsed into an “other opiates and synthetics” category. Other hallucinogens and PCP were collapsed into one “other hallucinogens” category. Benzodiazepines, other non-benzodiazepine tranquilizers, barbiturates, and other non-barbiturate sedatives or hypnotics were collapsed into an “other non-barbiturates” category. Other stimulants and other amphetamines were collapsed into an “other stimulants” category. Inhalants,

2.1. Data sources The Substance Abuse and Mental Health Services Administration (SAMHSA) requests admission and discharge information from all public and private treatment facilities receiving public funding in the United States. The treatment facilities include those found in urban and rural counties. These data are available as the Treatment Episode Datasets—Discharge (TEDS-D). We used the concatenated 2006–2008 dataset (United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, & Office of Applied Studies, 2009) and the 2009 dataset (United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, & Office of Applied Studies, 2010) providing 5 years of discharge data (N = 8,096,795). We then selected only clients ages of 18 and older (n = 7,499,046). In addition, clients not receiving

2.2. Primary outcome variable The primary outcome variable of successful treatment completion was coded into several categories by treatment agency staff. We dichotomized successful treatment completion as “Treatment Completed” versus all other reasons (e.g., left against professional advice, terminated by facility, incarcerated, transferred, other). We then compared successful treatment completion percentages with race and referral source. We also ran a complete set of analyses using only the “Treatment Completed” versus left against professional advice. As the results were not appreciably different, we only report only the contrast with all other reasons. 2.3. Demographic variables At admission, agency staff identified patients' demographic and treatment characteristics by interview. Individual treatment facility staff collects demographic characteristics at admission and reports data to SAMHSA. The current study analyzed age, gender, race/ethnicity, education, region, and living arrangements. Age was recoded into a categorical variable by SAMHSA for confidentiality purposes. In addition, we categorized race and ethnicity into two groups. The White group included all Caucasians who did not indicate Hispanic/Latino ethnicity (n = 1,060,444, 76.56%). The Black group included all admissions indicating their race as Black/African American regardless of ethnicity (n = 324,625, 23.44%). 2.4. Treatment variables

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over-the-counter medications, other low frequency drugs, and no primary substance were added to an “other” category.

Table 1 Demographics and treatment characteristics. Black (%) n = 324,625

White (%) n = 1,060,444

69.76 30.24

64.31 35.69

4.76 33.68 43.11 15.82 2.62

4.85 22.02 45.03 21.17 6.92

34.67 9.79 7.42 18.92 29.20

52.69 4.44 4.82 16.31 21.74

6.84 22.13 71.02

3.58 18.01 78.41

10.17 14.90 16.99 12.67 10.99 11.32 10.62 6.96 5.38

12.12 17.12 17.55 12.24 11.00 10.48 9.10 5.53 4.87

5.57 17.74 30.11 20.11 11.22 6.92 3.68 2.20 1.26 0.71 0.34 0.17

5.53 18.41 35.57 20.31 8.99 4.69 2.67 1.71 1.10 0.60 0.27 0.16

Individual Alcohol & drug care provider Other healthcare provider School Employer Community referral Criminal justice Primary substance ⁎⁎⁎

18.61 4.13 4.61 0.40 1.24 16.18 54.83

20.18 4.05 5.21 0.37 1.23 12.40 56.57

Alcohol Cocaine/crack Marijuana/hashish Heroin Other opiates/synthetics Other hallucinogens Methamphetamine Other stimulants Other non-barbiturate/sedatives Other Number of substances ⁎⁎⁎ One Two Three

33.00 18.74 37.94 4.46 0.85 0.77 1.65 0.31 0.21 2.08

51.18 6.87 18.70 2.94 5.76 0.14 10.93 0.70 0.99 1.79

49.15 38.06 12.79

49.72 33.71 16.57

2.5. Data analysis All data analyses were conducted using SAS 9.35 and STATA 13.1 to assure data integrity. Descriptive tables of client and substance use characteristics were generated for Black and White subjects. Covariates such as age, referral source, number of substances used, and age at first use were assessed initially using chi-square tests. Because of the very large sample size and multiple tests, trivial differences have the potential to be statistically significant. To avoid misidentifying trivial significance, we only considered p b 0.0001 as significant. Measures of association between demographics and treatment characteristics were measured using risk difference (RD). RDs greater than 5 percentage points were considered clinically meaningful measures of effect. Multivariable logistic regression models were constructed to control for potential confounders and account for unequal group samples. The final multivariable logistic regression included the covariates and the race to predict successful treatment completion. The primary test of our hypothesis will analyze the effects of referral source differences in our two groups and will assess the interaction of race group and referral source. 3. Results The overall successful treatment completion rate for all clients was 44.27%. The simple successful treatment completion rate for Whites was 47.14% and for Blacks was 34.90%. Generally, Black clients were significantly less likely to successfully complete treatment (z = 122.83, p b 0.0001) and the effect size was considered clinically meaningful (RD = 12.24, 95% CI = 12.05–12.43). Table 1 shows the descriptive percentages of demographics and treatment characteristics between Black and White clients in the sample. Race significantly moderated the difference between referral source and successful treatment completion (Wald χ2 = 1477.73, df = 6, p b 0.0001) with clinically meaningful differences. Fig. 1 illustrates the interaction effect. Differences were present between races in successful treatment completion rates by referral source. For White clients, criminal justice referral sources are associated with the greatest percent of successful treatment completion (Wald z = 715.64, p b 0.0001). For Black clients, employer referral sources are associated with the greatest percentage of successful treatment completion (Wald z = 52.92, p b 0.0001). In addition, school referral sources were associated with the second highest percentage of successful treatment completion for both Black and White groups. Health care referral sources were associated with the lowest percentage of successful treatment completion for both Black (Wald z = 60.77, p b 0.0001) and White groups (Wald z = 123.26, p b 0.0001). 4. Discussion The source of referral had pronounced effects on successful treatment completion and these effects differed by race group, supporting our hypothesis. Coercion may play a role as a factor fostering successful treatment completion. However, research in the influence of coercion is ambivalent (Urbanoski, 2010; Wild et al., 2006; Wolfe, Kay-Lambkin, Bowman, & Childs, 2013). Perhaps the influence of coercion is associated with racial and cultural differences in perceived coercive value (Arfken et al., 2012; Mulvaney-Day et al., 2012; Saloner & Lê Cook, 2013) and this has not yet been accounted for in the research. The coercive incentive of referral sources results from an ultimatum. One either completes treatment, or consequently loses freedom, employment, or education. Thus, the coercive incentive from criminal justice, employer, or school referral sources may be valued differently because of racial and cultural differences. For instance, Blacks are disproportionally

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Demographic Sex ⁎⁎⁎ Male Female Education⁎⁎⁎ ≤8 years 9–11 years 12 years 13–14 16 ≤ Primary income ⁎⁎⁎ Salary/wages Public assistance Retirement/disability Other None Living arrangement ⁎⁎⁎ Homeless Dependent living Independent living Age ⁎⁎⁎ 18–20 21–24 25–29 30–34 35–39 40–44 45–49 50–54 55+ Treatment characteristic Age at first use ⁎⁎⁎ ≤11 12–14 15–17 18–20 21–24 25–29 30–34 35–39 40–44 45–49 50–54 55+ Referral source ⁎⁎⁎

Boldface, large risk difference. Percentages may not equal 100% due to rounding. ⁎⁎⁎ Chi square p b .0001.

incarcerated in the United States which has led to a decrease in trust for law enforcement officials and the criminal justice system (Bobo & Thompson, 2006). We cannot say for certain why the difference in

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Fig. 1. Percent successful treatment completion by race and referral source. Note. Percentages represent successful treatment completion from treatment setting at discharge, treatment setting at admission may differ; error bars represent 95% confidence intervals.

successful treatment completion and race exists, but perhaps the threat of incarceration may pose less incentive to Blacks because they may believe that their behavior has little impact on the consequence. Referral sources that employ higher levels of coercion were more associated with successful treatment completion than those with less coercive incentive. Criminal Justice, Employer, and Student referral sources were the greatest for both Black and White clients. Selfreferral and Health Care Provider referrals were the worst for both Blacks and Whites. Criminal Justice, Employer, and Student referral sources all pose significant consequences if treatment is unsuccessfully completed. For substance abuse treatment clients, knowledge of one's health appears to be an ineffective factor fostering successful treatment completion, evidenced by a low rate in health care referral. Blacks had the greatest successful treatment completion when referred by employers. This finding supports the notion that Black clients may derive more motivation to complete treatment successfully if referred through employers. Interventions may improve by focusing on the cultural incentive of value. The effectiveness of drug courts are equivocal but tend to be empirically supported as an intervention associated with decreased recidivism (Wilson, Mitchell, & MacKenzie, 2006). Funding for drug courts is dependent on successful treatment completion rates. However, Black clients are performing better when referred through employers rather than criminal justice agencies. This finding suggests that employment and education support in addiction treatment may improve outcomes for many Black clients. Furthermore, Whites had the greatest rates of successful treatment completion when referred by criminal justice referral sources. The racial disparity in addiction treatment and criminal justice populations may suggest that this is a systemic issue. Blacks may not be as affected by the coercive nature of possible incarceration as Whites. Whites also had high successful treatment completion when referred through their employers. The largest concern for many offenders transitioning into the community is employment readiness (Bucklen & Zajac, 2009), which may also be a factor fostering successful treatment completion. Findings from the current study support the use of employment support services for addiction treatment clients, and in particular, culturally competent services. Interestingly, health care provider referrals were associated with the worst outcomes for both Black and White clients. The present study suggests the current health care approach to addiction treatment may

require more attention to improve further upon the current outcomes associated with health care referrals. For example, doctor follow-ups could improve these outcomes. However, motivation to change is a complex factor that may confound health care provider referrals and doctor follow-ups. In addition, coercion is a factor contributing to successful treatment completion among in criminal justice referral sources (Defulio et al., 2013; Wild et al., 1998, 2006). The present study adds to the literature by demonstrating that Health Care referrals may not foster the same coercive incentives other referral source may provide. 4.1. Limitations This study has limitations worth noting. First, data were collected from self-report, which may have limited validity. For instance, clients may have been referred by Health Care sources, but upon arrival to a treatment facility, they report Self-Referral. Error associated with selfreport cannot be accounted for in the dataset. Second, the present study measures successful treatment completion. Improved measures of success as an outcome variable would analyze long-term reports of substance use and abstinence data beyond the treatment milieu. Future research could employ longitudinal designs analyzing use and dependence outcomes associated with race and referral source. Third, the present analysis of interest was limited to Black and White nonHispanic clients. Hispanics represent a distinctive homogeneous treatment population. However, this exclusion limits the present findings to two racial or ethnic groups. Future studies would greatly add to the literature by examining Hispanic treatment characteristics. Finally, cultural value orientations are not truly accounted for in the results. Cultural differences are inferred based on racial differences in completion. Future research can examine the value of coercive incentives differences between races in addiction treatment programs. 4.2. Clinical implications Results from the present study support a reevaluation of incentives to complete treatment with a multicultural perspective. Client referral sources should consider outcomes predictive of successful treatment completion. Successful treatment completion appears to be a factor of race when comparing Black and White racial groups. For instance

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employment support services are important for both White and Black clients, but more so for Black clients. Incentives for employers who hire substance abuse treatment graduates in employee assistance programs may improve sources for support and more treatment options for employees dealing with substance issues. Employer incentives for treatment options will be especially important for black clients. This research also has implications for employment counselors and vocational psychologists who work with clients on work related issues. These professionals are charged with helping individuals deal with mental health issues that may impede their working lives and ability to maintain gainful employment (Blustein, 2008). Understanding the factors that relate to increased compliance and success of substance abuse treatment programs is crucial to enhance the services that these professionals can provide and helps to interface with employers and health practitioners in making appropriate referrals for substance abuse problems. The deficit in health care referrals suggests a need to evaluate health practitioners' effectiveness in the intervention process. More training and increased doctors' aide responsibilities may improve effectiveness. For example, nurse, social worker, and health psychologist involvement with clients flagged for substance abuse referrals may contribute to better treatment referral outcomes. It is clear that race relates to addiction treatment outcomes in relation to referral source. The current data highlight new areas in referral source effectiveness further improving upon information aiding in effective treatment programming. Role of funding sources This study was conducted without funding. Contributors Mr. Sahker and Dr. Arndt designed the study and wrote the protocol. Mr. Sahker conducted literature searches and provided summaries of previous research studies. Ms. Toussaint, Mr. Sahker, and Dr. Arndt conducted the statistical analysis. Mr. Sahker and Ms. Toussaint wrote the first draft of the manuscript and Drs. Ramirez, Ali, and Arndt edited and contributed to the writing of subsequent drafts. All authors contributed to this work, and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest.

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