SUBSTANCE ABUSE TREATMENT FOR WOMEN CHANGES IN NEED FOR TREATMENT

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SUBSTANCE ABUSE TREATMENT FOR WOMEN: CHANGES IN NEED FOR TREATMENT, TREATMENT UTILIZATION, AND SERVICES PROVIDED, 1985-1999 December 2002 SUBSTANCE ABUSE TREATMENT FOR WOMEN: CHANGES IN NEED FOR TREATMENT, TREATMENT UTILIZATION, AND SERVICES PROVIDED, 1985-1999 Prepared by Christine E. Grella Lisa Greenwell Integrated Substance Abuse Programs Neuropsychiatric Institute University of California, Los Angeles 1640 S. Sepulveda Blvd., Suite 200 Los Angeles, California 90025 December 2002 This document was supported by the Center for Substance Abuse Treatment, Department of Health and Human Services, Caliber/NEDS Contract No. 270-00-7078. The perspective offered in this document is solely that of the author(s) and does not reflect the policies or views of the Federal government, or any of its Departments or Agencies. TABLE OF CONTENTS Page FOREWORD ACKNOWLEDGMENTS ABSTRACT EXECUTIVE SUMMARY ........................................................................................................... i I. INTRODUCTION............................................................................................................. 1 1. OVERVIEW OF MAJOR POLICY INITIATIVES AND RELEVANT WORK.. 1 1.1 1.2 1.3 1.4 2. 3. II. Treatment Needs of Substance-abusing Women ........................................ 2 Substance Abuse Treatment Services for Women...................................... 3 Criminal Justice System Initiatives Affecting Substance-abusing Women........................................................................................................ 6 Welfare Reform and Child Welfare Initiatives Affecting Substanceabusing Women .......................................................................................... 7 PURPOSE AND PARAMETERS OF THE ANALYSIS ...................................... 8 ORGANIZATION OF THIS REPORT.................................................................. 9 METHODS ...................................................................................................................... 11 1. UNITS OF ANALYSIS........................................................................................ 11 1.1 1.2 2. National Household Survey on Drug Abuse (NHSDA) ........................... 11 National Drug and Alcohol Treatment Unit Survey (NDATUS)/ Uniform Facility Data Set (UFDS) ........................................................... 12 MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS .................. 14 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 NHSDA – Need for Treatment and Dependence...................................... 14 NHSDA – Treatment Received in the Past Year ...................................... 15 NHSDA – Characteristics of Women Treated for Alcohol/Drug Use in the Past Year ......................................................................................... 15 NHSDA – Treatment Settings in the Past Year ........................................ 16 NDATUS/UFDS – Primary Substance Treated in Treatment Settings .... 16 NDATUS/UFDS – Type of Treatment Provided in Treatment Settings .. 16 NDATUS/UFDS – Percentage of Women Clients in Treatment Settings...................................................................................................... 17 NDATUS/UFDS – Services Provided in Treatment Settings................... 17 TABLE OF CONTENTS (CONT.) Page 3. 4. III. ANALYTIC METHODS...................................................................................... 18 CONSTRAINTS OF THE ANALYSIS ............................................................... 18 FINDINGS ...................................................................................................................... 22 1. 2. RATES OF WOMEN WHO NEEDED AND RECEIVED TREATMENT FOR ALCOHOL AND DRUG PROBLEMS....................................................... 22 CHARACTERISTICS OF WOMEN WHO RECEIVED TREATMENT........... 24 2.1 2.2 3. 4. Women Treated for Alcohol Problems ..................................................... 24 Women Treated Only for Drug Problems................................................. 29 SETTINGS IN WHICH WOMEN RECEIVED TREATMENT ......................... 33 PERCENTAGES OF WOMEN CLIENTS AND SERVICES PROVIDED TO WOMEN IN TREATMENT SETTINGS............................................................. 36 4.1 4.2 Percentages of Women Clients in Treatment Settings, by Primary Substance Treated and Type of Treatment Provided................................ 37 Types of Services Provided, by Primary Substance Treated and Percentage of Women Clients in Treatment Settings ............................... 41 IV. SUMMARY AND IMPLICATIONS ............................................................................ 46 1. SUMMARY AND DISCUSSION OF KEY FINDINGS FROM THE ANALYTIC QUESTIONS................................................................................... 46 1.1 1.2 1.3 1.4 Changes in the Rates of Women Who Needed and Received Treatment for Alcohol and Drug Problems From 1985 to 1999............... 46 Changes in the Characteristics of Women Who Received Treatment for Alcohol and Drug Problems From 1985 to 1999 ................................ 47 Changes in the Settings in Which Women Received Treatment for Alcohol and Drug Problems From 1985 to 1999...................................... 48 Changes in the Proportion of Women Who Received Treatment in Different Types of Treatment Settings and in the Types of Services Provided in These Settings From 1987 to 1998........................................ 48 TABLE OF CONTENTS Page 2. IMPLICATIONS OF THE FINDINGS FOR TREATMENT PROVIDERS, POLICYMAKERS, AND RESEARCHERS/EVALUATORS............................ 50 2.1 2.2 2.3 Implications for Treatment Providers ....................................................... 50 Implications for Policymakers .................................................................. 51 Implications for Researchers/Evaluators .................................................. 52 REFERENCES............................................................................................................................ 55 APPENDIX A APPENDIX B MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS NHSDA MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS NDATUS/UFDS FOREWORD The mission of the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), is to improve the lives of individuals and families affected by alcohol and drug abuse by ensuring access to clinically sound, cost-effective addiction treatment that reduces the health and social costs to our communities and the nation. As part of its mission, CSAT supports the development of innovative treatment approaches, based on sound data and state-of-the-art analyses, and disseminates information on treatment approaches shown to be effective for curbing addiction and related behaviors. In 1997, CSAT established the National Evaluation Data Services (NEDS) contract to support the CSAT mission. In 2000, through a new contract (Contract No. 270-00-7078), CSAT continued and expanded the scope of NEDS. NEDS activities help to foster collaboration and partnering among the public and private sectors along the Federal-state-local community-based treatment continuum. The three major activities of NEDS, under the current contract, are to assist in developing data infrastructure vehicles and tools, to perform treatment services secondary analyses on existing data, and to support the Government Performance Results Act (GPRA) activities. NEDS, through its Secondary Analysis Technical Reports, provides evidence-based information on substance abuse treatment issues relevant to treatment needs, access, utilization, efficacy, effectiveness, and efficiency. NEDS analyses focus on treatment needs, services received, and populations of interest to the substance abuse treatment field in order to provide new information about which services yield the best outcomes for what types of clients, at what cost. This information helps address treatment issues such as the treatment gap, culturally competent treatment services, and recovery. This report examines the provision of substance abuse treatment to women in the United States from about 1985 to about 1999. This period coincides with several major policy developments that had the potential to affect the delivery of substance abuse treatment services to women. These policy developments included changes in the health care, welfare, child welfare, and criminal justice systems. This report addresses whether and how the provision of substance abuse treatment to women changed over the period coinciding with these changes across policy domains. The findings from this analysis are of relevance to those providing treatment to substance-abusing women, both in substance abuse treatment settings and other settings; to policymakers concerned with improving the organization and delivery of treatment services to substance-abusing women; and to researchers/evaluators interested in studying changes in the delivery of treatment services to women over time and the factors associated with treatment utilization. The findings of the analysis described in this report suggest that major changes in the provision of substance abuse treatment to women corresponded with the dramatic developments in social policies that occurred over the same time period examined. This report suggests areas to consider in developing future policies to improve service delivery to this population. Patrick J. Coleman Project Director National Evaluation Data Services (NEDS) ACKNOWLEDGMENTS We wish to acknowledge our reliance upon the guidance and direction of Ron Smith, the Government Project Officer for the NEDS contract. Caliber Associates is the prime contractor for NEDS in partnership with DeltaMetrics, The Lewin Group, the National Development and Research Institutes (NDRI), the National Opinion Research Center (NORC), Science Applications International Corporation (SAIC), and UCLA Integrated Substance Abuse Programs (ISAP). We wish to thank Lynn Brett, who directed the NEDS subcontract at the UCLA Integrated Substance Abuse Programs, and Elizabeth Teshome, who performed word processing, conducted literature searches, and developed all graphics. We also wish to thank Karol Kaltenbach of the Maternal Addiction Treatment Education and Research Department, Thomas Jefferson University, and Wendee M. Wechsberg, Substance Abuse Treatment Evaluations & Interventions, Center for Interdisciplinary Substance Abuse Research, RTI International, for their valuable and insightful comments on an earlier draft of this paper. Thanks are also due Substance Abuse and Mental Health Services Administration (SAMHSA) staff who reviewed and commented on an earlier draft of this paper. Many individuals on the NEDS team contributed to this report through content and editorial reviews, and final document preparation. Special thanks go to Sheila McKinney, Kathy Karageorge, Sandra Pertica, Sharyn Berg, and Iris Mensing. ABSTRACT The treatment needs of substance-abusing women have historically been obscured because of the comparatively lower rates of substance use among women than men; hence, treatment approaches have typically been developed for male clients. In recent years, however, considerable attention has been focused on substance-abusing women, particularly those who are pregnant or parenting. Changes in social policy during the past two decades had major implications for the provision of substance abuse treatment services to women. The goal of this analysis was to examine changes in the need for and utilization of substance abuse treatment among women over the period corresponding to these policy changes. Data were analyzed from the National Household Survey on Drug Abuse and the National Drug and Alcohol Treatment Unit Survey/Uniform Facility Data Set for the period from approximately 1985 through 1999. Overall, during the period of time covered in this report, the proportion of women in the general population who needed treatment for substance abuse decreased. This decrease corresponded to a general decline in substance use and need for treatment among the general population. At the same time, a broader range of women in the population utilized treatment services, and they accessed services across a broader range of treatment settings, than in the past. There were gradual increases in the proportion of women clients across treatment settings, particularly in residential and intensive outpatient treatment settings and in the criminal justice system. There were also gradual increases in providers who offered services that address women’s needs. In addition, there were increases in the provision of services that addressed women’s treatment needs across all types of treatment settings, especially within treatment settings in which there were only women clients. Although the rate of treatment among women who needed treatment increased, only a small portion of women who needed treatment actually received it. These findings can be used to monitor and assess the potential impact of social policies on the accessibility and utilization of treatment services among substance-abusing women. EXECUTIVE SUMMARY EXECUTIVE SUMMARY The goal of this analysis was to examine the provision of substance abuse treatment services to women over a period of time from approximately 1985 to 1999. This period of time corresponded to the implementation of several major policy changes that had implications for the availability and accessibility of substance abuse treatment services for women. The analysis did not monitor the gap between need for and utilization of treatment among women by assessing gender differences in these trends. Rather, it details the gap in treatment need and treatment utilization by women over a period of time. 1. INTRODUCTION The treatment needs of substance-abusing women have historically been obscured because of the comparatively lower rates of substance use among women than men and the greater stigma accorded to women who abuse alcohol or drugs, particularly those who are pregnant or parenting. In recent years, however, considerable attention has been focused on substance-abusing women. This attention has been driven both by treatment advocates for women and by public concern about the social and economic costs associated with substance abuse among women with children. In response to this attention, a range of social policies were implemented over the past 15 to 20 years. Those social policies had the potential to alter dramatically the delivery of substance abuse treatment services to women. They included increases in the funding and development of substance abuse treatment services that address the needs of pregnant and parenting women; the development of new laws and sentencing policies regarding substance abuse; welfare policies that provide states with the option to screen potential recipients for substance use problems, refer individuals to treatment if needed, and deny benefits to individuals with a history of drug-related convictions; greater recognition of substance abuse problems among pregnant women and women who come into contact with the child welfare system; and changes in the organization, financing, and delivery of health services generally, including substance abuse treatment services. As an example, in 1984, the Federal government amended block grant legislation to require that each state set aside 5 percent of its block grant allocation for new or expanded substance abuse services for women. There remains limited understanding, however, of how the provision of substance abuse treatment to women has changed over the period of time corresponding to these dramatic changes in social policies and in service delivery systems. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page i Executive Summary 2. METHODS To address the changes in service delivery to substance-abusing women that took place from approximately 1985 through 1999, the following analytic questions were examined in this secondary analysis: Are there changes in the rates of women needing treatment for alcohol and drug problems among women in the general population, and changes in the rates of women who received treatment, both among women in the general population and among women who needed treatment for specific substances, during this time period? Are there changes in the characteristics of women who received treatment for alcohol and drug problems during this time period? Are there changes in the settings in which women received treatment for alcohol and drug problems during this time period? Are there changes in the proportion of women who received treatment in different types of treatment settings and in the types of services that were provided to women in these treatment settings during this time period? The analysis described in this report used data from the National Household Survey on Drug Abuse (NHSDA) (SAMHSA, 1985, 1991, 1994, 1999), which is a national probability survey of households in the United States concerning substance use and treatment utilization, and the National Drug and Alcohol Treatment Unit Survey (NDATUS; 1987, 1991, 1994)/Uniform Facility Data Set (UFDS; 1998), which is an annual census of public and private substance abuse treatment providers on the characteristics of providers of substance abuse treatment services, the characteristics of clients served by these providers across types of treatment settings, and the types of services provided. The analysis consisted of computing the number of women who needed treatment, both generally and for specific substances. It included constructs for frequency of use, dependence criteria, and problems related to use; rates of treatment utilization, both in the general population and among women who needed treatment for specific substances; frequency distributions of basic demographic characteristics of women who received treatment for alcohol problems and for drug problems; rates of treatment utilization in different types of settings; frequency distributions of the percentages of women in treatment settings, by type of primary substance treated and type of treatment provided; and the distributions of various services provided that addressed women’s treatment needs, by the percentage of women within these treatment settings. All constructs referred to the past year and were developed to be as comparable as possible across the years examined for each data set, although data were not available across all years for some constructs. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page ii Executive Summary 3. FINDINGS The analysis showed that, over the time period from approximately 1985 to 1999, the proportion of women in the general population who needed treatment for substance use problems decreased. This finding paralleled a trend observed in the general population. (Data from other analyses show a general decrease in substance use problems for both men and women during this period.) At the same time, the proportion of women who were treated for substance use problems, among those who needed treatment, increased. The gap between the number of women who needed treatment and the number of women who received it remained substantial, however: less than one-fourth of women who needed treatment actually received it over the period of time examined. The sociodemographic characteristics of women treated for either alcohol or drug problems changed considerably over this time. In general, there were increases in the ages of women treated for alcohol or drug problems, decreases in the proportion of white women and increases in the proportions of women of other ethnic groups treated for substance use problems, increases in the level of education and rates of employment of women treated for substance use problems, and increases in the proportions of women treated for substance use problems who were married, had children younger than 18 years of age, or were receiving Medicaid. Rates of treatment women received generally increased across a wide range of treatment settings, including hospitals, inpatient rehabilitation facilities, mental health centers, private doctors’ offices, schools, and churches. The rate of self-help participation stayed the same among women with alcohol problems and decreased among women with drug problems, but self-help participation was the most frequently accessed type of treatment over all time points. Across all types of treatment settings and for any substance, the proportion of clients receiving treatment who were woman gradually increased, from 28 percent to 32 percent. The largest share of women clients accessed treatment in settings that provided residential and intensive outpatient treatment. There were also increases in the proportion of women receiving treatment within the criminal justice system. Treatment settings in which women were 100 percent of the clients, although constituting a small proportion of the overall treatment system, had higher rates of providing services that addressed women’s treatment needs. These services included providing child care, services for pregnant and postpartum women, family/parenting services, women’s groups, and domestic violence services, as well as providing staff who had been specifically trained to provide treatment services to women. 4. SUMMARY AND IMPLICATIONS The analysis described in this report shows that, from about 1985 to about 1999, there were several significant changes in the rates of need for and utilization of substance abuse J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page iii Executive Summary treatment among women in the United States, the characteristics of women who utilized treatment services, the settings in which they received treatment, and the types of services provided in women's different treatment settings. Treatment providers can use these findings to assess the range of services needed by women, their ability to address women’s treatment needs, and the resources necessary to provide these services. Policymakers can use them to assess the potential impact that policies under consideration may have on the provision of substance abuse treatment to women and to develop strategies for increasing access to and utilization of treatment services among women who need treatment. Researchers/evaluators can use these findings to develop future analyses of the adequacy of the nation’s substance abuse treatment system for women, in particular, by monitoring the gap between need for and utilization of treatment among women and assessing gender differences in the rates of treatment need and utilization. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page iv I. INTRODUCTION I. INTRODUCTION The goal of the analysis described in this report was to examine the provision of substance abuse treatment services to women over a period of time (from about 1985 to about 1999) that corresponded to the implementation of major policy changes affecting substanceabusing women. The analysis did not monitor the gap between need for and utilization of treatment among women by assessing gender differences in these trends. Rather, it details the gap in treatment need and treatment utilization by women over a period of time. This chapter briefly reviews these major policy initiatives, as well as relevant research literature. It also describes the purpose and parameters of the analysis. 1. OVERVIEW OF MAJOR POLICY INITIATIVES AND RELEVANT WORK In the past 15 to 20 years, much attention has been given to the problems of substanceabusing women. Treatment advocates, program providers, and policymakers have called for improved access to substance abuse treatment for women, increased rates of treatment utilization among women, and more appropriate services that address the specific treatment needs of women substance abusers. There has been little examination of how the provision of substance abuse treatment to women has changed, however, and specifically whether there were increases in treatment access, utilization, and types of services provided over this period of time. The aim of the analysis was to examine, for the time period from about 1985 to about 1999, the: Need for substance abuse treatment among women in the United States Rates of treatment utilization among women Characteristics of women who received substance abuse treatment services Settings in which women received treatment Types of services specific to women’s needs that were provided within the settings in which women received treatment. The prominent social policy issues surrounding the provision of substance abuse treatment to women in the United States provide a context for this analysis. These issues are reviewed below, as is relevant research. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 1 Introduction 1.1 Treatment Needs of Substance-abusing Women Historically, substance abuse has been viewed as a male problem, even though drug addiction among women dates back to the medicinal use of cocaine and opiates in the 19th century (Kandall, 1996). Similarly, women's use of alcohol remained largely hidden within the domestic sphere through much of the 20th century, and women alcoholics whose alcohol problems were visible in the public sphere were stigmatized as sexually deviant and were socially outcast (Blume, 1986). Because women have lower rates of alcohol and drug use overall than men (Kandel, 1998), treatment planners and developers have overlooked women’s need for treatment, and treatment approaches have traditionally been designed with the assumption of a male client (Reed, 1985, 1987). As a consequence, women who have alcohol and drug problems have had lower rates of treatment utilization than men (Office of Applied Studies, 1997). Over the past two decades, however, considerable evidence has accumulated about gender differences in alcohol and drug use patterns and the specific treatment needs of women (Wetherington & Roman, 1998). Women and men differ in their initiation of alcohol and drug use, the progression to dependence, and the psychosocial correlates of use (Anglin, Hser, & Booth, 1987; Anglin, Hser, & McGlothlin, 1987; Hser, Anglin, & Booth, 1987; Hser, Anglin, & McGlothlin, 1987). Furthermore, women and men differ in when they initiate treatment, their sources of referral to and social support for entering treatment, their perceptions of and attitudes toward treatment, and the settings in which they access treatment (Beckman & Amaro, 1986; Grella & Joshi, 1999; Kline, 1996; Schober & Annis, 1996; Weisner & Schmidt, 1992). Several studies have shown that women substance abusers are more likely than men substance abusers to have a spouse or partner who is also a substance abuser, a situation that can inhibit their ability to participate in treatment or to sustain abstinence following treatment (Schneider, Kviz, Isola, & Filstead, 1995; Westermeyer & Boedicker, 2000). Women face several practical and logistical barriers to accessing substance abuse treatment. These barriers, such as lack of transportation and child care (Kline, 1996; Marsh, D’Aunno, & Smith, 2000; Marsh & Miller, 1985), stem from their generally lower levels of income and/or employment and their primary responsibility for child rearing. Women who are pregnant or have dependent children often are hindered from entering or completing substance abuse treatment because of the absence of child care or of treatment services geared to women, especially among providers who serve both men and women (Haller, Knisely, Elswick, Dawson, & Schnoll, 1997; Lewis, Haller, Branch, & Ingersoll, 1996; Prendergast, Wellisch, & Falkin, 1995), and because of a lack of referrals for needed services, such as those related to pregnancy (Breitbart, Chavkin, & Wise, 1994). Furthermore, many substance-abusing mothers fear that, by entering treatment, they may jeopardize their custody of their children (Finkelstein, 1994). It is also the case, however, that substance-abusing women who are pregnant and/or have children J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 2 Introduction may also be motivated to enter treatment by concern for their children and a desire to be better parents (Sterk, 1999). Substance-abusing women have high rates of co-occurring mental disorders, particularly depressive and anxiety disorders. Moreover, considerable research has documented high rates of childhood trauma, parental substance abuse, exposure to violence and victimization, and abusive adult relationships among women substance abusers (Brady, Killeen, Saladin, Dansky, & Becker, 1994; Fullilove et al., 1993; Najavits, Weiss, & Shaw, 1999). Posttraumatic stress disorder (PTSD) is highly prevalent among substance-abusing women, who have a history of exposure to trauma (Brown & Wolfe, 1994; Najavits, Weiss, & Shaw, 1997). Among women who have PTSD, recent studies have demonstrated poorer substance abuse treatment outcomes across several domains. These domains include treatment retention, substance use, psychological status, and psychosocial functioning (Brown, Stout, & Mueller, 1996; Killeen, Brady, & Thevos, 1995; Ouimette, Brown, & Najavits, 1998). Most substance abuse treatment providers have not been trained to assess, diagnose, or treat trauma-related disorders, and women who have co-occurring mental disorders encounter additional problems accessing appropriate services because of the typical separation of mental health and substance abuse services which results in fragmentation of service delivery systems (Grella, 1996). Substance-abusing women entering into drug treatment report more physical health problems than their male counterparts (Chatham, Hiller, Rowan-Szal, Joe, & Simpson, 1999; Wechsberg, Craddock, & Hubbard, 1998). Their physical health problems often remain untreated, however, because of the lack of integration of physical health care and substance abuse treatment services (Reed & Mowbray, 1999). Women substance abusers are also at high risk of HIV infection from injection drug use, as well as from sexual contact with infected individuals, particularly other injection drug users. Substance abuse treatment providers now offer a range of HIV education and prevention services to address these risks, but some research has indicated that, although women are more likely than men to have high-risk sexual partners, they are less likely to receive HIV risk reduction services while in substance abuse treatment (Grella, Etheridge, Joshi, & Anglin, 2000). 1.2 Substance Abuse Treatment Services for Women In the 1980s, public attention focused increasingly on reports of cocaine/crack use among women, particularly those who were pregnant or had children, with much of the media coverage during this time featuring sensational depictions of drug-using mothers (Mahan, 1996). Concern about the public health and economic consequences of maternal substance abuse lead to several social policy initiatives. One response was to increase funding for special treatment services J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 3 Introduction designed specifically for women with substance abuse problems (Breitbart, Chavkin, & Wise, 1994; Schmidt & Weisner, 1995). In 1984, the Federal government amended block grant legislation to require that each state set aside 5 percent of its block grant allocation to provide new or expanded substance abuse treatment services for women. States were encouraged to spend set-aside funds to develop women-only treatment units, special ancillary services for women, and services for pregnant women. By 1988, amid media depictions of the problems of drug-exposed infants that were often sensational and policy attention that was focused on the national war on drugs, Congress doubled the women’s set-aside to 10 percent (Chavkin, Breitbart, Elman, & Wise, 1998). In 1990, the General Accounting Office (GAO) called for an urgent national response to the thousands of drug-exposed infants born each year in the United States (GAO, 1990; GAO, 1991). In the early 1990s, Congress enacted legislation that funded demonstration grants for prenatal and infant care services through the Medicaid program. Treatment models for substance-using pregnant and postpartum women were sponsored by the Substance Abuse Mental Health Services Administration (SAMHSA), through the Residential Women and Children/Pregnant and Postpartum Women Demonstration Program (Center for Substance Abuse Treatment, 2001), and by the National Institute on Drug Abuse (NIDA), through the Perinatal-20 initiative (Nunes-Dinis, 1993; Rahdert, 1996). These funding and policy initiatives led to increased availability of treatment services for women and thus enabled researchers and evaluators to study gender-specific treatment outcomes, particularly those resulting from treatment in settings providing treatment services that address women’s needs. Such services typically address women's psychosocial problems and their need for comprehensive services, particularly with regard to parenting issues, mental health issues, and history of trauma and victimization (Comfort & Kaltenback, 2000; Stevens & Patton, 1998). Overall, the resulting body of research, which is growing, has shown that substance abuse treatment services that address women’s needs have promising results (Stevens & Arbiter, 1995). Several studies have demonstrated that treatment outcomes for women are improved when residential treatment settings have live-in accommodations for children (Hughes et al., 1995; Wobie, Eyler, Conlon, Clarke, & Behnke, 1997); when outpatient services, particularly family therapy (Zlotnick, Franchino, St. Claire, Cox, & St. John, 1996), individual counseling (Volpicelli, Markman, Monterosso, Filing, & O’Brien, 2000), and family services, are provided (Wingfield & Klempner, 2000); and when comprehensive supportive services, such as case management, child care, parenting classes, and vocational training are provided (Brindis, Berkowitz, Claysen, & Lamb, 1997; Howell, Heiser, & Harrington, 1999; Strantz & Welch, 1995). A growing literature has examined the characteristics of settings in which women receive treatment, both settings that provide treatment exclusively to women and mixed-gender settings J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 4 Introduction that provide services specifically designed to meet women’s needs. Treatment settings that provide services to women only, or in which there is a higher concentration of women, provide a wider range of services designed to meet women’s specific treatment needs (Grella, Joshi, & Hser, 2000; Uziel-Miller & Lyons, 2001). One study showed that women who were treated in women-only residential settings had more severe problems before treatment entry but were twice as likely to complete treatment as women in mixed-gender treatment settings (Grella, 1999). A study that used Drug Abuse Treatment Outcome Study (DATOS) data found that pregnant and parenting women treated in residential settings in which there were higher proportions of other such women had longer stays in treatment and that longer stays in turn were positively associated with post-treatment abstinence (Grella, Joshi, & Hser, 2000). In such settings, providers offered more services, both generally and in specifically addressing family and mental health needs. A meta-analysis of treatment outcome studies showed that women who received services in women-only settings or in settings that provided specialized services for women had better treatment outcomes in several domains, compared to women treated in mixed-gender settings or in settings that did not offer specialized services (Orwin, Francisco, & Bernichon, 2001). This accumulation of findings shows the benefits of substance abuse treatment services that are specifically designed to meet women’s needs. Recent evidence suggests, however, that funding for services for women and the priority given to treatment for pregnant and parenting women may have been implemented unevenly across states and are now decreasing. Findings from a study conducted by Dr. Beth Glover Reed and sponsored by the Robert Wood Johnson Substance Abuse Policy Research Program showed that, although every state has begun to provide some gender-specific services for women, the extensiveness of such services and the types of strategies pursued often differ markedly (Reed, personal communication, June 2000). Such differences in funding and policies, and their decline, have been attributed to the shift from Federal to state and local control of funding (Chavkin & Breitbart, 1997; Chavkin, Wise, & Elman, 1998). One report showed that Congressional allocations to fund treatment services demonstrations targeted to women dropped 38 percent from 1994 to 1998 and that funding for services targeting pregnant and postpartum women and their children in 1998 was at only 10 percent of its 1995 level (Drug Strategies, 1998). The report suggested that waning public concern about the effects of maternal crack abuse, coupled with welfare reform and changes in the delivery of health services, underlies the decreased level of funding allocated for specialized treatment services for women that has occurred despite the accumulation of research findings demonstrating the effectiveness of such services. Increasingly, substance abuse treatment providers are operating in a managed care environment that places a premium on cost containment. Policymakers have a choice of options for financing treatment. Under these options, the package of services and length of treatment J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 5 Introduction provided to individuals vary (Shepard, Larson, & Hoffmann, 1999). Within this context, approaches to behavioral health care may be subsumed under more generic health care services (Blanch & Levin, 1998; Schreter, 1993). As a consequence, because the broader range and more intensive nature of services targeted to women’s needs typically result in higher costs, specialized treatment services for women are vulnerable to budget cuts (Grella, Polinsky, Hser, & Perry, 1999). Managed care systems that carve in benefits, that is, manage benefits through a single provider, may provide more comprehensive services than carve-out care, in which substance abuse treatment is contracted out to another provider. How these various methods of financing treatment affect access to and utilization of substance abuse treatment services for women has yet to be determined (Reed & Mowbray, 1999). 1.3 Criminal Justice System Initiatives Affecting Substance-abusing Women Concurrent with changes in the delivery of substance abuse treatment services to women, several criminal justice initiatives with major implications for substance-abusing women were implemented. Several states enacted legislation imposing criminal penalties on pregnant substance-abusing women (Chavkin, Wise, & Elman, 1998; Whiteford & Vitucci, 1997). In South Carolina, for example, a conviction for child abuse stemming from substance abuse during pregnancy was upheld by the state’s supreme court and is one of over 200 such cases in three states, although most such convictions were overturned on appeal. The criminalization of perinatal substance abuse may actually have harmful effects on infant health, however, if pregnant women forego prenatal care or substance abuse treatment because of fear of losing their children or being arrested. In addition, these criminal justice initiatives disproportionately target poor and minority women, who are more likely to use illicit drugs, as opposed to white women, who are more likely to use alcohol and tobacco (Gustavsson & MacEachron, 1997). Although past research showed that women substance abusers were less involved in criminal activity, particularly drug dealing, than their male counterparts (Anglin & Hser, 1987), criminal involvement appears to be increasing among women substance abusers. In particular, women who use stimulants, including cocaine (Fagan, 1994; Somers, Baskin, & Fagan, 1996) and methamphetamines (Morgan & Joe, 1997), appear to be more involved in criminal activity than primary alcohol abusers and earlier generations of female opiate users. In addition to the increase in criminal behavior among substance-abusing women, changes in drug laws and sentencing policies over the past 15 years have drastically increased the number of women substance abusers entering the criminal justice system (Marquart, Brewer, Mullings, & Crouch, 1999; Mauer, Potler, & Wolf, 1999). Nationally, the number of women incarcerated for drug offenses rose by 888 percent from 1986 to 1996, in contrast to a rise of 129 percent for all nondrug offenses (Mauer, Potler, & Wolf, 1999). Approximately two-thirds of incarcerated women J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 6 Introduction are mothers (GAO, 1999). Studies show that a majority of incarcerated women meet criteria for alcohol or drug dependence and most have received substance abuse or mental health services, or both, in the past (Jordan et al., 2002; Teplin, Abram, & McClelland, 1996). Although substance abuse treatment is increasingly provided to women in prison and in community settings upon parole (Prendergast, Wellisch, & Wong, 1996), the effects of these changes in criminal justice policies on the provision of substance abuse treatment to women are largely unknown. 1.4 Welfare Reform and Child Welfare Initiatives Affecting Substance-abusing Women Welfare reform legislation adopted by Congress in 1996, the Personal Responsibility and Work Opportunity Reconciliation Act, had major implications for the delivery of public-sector substance abuse treatment to welfare recipients, the majority of whom are women (Schmidt & McCarty, 2000; Schmidt, Weisner, & Wiley, 1998; Young & Gardner, 1997). The legislation established a block grant for Temporary Assistance for Needy Families (TANF). It also mandated the lifetime elimination of welfare benefits to individuals convicted of a drug-related felony since August 22, 1996, and authorized states to drug-test welfare recipients. The states have wide discretion to override sections of the Federal law by passing their own regulations for Medicaid eligibility, drug testing, and the provision of cash benefits and food stamps to drug felons. Consequently, the effects of these changes in Medicaid policies are highly variable across states. Forty-two states have enforced the welfare ban in full or in part, and only eight states and the District of Columbia have opted out (Allard, 2002). On the one hand, because publicly funded substance abuse treatment services are optional under Medicaid, some states provide limited services or none at all. Many states lack mechanisms to identify and track substance abuse among TANF participants, and case workers lack training in identifying or assessing substance abuse problems (Center on Addiction and Substance Abuse, 1999). On the other hand, mandatory screening for alcohol and other drug (AOD) problems among applicants for welfare may result in increased referral to and utilization of treatment, particularly among women who have never participated in treatment. In addition, a major emphasis of welfare reform has been to move recipients into the labor force. Thus, as part of their participation in TANF, welfare recipients may also receive vocational services and training (Metsch, McCoy, Miller, McAnany, & Pereyra, 1999). Federal mandates to move welfare recipients into the workforce, such as the Workforce Investment Act of 1998, which provides welfare-to-work grants to states and communities that provide substance abuse services to the unemployed, are also creating new relationships between welfare and substance abuse treatment providers. Greater awareness of the effects of parental substance abuse on children has resulted in increased attention to substance abuse on the part of the child welfare system, including screening and referral for substance abuse treatment (GAO, 1994; Young, Gardner, & Dennis, J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 7 Introduction 1998). Pregnant women who use drugs are likely to use alcohol and tobacco as well and to live in impoverished and disorganized households (Lester, LaGasse, & Brunner, 1997). National survey data show that about 13 percent of pregnant women age 15 to 44 reported drinking alcohol in the past month, with 3 percent reporting binge drinking (Office of Applied Studies, 2001d). Additionally, about 4 percent of pregnant women reported use of an illicit drug, with higher rates among younger women (Office of Applied Studies, 2001c). Accumulating research has shown that children of women who use drugs during pregnancy are at greater risk for poor developmental outcomes, in part because they are more likely to be born prematurely and to have low birth weight, compared to children of non-abusers (Howard, Beckwith, Espinosa, & Tyler, 1995). In addition to developmental risks, children of substance abusers are more likely to have psychological and behavioral problems, compared to children of non-abusers (Kolar, Brown, Haertzen, & Michaelson, 1994; Magura & Laudet, 1996; Stanger et al., 1999). Several studies have also shown that children of substance abusers are at greater risk for becoming substance abusers themselves (Caudill, Hoffman, Hubbard, Flynn, & Luckey, 1994; Hops, Duncan, Duncan, & Stoolmiller, 1996; Merikangas, Dierker, & Szamari, 1998). Finally, substanceabusing mothers have been found to be at greater risk of abusing or neglecting their children, or both (Ammerman, Kolko, Kirisci, Blackson, & Dawes, 1999; Chaffin, Kelleher, & Hollenberg, 1996; Williams-Peterson et al., 1994; Wolock & Magura, 1996). Increased attention to the problems of substance-abusing mothers, particularly to the effects of their substance use on their children, has the potential to increase interactions between the child welfare and substance abuse treatment systems (Peterson, Gable, & Saldana, 1996). In sum, system-level changes across several policy domains—substance abuse treatment, health services, criminal justice, welfare, and child welfare—are interrelated in ways that affect the availability, financing, and types of substance abuse treatment services provided to women. Policy changes are resulting in new inter-organizational relations among service providers and creating new mechanisms for screening substance abuse problems, linking and referring clients across service systems, and integrating service delivery. At the same time, it is unclear how the provision of substance abuse treatment services to women has changed over the period of time corresponding to these changes in social policies. In particular, the rate of treatment utilization among women who need treatment, the characteristics of women who utilize substance abuse treatment services, the settings in which they receive treatment, and the types of services provided to women within these settings remain unclear. 2. PURPOSE AND PARAMETERS OF THE ANALYSIS The purpose of the analysis described in this report was to examine changes in the provision of substance abuse treatment to women from about 1985 to about 1999, a period of J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 8 Introduction time that coincided with the implementation of the social policy initiatives discussed above. Publicly available, national data sets (the National Household Survey on Drug Abuse, or NHSDA, and the National Drug and Alcohol Treatment Unit Survey/Uniform Facility Data Set, or NDATUS/UFDS) were used to examine changes in the provision of substance abuse treatment to women in the United States during this period. The specific analytic questions addressed are as follows: Are there changes in the rates of women needing treatment for alcohol and drug problems among women in the general population, and in the rates of women who received treatment, both among women in the general population and among women who needed treatment for specific substances, during this time period? Are there changes in the characteristics of women who received treatment for alcohol problems and for drug problems during this time period? Are there changes in the settings in which women received treatment for alcohol and drug problems during this time period? Are there changes in the proportion of women who received treatment in different types of treatment settings and in the types of services provided to women in these settings during this time period? Findings from the analysis have implications for the evaluation of existing and proposed social policies, including their potential effects on access to and utilization of substance abuse treatment services among women. 3. ORGANIZATION OF THIS REPORT This introductory chapter has briefly reviewed the major policy initiatives implemented during the period under study, as well as the relevant literature. Chapter II provides detailed information on the methods used in the analysis. Chapter III discusses the findings of the analysis, in terms of each analytic question posed. Chapter IV summarizes and discusses the implications of the findings for treatment providers, policymakers, and researchers/evaluators. The implications that the findings of the analysis have for future policy development and research/evaluation are also addressed. Appendix A and Appendix B provide the measurement and definitions of key constructs in the NHSDA and the NDATUS/UFDS, respectively. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 9 II. METHODS II. METHODS This analysis consisted of a secondary analysis of two national data sets to examine changes in access to and utilization of substance abuse treatment among women and the types of services provided to women in different types of treatment settings from about 1985 to 1999. This chapter describes two national surveys, the variable definitions, the analytic methods, and the constraints of the analysis. 1. UNITS OF ANALYSIS All units of analysis are based on respondents from two surveys, which are described below. 1.1 National Household Survey on Drug Abuse (NHSDA) The National Household Survey on Drug Abuse (NHSDA) is an annual survey designed to measure the prevalence and correlates of drug use in the United States and to monitor trends in drug use over time. The NHSDA began in 1971 under the auspices of the National Commission on Marijuana and Drug Abuse. Responsibility for the NHSDA shifted to the National Institute on Drug Abuse (NIDA) from 1974 to 1991. In October 1992, the Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration (SAMHSA), became the lead agency responsible for conducting the NHSDA. Survey Method The NHSDA sample consists of civilian, non-institutionalized individuals age 12 and older living in the United States. Homeless individuals who do not use shelters, active military personnel, and residents of institutional group quarters such as jails and hospitals are excluded from the survey. Beginning in 1985, African-Americans and Hispanics were oversampled, and the total sample size was increased to approximately 8,000 respondents. Alaska and Hawaii were included in the survey for the first time in 1991, as were civilians living on military bases and in college dormitories, rooming houses, and homeless shelters. Beginning in April 1997, residents of Arizona and California were over-sampled to provide survey estimates for these state populations to measure the impact of propositions related to illicit drugs that were passed by voters in 1996. The sample was selected using a deeply stratified, multistate area probability sample design that over-sampled Hispanics, African-Americans, younger respondents, and current smokers. Additionally, to permit generalizations to be made at the state level of analysis, beginning in 1999 the sample size was increased to approximately 70,000 respondents. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 11 Methods Sampling weights are applied to adjust for the varying probability of selection. Respondents are asked about the recency and frequency of use of various illicit drugs and alcohol; whether they have received treatment for alcohol and drug use and, if so, the settings in which treatment was received; whether they have any problems related to drug or alcohol use; and their perceptions of the risk of substance use. These data can be used to derive prevalence estimates of drug and alcohol use and need for treatment and can be analyzed by specific demographic group (e.g., gender, age, ethnicity, marital/parental status), as well as by users of specific substances. Changes in the Administration of the NHSDA In 1994, two separate versions of the NHSDA questionnaire were administered as part of a split-sample experiment. The 1994-A survey was similar to the previous NHSDA surveys. The 1994-B version was changed, however, to create a core of demographic and drug use items, to make wording consistent across answer sheets, and to increase comprehension of the survey among respondents. The number of questions asked was reduced, the questions were reordered, and some sections were asked using a self-administered rather than an interviewer-administered answer sheet to increase the reliability of self-reported data. Subsequent NHSDA questionnaires are modeled after the 1994-B version. In addition, before 1999 the survey was conducted in person by an interviewer in the respondent’s home and took about one hour to complete. Individuals were interviewed once and not followed up for subsequent interviews. Beginning in 1999, the survey was administered using computer-assisted interviewing, including audio computer-assisted self-interviewing in lieu of the paper answer sheets used previously. New procedures for editing and imputing the data were also implemented. 1.2 National Drug and Alcohol Treatment Unit Survey (NDATUS)/Uniform Facility Data Set (UFDS) The NDATUS/UFDS was designed to measure the location, characteristics, and use of alcohol and drug abuse treatment facilities and services throughout the United States, the District of Columbia, and other United States jurisdictions. Data Collection The survey method and content evolved from national survey efforts begun in the 1970s by NIDA to measure the scope and use of drug abuse treatment services in the United States. The sixth of these surveys, which was conducted in 1976, introduced the data elements and format that have formed the core of subsequent surveys. These data elements include organizational setting; service orientation; services available; clients in treatment, by type of J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 12 Methods care; capacity; and annual revenue sources and amounts. The 1976 survey, called the National Drug Abuse Treatment Utilization Survey, was repeated in 1977 and 1978. In 1979, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) became a co-sponsor of the survey, alcohol treatment facilities were added, and the survey was renamed the National Drug and Alcoholism Treatment Utilization Survey. This survey was repeated in 1980 and 1982. In 1984, a one-page version was used (the National Alcoholism and Drug Abuse Program Inventory). In 1987, the full version of the survey was reinstated, and it was renamed the National Drug and Alcoholism Treatment Unit Survey (NDATUS). NDATUS was conducted annually from 1989 to 1993. In 1992, with the creation of SAMHSA, responsibility for conducting the survey shifted to SAMHSA’s Office of Applied Studies. The survey was then redesigned and conducted annually as the Uniform Facility Data Set (UFDS) survey beginning in 1995. Until 1996, state substance abuse agencies distributed and collected the UFDS survey forms. Beginning in 1996, data collection was centralized, and UFDS forms were sent directly to the participating treatment facilities. Beginning in 2000, the survey was renamed the National Survey of Substance Abuse Treatment Services (N-SSATS). Survey Method The survey collects one-day census data using a point-prevalence method based on the National Master Facility Inventory, which is a continuously updated master list of all organized substance abuse treatment providers known to SAMHSA and includes both public and private facilities. The survey is conducted annually between October and March, with a reference date of October 1st of each year. Before the survey is administered, faxes or letters are sent to all facilities to permit the updating of address information and to alert facilities to expect the survey. Data collection instruments (with state letters of endorsement or other enclosures) are then mailed to each facility. During the data collection phase, contract personnel are available to answer facilities' questions about the survey. Four weeks after the initial mailing, thank you/reminder letters are sent to all facilities. Five to six weeks after the initial mailing, nonresponding facilities are sent a second mailing. About five weeks after the second mailing, nonrespondents receive a reminder telephone call. Facilities that have not responded within two to three weeks of the reminder call are telephoned and asked to complete a slightly abbreviated version of the survey by telephone. Follow-up calls are made to all facilities, as needed, to collect missing data and to correct erroneous data. The survey questionnaire includes organizational, structural, financial, and services data about organized public and private substance abuse treatment facilities in the United States. Treatment facilities are asked to report data on the types of services provided, numbers of clients, client demographics (i.e., age, sex, race/ethnicity), other client characteristics, number of beds, J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 13 Methods and sources and amounts of revenue. Annual reports based on the survey data include information on the range and type of services offered, aggregate estimates of utilization, and other variables for services administration and policy analysis. Exhibit II-1 shows the years for which public use data sets for NHSDA and NADTUS/UFDS were available and the data sets that were selected for use in the analysis described in this report. EXHIBIT II-1 DATA SETS USED IN THE ANALYSIS Study Data Sets NDATUS (1980-1994) UFDS (1995 ff.) Year 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Y = Public use data set available Y = Years used in the analysis NHSDA Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y 2. MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS This section provides a brief description of the variables. More detailed information on variable construction across each year of the surveys for which data were included in the analysis is provided in Appendix A. 2.1 NHSDA – Need for Treatment and Dependence Need for treatment was based on the definition used in prior analyses of the NHSDA conducted by OAS (Epstein & Gfroerer, 1998). Need for treatment was assessed for any type of J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 14 Methods substance use and for specific drugs and alcohol. The construct included four components: (1) dependence, based on the current version of the Diagnostic and Statistical Manual of Mental Disorders, or DSM (American Psychiatric Association, 1994), (2) frequency of use, (3) injection drug use, and (4) having received treatment for substance use. The variables used to construct need for treatment for any type of drug use and for specific substances are shown for each survey year in Appendix A. The definitions vary across survey years, depending on which version of the DSM was current in a given survey year (i.e., DSM III in 1985, DSM-III-R in 1991, DSM-IV in 1994 and 1999). They also vary depending on the availability of certain variables (e.g., injection use was available only for heroin and cocaine in 1985). The definitions were developed with the goal of achieving the greatest degree of consistency possible across survey years, given the constraints of the data available. The definitions used for dependence, which are included within the definition of need for treatment, are presented in Appendix A. These definitions vary according to the version of the DSM in use during each survey year. 2.2 NHSDA – Treatment Received in the Past Year Data on treatment received in the past year varied across survey years with regard to the specificity of the substance of abuse for which treatment was received (see Appendix A). Rates of having received treatment were calculated separately for women in the general population and for women who had a need for treatment, both generally and for specific substances, depending on the availability of these data (e.g., in 1985, treatment received was available only for any drug, and in 1991, treatment received was available only for alcohol or any drug). 2.3 NHSDA – Characteristics of Women Treated for Alcohol/Drug Use in the Past Year The characteristics of women who received treatment in the past year were examined separately for those who received treatment for alcohol problems (except in 1985, when these data were not available) and for those who received treatment for drug problems (see Appendix A). The following measures were examined: age, ethnicity, educational status, work status, marital status, whether a respondent had children under 18 years of age (in 1999 this question referred only to dependent children who were currently living in the household), health insurance status (private, Medicaid, other types, or none), and welfare status (both for the respondent and for any member in the respondent’s household, for 1994 and 1999 only). J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 15 Methods 2.4 NHSDA – Treatment Settings in the Past Year The settings in which treatment was received in the past year were examined for women receiving treatment for alcohol problems (1994 and 1999 only), for drug problems (1991, 1994, and 1999 only), and for either alcohol or drug problems (1994 and 1999 only) (see Appendix A). Treatment setting was defined as a nonpersonal setting, and responses concerning self, family, or friends were not included. Classification of treatment settings varied slightly across survey years. For example, no distinction was made between inpatient and outpatient rehabilitation in 1991. In later survey years, additional categories were constructed from other classifications, such as treatment received in schools or churches, reflecting the increase in types of settings in which treatment was provided. Self-help groups were included as a setting where treatment was received, given their policy significance and importance within the overall substance abuse treatment system. 2.5 NDATUS/UFDS – Primary Substance Treated in Treatment Settings Treatment settings were classified into mutually exclusive categories according to the primary substance treated. These categories were alcohol only, drug only, or combined alcohol and other drug (AOD). These categories of primary substance treated were derived on the basis of the percentage of clients in the setting who were receiving a particular type of treatment on the date of the point-prevalence survey. This approach was used because of the lack of a consistent treatment orientation variable across the years examined (the orientation variable was not included in the 1998 survey) and to maintain consistency with analyses of the NHSDA, in which treatment for alcohol problems and treatment for drug problems were examined separately. In 1987, these percentages were available only for clients receiving either alcohol or drug treatment. In 1991, 1994, and 1998, these percentages were available for clients receiving alcohol, drug, or AOD treatment. The construction of primary substance treated within treatment settings for each survey year is shown in Appendix B. 2.6 NDATUS/UFDS – Type of Treatment Provided in Treatment Settings Treatment settings were classified according to the type of treatment provided in the setting, using commonly accepted categories of treatment (Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997; Gerstein & Harwood, 1990). Definitions used for these constructs are shown in Appendix B. Because detoxification is not generally considered to be treatment in the absence of other services, the detoxification services only construct was excluded from the treatment categorization schema. Clients were enumerated in the different types of treatment settings to determine the percentage of women clients in these settings. The categories for J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 16 Methods enumerating clients by type of treatment provided differed from year to year and by type of primary substance treated. In 1987, categories of type of treatment provided for alcohol and drug problems varied markedly across the surveys, and there was no classification specific to combined AOD treatment. In 1991 and 1994, clients receiving treatment for different types of substances (i.e., alcohol, drug, AOD) were enumerated within the different types of treatment (i.e., residential, outpatient, hospital). In 1998, clients were enumerated by type of treatment provided, independent of the type of primary substance treated. To maintain mutually exclusive categories of treatment settings, when more than one type of treatment was provided in a given setting, the setting was assigned to a type of treatment on the basis of a hierarchical order of intensity of treatment (e.g., hospital inpatient, residential rehabilitation, intensive outpatient, and outpatient/non-intensive). Separate categories were created for treatment received within the criminal justice system and for outpatient methadone maintenance treatment. 2.7 NDATUS/UFDS – Percentage of Women Clients in Treatment Settings Percentages of women clients (calculated from the number of women clients divided by the total number of clients, including those with unknown gender) in treatment settings were available for global categories of types of treatment that varied across survey years (i.e., inpatient and ambulatory/outpatient in 1987, 1991, and 1994; hospital inpatient, residential, and outpatient in 1998). Furthermore, these enumerations were given by type of primary substance treated in 1987, 1991, and 1994, but not in 1998. Therefore, the percentage of women clients in these global categories of types of treatment was used to estimate the percentage of women clients in more specific subcategories of treatment (i.e., short-term residential rehabilitation, long-term residential rehabilitation, intensive outpatient, non-intensive outpatient), within type of primary substance treated, which was derived by the rules stated previously. The distribution of treatment settings was then categorized across the categories of type of treatment and type of substance treated according to the following percentages of women in treatment settings: 0 percent, 1-49 percent, 50-99 percent, and 100 percent. See Appendix B for a description of the rules used for deriving estimates of percentages of women clients in treatment settings. 2.8 NDATUS/UFDS – Services Provided in Treatment Settings The following variables were examined: child care (in all survey years); the availability of staff specially trained to provide women’s services (in 1987, 1991, and 1994); parenting/family services; services for pregnant/postpartum women; women’s groups; and domestic violence services (1998 only). The distributions of these variables were calculated by the percentage of women clients receiving different types of treatment and by the type of primary J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 17 Methods substance use problem treated (i.e., alcohol, drug, AOD). These variables are shown in Appendix B. 3. ANALYTIC METHODS Analyses of data from the NHSDA consisted of frequency distributions for each of the constructs described above. Frequency distributions were originally calculated from the raw survey data and then weighted for population-based estimates, using the standard weights included with the data set for each year. Confidence intervals (95 %) for estimates of the percentages of women in the population who needed treatment and received treatment were computed using the weighted survey sample and adjusting for the survey sample design. Analyses of data from the NDATUS/UFDS consisted of frequency distributions for each of the constructs described previously. The average percentage of women in treatment settings was calculated by type of primary substance treated for each type of treatment. Cross-tabulations were calculated for the percentage of providers that stated specific services were available, by the percentage of women in those treatment settings (i.e., 0%, 1-49%, 50-99%, and 100%). Although these cross-tabulations were initially calculated for each type of treatment provided (i.e., residential, outpatient, hospital-based), for ease of presentation, findings are reported for all types of treatment, aggregated by type of primary substance treated (i.e., alcohol, drugs, AOD). Cross-tabs significant at p < .05 are reported. 4. CONSTRAINTS OF THE ANALYSIS Several constraints to interpretation of the analysis should be noted. As discussed previously, the data sets were selected for analysis on the basis of their availability within the public domain at the same time points, taking into consideration the consistency of variables across survey years. For example, although NDATUS data were collected in 1984, the version administered in that year was highly abbreviated and contained no measures on services received. Similarly, although use of the 1990 NHSDA would have allowed for more consistent intervals of time between the data sets examined, the NHSDA from 1991 was included in the analysis (and thus also NDATUS from that same year) because the 1990 NHSDA contained limited information on the settings in which treatment was received. Every effort was made to construct measures that were comparable across the data sets examined, but in some instances comparability was limited (such as with defining drug dependence in the NHSDA and type of treatment categories in the NDATUS/UFDS), and in others variables were missing in some years, precluding comparisons. Hence, differences in the rates of the constructs examined, such as need for treatment, treatment received, or settings in which treatment was received, may vary in part because of differences in how these constructs were defined across the data sets. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 18 Methods Both surveys were changed over time, as survey items were added, refined, or eliminated to reflect changes in knowledge or priorities in issues about which information was needed. One example of this type of change is the reduced distinction between “primary alcohol” and “primary drug” treatment providers and the growth in combined AOD providers, two changes that reflect the increased rate of polysubstance use among individuals seeking substance abuse treatment over the time period examined (Hubbard, 1990). Hence, the “orientation” variable that measured whether treatment was provided primarily for alcohol or drug problems was dropped in UFDS. Because of the differences in client characteristics and services provided among providers of alcohol, drug, and AOD treatment, an empirical classification was used so that comparisons could be made across these categories over the survey years examined. This empirical classification of providers by primary type of substance treated, like the empirical classification of treatment settings on the basis of the percentage of women clients, may not correspond with a provider’s treatment approach or practice in all cases. Given the pointprevalence nature of the NDATUS/UFDS, providers were classified on the basis of the distribution of clients (with regard to both type of substance being treated and gender) on the designated survey day and may not be representative of the types of clients served within a given setting over time. Other changes in the survey design reflected refinement in measures, several of which are of central concern in this analysis. For example, questions regarding pregnancy status in the NHSDA were not available in the 1985 survey, were asked only in relation to work status in 1991 (e.g., on leave from work due to pregnancy), and were directly assessed in the 1994 and 1999 surveys. Questions regarding a respondent’s number of children asked about the total number of children less than 18 years of age in 1985, 1991, and 1994, whereas in 1999 the question asked only about the number of children under 18 years of age currently living in the household. Similarly, questions about receipt of welfare in the NHSDA in 1999 reflected changes in welfare policy resulting from legislation enacted in 1996 (i.e., change in terminology and in types of benefits provided). In addition, changes in how the surveys are administered over time, such as changing from face-to-face to computer-assisted interviewing, may affect the nature of responses received and the comparability of estimates derived from the surveys over time. As with all data based on self-report, estimates of drug use and other behaviors may be underreported, given the sensitive nature of the information solicited, despite efforts to ensure accurate reporting. Further, low or inconsistent response rates to the NDATUS/UFDS may lead to biased estimates of the characteristics of treatment providers based on data from these surveys. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 19 Methods Lastly, it is important to note that the data obtained from the NHSDA are based on noninstitutionalized individual respondents in the general population as the units of analysis, whereas the data from the NDATUS/UFDS are based on treatment providers as the units of analysis. Thus, the data sets may diverge with regard to analyses of similar constructs, such as settings in which treatment was received. For example, the NHSDA does not include individuals who are institutionalized, such as those in the criminal justice system. Estimates of treatment received in the criminal justice system from the NHSDA are limited to individuals who reported having received treatment in the past year within the criminal justice system but were no longer institutionalized at the time of the survey. In contrast, the NDATUS/UFDS surveys treatment providers, including those within the criminal justice system. Estimates of individuals treated within the criminal justice system will differ from those based on surveys of the general population. Use of data from both surveys provides complementary information for examining areas of convergence as well as divergence of data obtained from respondents in the general population and from providers. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 20 III. FINDINGS III. FINDINGS This chapter discusses findings for each of the analytic questions. These findings pertain to substance abuse treatment need and utilization among women, characteristics of women who utilized treatment, settings in which women received treatment, and services provided to women in different types of treatment settings, over the period from about 1985 to about 1999. 1. RATES OF WOMEN WHO NEEDED AND RECEIVED TREATMENT FOR ALCOHOL AND DRUG PROBLEMS Estimates of the proportion of women in the general population who needed and received treatment for specific types of substance use problems are shown in Exhibit III-1. Over the time period examined, there were consistent decreases in the proportion of women in the general population who needed treatment for alcohol problems, ranging from 7.8 percent in 1985 to 3.7 percent in 1999. Similarly, need for treatment for use of any illicit drug showed an overall decrease, from 3.1 percent in 1985 to 2.6 percent in 1999. (The rates were lower in 1991 and 1994, however, at 2.3% and 2.0%, respectively.) There was also a general decline in the proportion of women in the general population who needed treatment for either substance use, from approximately 10 percent in 1985 to approximately 5 percent in 1999. With regard to specific drugs, the proportion of women in the general population who needed treatment for heroin increased from 0.1 percent in 1985 to 0.19 percent in 1991 and then decreased to 0.16 percent in 1999. Increases were observed in the estimated need for treatment for use of cocaine, tranquilizers, sedatives, hallucinogens, stimulants, inhalants, and analgesics. The proportion of women in the general population who needed treatment for marijuana use decreased from 2.1 percent in 1985 to approximately 1 percent in each of the following years examined. The proportion of women in the general population who received treatment varied over time and by type of substance use. The proportion of women who received treatment for alcohol problems was approximately 0.7 percent in both 1991 and 1999, although the rate increased to 0.9 percent in 1994. The proportion of women who were treated for any illicit drug use increased from 0.13 percent in 1985 to approximately 0.6 percent in 1999. The proportion of women who received treatment for substance abuse increased from 0.94 percent in 1991 to 1.0 percent in 1994 but decreased slightly to 0.87 percent in 1999. Rates of treatment for use of specific drugs remained approximately the same from 1994 to 1999, although there were slight increases in the rates of treatment for women who used cocaine, tranquilizers, hallucinogens, and analgesics. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 22 Findings EXHIBIT III-1 ESTIMATED PERCENTAGE OF WOMEN IN THE GENERAL POPULATION WHO NEEDED AND RECEIVED TREATMENT IN THE PAST YEAR, BY TYPE OF SUBSTANCE (SOURCE: NHSDA) % Need Tx 7.79 0.10 0.57 0.25 0.11 0.02 0.32 0.03 2.08 0.06 3.13 1985 (N = 100,776,309) Lower % Lower - Upper Rec’ - Upper 95% CI d Tx 95% CI 6.50-9.09 0.03-0.16 0.34-0.79 0.06-0.44 0.00-0.28 0.00-0.05 0.14-0.49 0.00-0.09 1.68-2.49 0.01-0.11 2.60-3.66 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA % Need Tx 7.74 0.19 0.49 0.26 0.25 0.06 0.28 0.17 0.95 0.31 2.26 9.27 1991 (N = 105,617,338) Lower % Lower - Upper Rec’d - Upper Tx 95% CI 95% CI 6.87-8.61 0.10-0.28 0.34-0.64 0.13-0.40 0.11-0.38 0.02-0.10 0.18-0.39 0.08-0.26 0.75-1.15 0.18-0.44 1.89-2.62 8.34-10.20 0.73 NA NA NA NA NA NA NA NA NA 0.42 0.94 0.52-0.95 NA NA NA NA NA NA NA NA NA 0.26-0.58 0.69-1.19 % Need Tx 6.19 0.12 0.39 0.26 0.19 0.15 0.32 0.14 0.99 0.33 1.99 7.14 1994 (N = 109,046,125) Lower % Lower - Upper Rec’d - Upper Tx 95% CI 95% CI 5.31-7.07 0.06-0.18 0.24-0.54 0.11-0.41 0.06-0.32 0.08-0.22 0.20-0.44 0.06-0.22 0.75-1.23 0.20-0.45 1.63-2.35 6.25-8.03 0.94 0.07 0.21 0.08 0.09 0.06 0.10 0.03 0.26 0.09 0.59 1.00 0.72-1.16 0.02-0.13 0.10-0.32 0.02-0.15 0.00-0.20 0.01-0.11 0.04-0.17 0.00-0.07 0.13-0.39 0.01-0.17 0.41-0.78 0.77-1.22 % Need Tx 3.73 0.16 0.65 0.35 0.15 0.29 0.48 0.17 1.11 0.84 2.56 5.38 1999 (N = 114,893,885) Lower % Lower - Upper Rec’d - Upper Tx 95% CI 95% CI 3.31-4.14 0.08-0.24 0.50-0.81 0.22-0.47 0.05-0.25 0.20-0.38 0.36-0.61 0.13-0.20 0.94-1.28 0.67-1.00 2.30-2.82 4.92-5.84 0.69 0.08 0.25 0.12 0.07 0.14 0.10 0.05 0.28 0.15 0.58 0.87 0.50-0.88 0.02-0.13 0.14-0.35 0.03-0.21 0.00-0.15 0.06-0.22 0.05-0.16 0.03-0.08 0.18-0.38 0.05-0.24 0.44-0.73 0.66-1.07 Substance Alcohol Heroin Cocaine Tranquilizers Sedatives Hallucinogens Stimulants Inhalants Marijuana Analgesics Any drug Any drug or alcohol 0.13 0.02-0.24 NA NA 10.07 8.58-11.55 NA = Data not available Tx = Treatment J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 23 Findings Estimates of the percentages of women age 12 and above in the general population who received treatment in the past year, among those who needed treatment, by type of substance, are shown in Exhibit III-2. There was a consistent increase in the proportion of women who both needed and received treatment for alcohol problems, from approximately 9 percent in 1991 to about 19 percent in 1999. Similarly, there was an increase in the proportion of women who both needed and received treatment for substance abuse, from approximately 4 percent in 1985 to 30 percent in 1994. The rate of treatment for women with illicit drug problems decreased to 23 percent in 1999. Overall, the rate of treatment for women who needed treatment for substance abuse problems increased from 10 percent in 1991 to 16 percent in 1999. EXHIBIT III-2 PERCENTAGE OF WOMEN WHO RECEIVED TREATMENT IN THE PAST YEAR, AMONG WOMEN WHO NEEDED TREATMENT, BY SUBSTANCE (1985-1999) (SOURCE: NHSDA) 1985 Substance Alcohol Any drug Any drug or alcohol % NA (N=3,151,818) 4.3 NA LowerUpper 95% CI NA 0.7-7.8 NA 1991 % (N=8,175,130) 9.4 (N=2,382,075) 18.5 (N=9,790,234) 10.1 LowerUpper 95% CI 6.7-12.1 12.4-24.6 7.5-12.8 1994 % (N=6,460,010) 15.7 (N=2,146,485) 30.2 (N=7,468,948) 14.5 LowerUpper 95% CI 11.8-19.5 23.2-37.2 11.2-17.8 1999 % (N=4,284,403) 18.5 (N=2,941,848) 22.7 (N=6,177,634) 16.1 LowerUpper 95% CI 14.0-23.1 17.8-27.6 12.7-19.5 NA = Data not available N = Number of women in the population age 12 and older who needed treatment for use of a particular substance 2. CHARACTERISTICS OF WOMEN WHO RECEIVED TREATMENT The characteristics of women who received substance abuse treatment were examined separately for women who were treated for alcohol problems and for women who were treated for drug problems. It is important to note that some variables either were not available in each survey year or were not defined consistently across the survey years examined (as described in Appendices A and B). 2.1 Women Treated for Alcohol Problems As shown in Exhibit III-3, among women who were treated for alcohol problems only, there was an increase in the proportion of adolescents (age 12 through 17), from 7 percent in 1991 to 12 percent in 1999, as well as an increase in women age 35 and older, from 33 percent to 59 percent. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 24 Findings EXHIBIT III-3 AGE OF WOMEN TREATED FOR ALCOHOL PROBLEMS IN THE PAST YEAR (1991-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1991 (N=769,608) 12-17 Years 1994 (N=1.0M) 18-25 Years 26-34 Years 1999 (N=793,491) 35+ Years Among women treated for alcohol problems, there was a decrease in the percentage of white women, from 83 percent in 1991 to 67 percent in 1999, and there were increases in the proportions of women of all other racial/ethnic groups who received treatment for alcohol problems during the same time period (see Exhibit III-4). EXHIBIT III-4 ETHNICITY OF WOMEN TREATED FOR ALCOHOL PROBLEMS IN THE PAST YEAR (1991-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1991 (N=769,608) White 1994 (N=1.0M) African-American 1999 (N=793,491) Hispanic Other J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 25 Findings The proportion of women treated for alcohol problems who had not completed high school decreased from 34 percent in 1991 to 19 percent in 1999. The proportion of women who had completed high school increased from 32 percent to 36 percent, and the proportion of women who had attended college increased from 19 percent to 28 percent (see Exhibit III-5). EXHIBIT III-5 EDUCATIONAL STATUS OF WOMEN TREATED FOR ALCOHOL PROBLEMS IN THE PAST YEAR (1991-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1991 (N=769,608) 1994 (N=1.0M) 1999 (N=793,491) < High School Some College High School College Graduate As shown in Exhibit III-6, there was an increase in the proportion of women treated for alcohol problems who were in the labor force, either full- or part-time, from 47 percent in 1991 to 53 percent in 1999, and a decrease in the proportion of women treated for alcohol problems who were homemakers, from 19 percent to 3 percent over this time period. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 26 Findings EXHIBIT III-6 WORK STATUS OF WOMEN TREATED FOR ALCOHOL PROBLEMS IN THE PAST YEAR (1991-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1991 (N=769,608) 1994 (N=1.0M) 1999 (N=793,491) Full-time Part-time Looking for work Homemaker Other There was an increase in the proportion of women treated for alcohol problems who were married, from 25 percent in 1991 to 47 percent in 1999, and there were decreases in the proportions of women treated for alcohol problems who had never been married, from 44 percent to 35 percent, and who had been divorced or separated, from 21 percent to 16 percent (see Exhibit III-7). EXHIBIT III-7 MARITAL STATUS OF WOMEN TREATED FOR ALCOHOL PROBLEMS IN THE PAST YEAR (1991-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1991 (N=769,608) 1994 (N=1.0M) 1999 (N=793,491) Married Divorced/Separated Never Married Widowed J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 27 Findings The proportion of women treated for alcohol problems who had children under 18 years of age increased from 34 percent in 1991 to 43 percent in 1994. The rate declined to 30 percent in 1999. The 1999 NHSDA asked only about the number of respondents’ children under 18 years of age who were currently in the household, however (see Exhibit III-8). EXHIBIT III-8 PERCENTAGE OF WOMEN TREATED FOR ALCOHOL PROBLEMS IN THE PAST YEAR WHO HAD CHILDREN UNDER 18 YEARS OLD (1991-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1991 (N=769,608) 1994 (N=1.0M) 1999* (N=793,491) *Refers only to children <18 currently in household As shown in Exhibit III-9, the rate of private health insurance coverage among women treated for alcohol problems increased over the time period studied, from 48 percent in 1991 to 58 percent in 1999. Similarly, the proportion of women receiving alcohol treatment who had Medicaid coverage increased from 15 percent in 1991 to 22 percent in 1999. Conversely, the rate of women treated for alcohol problems who had no form of health insurance decreased from 34 percent in 1991 to 20 percent in 1999. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 28 Findings EXHIBIT III-9 HEALTH INSURANCE STATUS OF WOMEN TREATED FOR ALCOHOL PROBLEMS IN THE PAST YEAR (1991-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1991 (N=769,608) 1994 (N=1.0M) 1999 (N=793,491) Private Medicaid Other None There was a dramatic reduction in the proportion of women receiving treatment for alcohol problems who were on welfare, from 19 percent in 1994 to about 5 percent in 1999. Similarly, in cases where either the respondent or a household member received welfare, the proportion of women treated for alcohol problems decreased from 26 percent in 1994 to 6 percent in 1999 (data not displayed). 2.2 Women Treated Only for Drug Problems There were similar changes in the sociodemographic characteristics of women treated only for drug problems and not for alcohol over the time period examined, with some exceptions. There was an increase in the proportion of women age 35 years and older who received treatment for drug problems, from 43 percent in 1985 to 49 percent in 1999, and a decrease in the proportion of adolescent women (age 12 through 17 years) who received drug treatment over this same time period, from 24 percent to 18 percent (see Exhibit III-10). J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 29 Findings EXHIBIT III-10 AGE OF WOMEN TREATED FOR DRUG PROBLEMS IN THE PAST YEAR (1985-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1985 (N=134,464) 12-17 Years 1991 (N=439,938) 18-25 Years 1994 (N=648,815) 26-34 Years 1999 (N=667,744) 35+ Years Among women treated for drug problems, there was a decrease in the proportion of white women from a high of 85 percent in 1994 to 72 percent in 1999. With the exception of Hispanics, there were increases in the proportions of women of all other racial/ethnic groups who were treated for drug problems. The proportion of Hispanics among women who were treated for drug problems decreased from 22 percent in 1985 to 8 percent in 1999 (see Exhibit III-11). EXHIBIT III-11 ETHNICITY OF WOMEN TREATED FOR DRUG PROBLEMS IN THE PAST YEAR (1985-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1985 (N=134,464) White 1991 (N=439,938) African-American 1994 (N=648,815) Hispanic 1999 (N=667,744) Other J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 30 Findings The proportion of women treated for drug problems who had attended or graduated from college increased from 10 percent in 1985 to 32 percent in 1999. There was a corresponding decrease in the proportion of women treated for drug problems who had less than a high school education, from 35 percent to 27 percent (see Exhibit III-12). EXHIBIT III-12 EDUCATIONAL STATUS OF WOMEN TREATED FOR DRUG PROBLEMS IN THE PAST YEAR (1985-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1985 (N=134,464) < High School 1991 (N=439,938) High School 1994 (N=648,815) Some College 1999 (N=667,744) College Graduate There was an increase in the rate of employment, either full- or part-time, among women treated for drug problems, from 25 percent in 1985 to 46 percent in 1999 (the rate of employment was highest in 1991, at 5%) (see Exhibit III-13). EXHIBIT III-13 WORK STATUS OF WOMEN TREATED FOR DRUG PROBLEMS IN THE PAST YEAR (1985-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1985 (N=134,464) Full-time 1991 (N=439,938) 1994 (N=648,815) 1999 (N=667,744) Other Part-time Looking for work Homemaker J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 31 Findings There was an increase in the proportion of women treated for drug problems who were married, from 21 percent in 1985 to 35 percent in 1999, and there were decreases in the proportions of women treated for drug problems who were never married, from 53 percent to 47 percent, and who were separated or divorced, from 26 percent to 17 percent (see Exhibit III-14). EXHIBIT III-14 MARITAL STATUS OF WOMEN TREATED FOR DRUG PROBLEMS IN THE PAST YEAR (1985-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1985 (N=134,464) Married 1991 (N=439,938) 1994 (N=648,815) Never Married 1999 (N=667,744) Widowed Divorced/Separated The proportion of women receiving drug treatment who had at least one child under 18 years of age increased from 20 percent in 1985 to 35 percent in both 1994 and 1999 (the latter year measured only children under 18 years of age currently in the household) (see Exhibit III15). EXHIBIT III-15 PERCENTAGE OF WOMEN TREATED FOR DRUG PROBLEMS IN THE PAST YEAR WHO HAD CHILDREN UNDER 18 YEARS OLD (1985-1999) (SOURCE: NHSDA) 100% The rate of private health insurance coverage among women treated for drug problems decreased from 54 percent in 1991 to 47 percent in 1999, while the rate of Medicaid coverage 80% among such women increased from 19 percent to 28 percent over this time (see Exhibit III-16). The proportion of women treated for drug problems who had no health insurance coverage 60% remained stable over this time at approximately 25 percent. 40% 20% 0% 1985 (N=134,464) 1991 (N=439,938) 1994 (N=648,815) 1999* (N=667,744) EXHIBIT III-16 *Refers only to children <18 years old currently in household J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 32 Findings The rate of private health insurance coverage among women treated for drug problems decreased from 54 percent in 1991 to 47 percent in 1999, while the rate of Medicaid coverage increased from 19 percent to 28 percent over this time period (see Exhibit III-16). The proportion of women treated for drug problems without any health insurance coverage remained stable at approximately 25 percent. EXHIBIT III-16 HEALTH INSURANCE STATUS OF WOMEN TREATED FOR DRUG PROBLEMS IN THE PAST YEAR (1991-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1991 (N=439,938) Private 1994 (N=648,815) Medicaid Other 1999 (N=667,744) None The proportion of women receiving drug treatment who were on welfare decreased dramatically, from 25 percent in 1994 to 7 percent in 1999. Similarly, the proportion of women treated for drug problems, where either the respondent or a household member was a welfare recipient, decreased from 29 percent in 1994 to 11 percent in 1999 (data not displayed). 3. SETTINGS IN WHICH WOMEN RECEIVED TREATMENT The settings in which women received treatment for alcohol problems in 1994 and 1999 are shown in Exhibit III-17. There were increases over this time period in the proportions of women who received treatment for alcohol problems in mental health centers, hospitals (both in emergency rooms and as inpatients), private doctors’ offices, and inpatient rehabilitation centers. The rates of treatment for alcohol problems in the criminal justice system, in outpatient rehabilitation, and through self-help participation remained approximately the same over this time period. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 33 Findings EXHIBIT III-17 SETTINGS OF TREATMENT RECEIVED, AMONG WOMEN WHO RECEIVED TREATMENT FOR ALCOHOL PROBLEMS IN THE PAST YEAR (1994-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1994 (N=1.0M) 1999 (N=793,491) Hospital Mental Health Center Criminal Justice System Inpatient Rehab Emergency Room Self-help Outpatient Rehab Doctor's Office As shown in Exhibit III-18, among women treated for drug problems only and not for alcohol problems, there were increases from 1991 to 1999 in the proportion who were treated in hospitals (both in emergency rooms and as inpatients), rehabilitation programs (inpatient or outpatient), mental health centers, and private doctors’ offices. There was also an increase in the proportion of women who received treatment for drug problems in the criminal justice system, from 2 percent in 1991 to 7 percent in both 1994 and 1999. Self-help participation among women treated for drug problems decreased from 81 percent in 1991 to 54 percent in 1999. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 34 Findings EXHIBIT III-18 SETTINGS OF TREATMENT RECEIVED, AMONG WOMEN WHO RECEIVED TREATMENT FOR DRUG PROBLEMS IN THE PAST YEAR (1991-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1991 (N=439,938) (N=439,938) Center Mental Health Criminal Justice System Hospital 1994 (N=648,815) (N=648,815) Emergency Room Self-help Inpatient Rehab 1999 (N=667,744) (N=667,744) Doctor's Office Outpatient Rehab* *No distinction was made between inpatient and outpatient rehabiliation in 1991; all rehabilitation programs were therefore coded as outpatient in 1991. As shown in Exhibit III-19, among women treated for substance use problems (alcohol or drugs, or both), there were increases from 1994 to 1999 in the rates of having been treated in hospitals (both in emergency rooms and as inpatients), mental health centers, and private doctors’ offices. The rate of treatment for such women in either inpatient or outpatient rehabilitation programs and in the criminal justice system remained approximately the same. Treatment received in churches or schools increased from 1 percent in 1994 to 9 percent in 1999. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 35 Findings EXHIBIT III-19 SETTINGS OF TREATMENT RECEIVED, AMONG WOMEN WHO RECEIVED TREATMENT FOR SUBSTANCE USE PROBLEMS IN THE PAST YEAR (1994-1999) (SOURCE: NHSDA) 100% 80% 60% 40% 20% 0% 1994 (N=1.1M) Hospital Mental Health Center Criminal Justice System Inpatient Rehab Emergency Room Self-help 1999 (N=994,574) Outpatient Rehab Doctor's Office Church/School In general, the findings of the analysis suggest that women with any kind of substance use problem received treatment in a variety of treatment settings over the time period examined, including both alcohol and drug treatment settings and other health care settings. Although the rate of participation in self-help groups appeared to decline over this time period, over half the respondents in each survey year reported self-help participation, which was greater than the rate of treatment received in any other type of setting in any survey year. 4. PERCENTAGES OF WOMEN CLIENTS AND SERVICES PROVIDED TO WOMEN IN TREATMENT SETTINGS The percentages of women clients in treatment settings were examined for two purposes. The first was to determine whether there were changes in the proportions of women who received treatment in different types of treatment settings over the period examined, using data from treatment providers. The second purpose was to determine if the types of services provided to women clients in these treatment settings changed over time or varied with the proportion of women in these treatment settings. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 36 Findings 4.1 Percentages of Women Clients in Treatment Settings, by Primary Substance Treated and Type of Treatment Provided The percentages of women clients in alcohol treatment settings, by the type of treatment provided across the four years of the analysis, is shown in Exhibit III-20. The percentages of women clients in drug treatment only settings and in combined alcohol and other drug (AOD) treatment settings are shown in Exhibit III-20 and III-21, respectively. In addition, mean percentages of women clients in treatment settings are shown for each type of treatment and for the aggregate of all types of treatment, by the type of primary substance treated. The grand total, or percentages of women clients in treatment settings, across all types of treatment provided and for all types of substances treated for each survey year, is shown in Exhibit III-22. As discussed in Chapter II, the types of treatment provided were more differentiated in later survey years (e.g., differentiation of residential rehabilitation into short-term, long-term, and therapeutic community; differentiation of outpatient treatment into intensive and non-intensive; and inclusion of treatment in alternative programs provided in the criminal justice system, such as probation and drug court). Overall, women comprised a smaller proportion of clients in facilities that provided primarily alcohol treatment, averaging approximately 25 percent of the clients in these facilities. They average approximately 35 percent of the clients in facilities offering primarily drug treatment, and approximately 30 percent of the clients in combined AOD treatment facilities, across all survey years. There was a gradual increase in the proportion of women clients in all types of treatment settings combined, from 28 percent in 1987 to 32 percent in 1998. The proportions of women clients declined in settings providing primarily alcohol treatment, remained relatively constant in settings providing primarily drug treatment, and increased in settings providing AOD treatment over the time period examined. Across all types of treatment providers (i.e., alcohol, drug, AOD), the largest concentrations of women clients were in residential rehabilitation and intensive outpatient settings, ranging from 25 percent to 50 percent of the clients in these treatment settings. Similarly, the largest concentrations of providers that served women only were in settings that provided residential rehabilitation and intensive outpatient treatment. There were also steady increases in the proportions of women receiving treatment for drug-only and AOD use in the criminal justice system over the time period examined, as well as increases in settings based on the criminal justice system that provided treatment to women only. In 1987, women accounted for 13 percent of the clients served by 48 AOD treatment providers in the criminal justice system; by 1999, women accounted for 21 percent of clients served by AOD treatment providers in the criminal justice system, and the number of providers had increased to 371. In addition, in 1999 women accounted for 28 percent of the clients receiving AOD treatment in alternative criminal justice system settings, such as drug courts, diversion programs, probation, or parole. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 37 Findings EXHIBIT III-20 PERCENTAGE OF ALCOHOL TREATMENT PROVIDERS, BY PERCENTAGE OF WOMEN CLIENTS AND TYPE OF TREATMENT (1987-1998) (SOURCE: NDATUS/UFDS) 1987 (N = 1,735) 1991 (N = 1,129) 1994 (N = 1,004) 1998 (N = 332) Percentage of Providers, by Percentage of Women Clients Type of Tx Outpatient Outpatient – Intensive Residential Rehab Short-term Residential Rehab Long-term Residential Rehab Other Residential Rehab Therapeutic Community CJS Alternative CJS Hospital Inpatient TOTAL (N = 4,200) 0% 6.6 NA 40.2 NA NA NA NA 70.0 NA 29.3 19.8 149% 85.0 NA 40.1 NA NA NA NA 20.0 NA 68.1 68.6 5099% 7.9 NA 1.7 NA NA NA NA 0.0 NA 2.7 5.3 100 % 0.5 NA 18.0 NA NA NA NA 10.0 NA 0.0 6.3 Avg. % (SD) 24.0 (16.7) NA 28.0 (36.3) NA NA NA NA 13.3 (31.2) NA 17.0 (15.7) 24.6 (25.1) Percentage of Providers, by Percentage of Women Clients 0% 13.8 12.0 NA 20.8 48.5 NA NA 100 NA 41.7 21.6 149% 76.2 79.6 NA 71.4 29.3 NA NA 0.0 NA 54.2 66.1 5099% 7.8 5.6 NA 5.2 2.9 NA NA 0.0 NA 0.0 6.4 100 % 2.2 2.8 NA 2.6 19.2 NA NA 0.0 NA 4.2 5.9 Avg. % (SD) 23.2 (21.0) 27.1 (19.8) NA 22.3 (19.3) 28.9 (38.0) NA NA 0.0 NA 17.5 (22.8) 24.6 (25.5) Percentage of Providers, by Percentage of Women Clients 0% 15.4 18.4 NA 26.7 45.8 NA NA 75.0 NA 19.6 21.5 149% 71.8 72.8 NA 73.3 28.9 NA NA 25.0 NA 76.1 65.0 5099% 9.7 8.8 NA 0.0 4.2 NA NA 0.0 NA 2.2 8.0 100 % 3.1 0.0 NA 0.0 21.1 NA NA 0.0 NA 2.2 5.5 Avg. % (SD) 23.9 (22.3) 25.0 (19.0) NA 15.6 (12.4) 30.6 (39.4) NA NA 6.0 (11.2) NA 22.2 (19.4) 24.7 (25.3) Percentage of Providers, by Percentage of Women Clients 0% 35.1 28.8 NA NA NA 45.0 66.7 16.7 25.0 60.0 33.1 149% 51.2 66.7 NA NA NA 25.0 33.3 83.3 62.5 10.0 54.5 5099% 10.4 1.5 NA NA NA 10.0 0.0 0.0 6.2 30.0 8.4 100 % 3.3 3.0 NA NA NA 20.0 0.0 0.0 6.2 0.0 3.9 Avg. % (SD) 30.0 (23.7) 17.4 (21.0) NA NA NA 30.2 (39.0) 2.8 (4.8) 19.5 (13.8) 24.2 (25.7) 18.6 (25.7) 20.7 (23.8) Tx = Treatment NA = Data not available CJS = Criminal justice system Avg % = Average percentage of women clients SD = Standard deviation J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 38 Findings EXHIBIT III-21 PERCENTAGE OF DRUG TREATMENT PROVIDERS, BY PERCENTAGE OF WOMEN CLIENTS AND TYPE OF TREATMENT (1987-1998) (SOURCE: NDATUS/UFDS) 1987 (N = 1,171) 1991 (N = 850) 1994 (N = 1,073) 1998 (N = 465) Percentage of Providers, by Percentage of Women Clients Type of Tx Outpatient Outpatient – Intensive Outpatient – Methadone/LAAM Residential Rehab Short-term Residential Rehab Long-term Residential Rehab Other Residential Rehab Therapeutic Community CJS Alternative CJS 0% 1.5 NA 11.5 18.2 NA NA NA NA 65.0 NA 149% 78.6 NA 76.6 68.2 NA NA NA NA 30.0 NA 5099% 18.7 NA 10.9 2.3 NA NA NA NA 0.0 NA 100 % 1.2 NA 1.0 11.2 NA NA NA NA 5.0 NA Avg. % (SD) 37.4 (17.4) NA 31.5 (17.8) 31.4 (28.3) NA NA NA NA 10.1 (22.7) NA 22.4 (17.4) 34.7 (20.3) Percentage of Providers, by Percentage of Women Clients 0% 2.6 5.8 2.0 NA 28.6 20.4 NA NA 65.7 NA 16.7 8.5 149% 75.6 69.2 87.0 NA 42.9 59.9 NA NA 14.3 NA 66.7 73.6 5099% 18.5 11.5 11.0 NA 0.0 5.4 NA NA 2.9 NA 0.0 12.5 100 % 3.3 13.5 0.0 NA 28.6 14.3 NA NA 17.1 NA 16.7 5.4 Avg. % (SD) 38.1 (20.8) 41.4 (28.6) 37.1 (11.2) NA 38.1 (43.6) 35.4 (31.2) NA NA 23.8 (38.4) NA 23.5 (37.9) 36.8 (22.4) Percentage of Providers, by Percentage of Women Clients 0% 5.8 2.4 0.5 NA 18.2 46.7 NA NA 69.0 NA 50.0 13.9 149% 75.1 58.5 89.6 NA 54.6 37.7 NA NA 6.9 NA 40.0 69.4 5099 % 14.7 13.4 9.1 NA 9.1 3.3 NA NA 6.9 NA 10.0 10.0 100 % 4.3 25.6 0.8 NA 18.2 12.3 NA NA 17.2 NA 0.0 6.7 Avg. % (SD) 37.3 (21.8) 51.0 (32.2) 37.9 (12.5) NA 35.6 (37.6) 25.0 (33.1) NA NA 23.7 (41.2) NA 14.7 (22.0) 35.5 (24.9) Percentage of Providers, by Percentage of Women Clients 0% 4.2 7.1 1.5 NA NA NA 27.3 18.2 28.6 50.0 100.0 5.6 149% 84.2 83.9 88.4 NA NA NA 36.4 54.6 28.6 50.0 0.0 82.6 5099% 10.3 7.1 8.7 NA NA NA 9.1 9.1 14.3 0.0 0.0 9.0 100 % 1.2 1.8 1.5 NA NA NA 27.3 18.2 28.6 0.0 0.0 2.8 Avg. % (SD) 34.4 (16.6) 31.2 (18.5) 37.5 (12.5) NA NA NA 39.6 (41.7) 40.2 (36.8) 43.6 (42.3) 12.5 (17.3) 0.0 35.4 (17.9) Hospital Inpatient 18.5 74.1 7.4 0.0 TOTAL (N = 3,559) 7.0 76.0 14.0 3.0 Tx = Treatment NA = Data not available CJS = Criminal justice system Avg % = Average percentage of women clients SD = Standard deviation J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 39 Findings EXHIBIT III-22 PERCENTAGE OF AOD TREATMENT PROVIDERS, BY PERCENTAGE OF WOMEN CLIENTS AND TYPE OF TREATMENT (1987-1998) (SOURCE: NDATUS/UFDS) 1987 (N = 3,584) 1991 (N = 5,534) 1994 (N = 8,068) 1998 (N = 10,540) Percentage of Providers, by Percentage of Women Clients Type of Tx Outpatient Outpatient – Intensive Residential Rehab Short-term Residential Rehab Long-term Residential Rehab Other Residential Rehab Therapeutic Community CJS Alternative CJS Hospital Inpatient TOTAL (N = 27,726) Grand Total (N = 35,485) 0% 5.2 NA 29.3 NA NA NA NA 72.9 NA 11.7 11.2 12.5 149% 86.5 NA 54.9 NA NA NA NA 16.7 NA 78.8 79.0 76.0 5099% 7.9 NA 3.8 NA NA NA NA 4.2 NA 8.1 6.7 7.5 100 % 0.4 NA 12.0 NA NA NA NA 6.2 NA 1.4 3.1 3.9 Avg. % (SD) 28.6 (15.5) NA 28.3 (30.7) NA NA NA NA 12.5 (29.0) NA 26.8 (18.0) 28.0 (20.3) 28.3 (21.9) Percentage of Providers, by Percentage of Women Clients 0% 20.4 13.8 NA 29.3 41.2 NA NA 62.9 NA 26.4 16.6 16.4 149% 60.5 70.4 NA 52.2 33.9 NA NA 26.4 NA 54.8 68.9 69.0 5099% 14.8 11.4 NA 11.7 6.2 NA NA 2.2 NA 15.1 8.5 8.6 100 % 4.3 4.4 NA 6.8 18.6 NA NA 8.4 NA 3.6 6.0 5.9 Avg. % (SD) 29.7 (24.8) 29.8 (23.1) NA 26.8 (27.3) 31.4 (37.2) NA NA 14.7 (29.3) NA 28.0 (24.3) 29.5 (24.8) 29.6 (24.9) Percentage of Providers, by Percentage of Women Clients 0% 14.3 11.1 NA 23.8 33.6 NA NA 55.9 NA 29.2 12.5 13.5 149 % 64.4 68.6 NA 59.2 38.5 NA NA 29.9 NA 50.8 70.0 69.5 5099% 16.4 14.0 NA 9.8 6.9 NA NA 3.4 NA 16.3 10.2 9.9 100 % 4.9 6.3 NA 7.1 21.1 NA NA 10.7 NA 3.7 7.3 7.1 Avg. % (SD) 31.9 (24.6) 33.4 (24.9) NA 29.4 (27.3) 36.0 (37.6) NA NA 18.9 (31.6) NA 27.2 (25.7) 32.4 (25.7) 32.0 (25.7) Percentage of Providers, by Percentage of Women Clients 0% 5.7 3.4 NA NA NA 30.8 30.5 42.3 14.6 20.0 11.4 11.8 149% 78.3 82.2 NA NA NA 43.4 44.0 46.1 73.0 64.4 71.8 71.8 5099% 14.2 10.5 NA NA NA 6.2 6.5 3.5 6.2 13.6 90.5 10.1 100 % 1.8 3.9 NA NA NA 19.6 19.0 8.1 6.2 1.8 6.6 6.3 Avg. % (SD) 31.9 (19.4) 33.0 (20.8) NA NA NA 35.2 (36.1) 34.9 (36.7) 21.3 (28.1) 28.1 (24.5) 29.1 (21.1) 32.4 (24.9) 32.1 (24.7) Tx = Treatment NA = Data not available CJS = Criminal justice system Avg % = Average percentage of women clients SD = Standard deviation J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 40 Findings 4.2 Types of Services Provided, by Primary Substance Treated and Percentage of Women Clients in Treatment Settings The types of services provided in treatment settings were examined by the type of substance treated and the percentage of women clients in treatment settings. Findings were collapsed across all types of treatment (e.g., inpatient, outpatient, residential) to consolidate the discussion of findings. Questions about child-care services were asked in all survey years (1987 to 1998); questions about other specialized services, such as parenting/family services, services for pregnant and postpartum women, women’s groups, and domestic violence services, were asked only in the 1998 survey. Among alcohol treatment providers, only a small percentage provided child-care services across the survey years examined. Fewer than 15 percent of alcohol treatment providers offered child-care services, regardless of the proportion of women clients in the settings (data not displayed). As shown in Exhibit III-23, in all survey years, alcohol treatment providers offering services to women only had higher rates of employing staff specially trained to provide services to women. The rate declined among these providers from 1987 to 1994, however. There were no significant differences in the proportion of alcohol treatment providers that provided specific services for women (i.e., parenting/family services, services for pregnant and postpartum women, women’s groups, domestic violence services), by the percentage of women clients in these settings in 1998 (data not displayed). J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 41 Findings EXHIBIT III-23 PERCENTAGE OF ALCOHOL TREATMENT PROVIDERS WITH SPECIALLY TRAINED STAFF FOR WOMEN'S SERVICES, BY PERCENTAGE OF WOMEN CLIENTS (SOURCE: NDATUS, 1987-1994)* 100% Percent of Alcohol Treatment Providers 80% 60% 40% 20% 0% 1987 (N=1,735) 1991 (N=1,129) 1994 (N=1,004) Percent of Women Clients 0% 1 - 49% 50 - 99% 100% * All differences across groups within survey years, p <.0001 Among drug treatment providers that served women only, there was an increase in the rate of providers offering child-care services, from 17 percent in 1987 to 45 percent in 1998. Fewer than 20 percent of all-male and mixed-gender drug treatment providers offered child-care services in any of the survey years examined (data not displayed). As shown in Exhibit III-24, there was an increase in the proportion of drug treatment providers offering services to women only that had staff specially trained to provide services to women, from 71 percent in 1987 to 89 percent in 1999, although this rate decreased to 61 percent in 1994. Settings providing services exclusively to women were more likely to have staff trained to provide services to women, as compared to settings that had either all-male or mixed-gender clients, at all time points. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 42 Findings EXHIBIT III-24 PERCENTAGE OF DRUG TREATMENT PROVIDERS WITH SPECIALLY TRAINED STAFF FOR WOMEN'S SERVICES, BY PERCENTAGE OF WOMEN CLIENTS (SOURCE: NDATUS, 1987-1994)* Pe rc en t of Dr ug Tr ea tm en t Pr ov id er s 100% Percent of Drug Treatment Providers 80% 60% 40% 20% 0% 1987 (N=1,171) 1991 (N=850) 1994 (N=1,073) Percent of Women Clients 0% 1 - 49% 50 - 99% 100% * All differences across groups within survey years, p <.0001 Similarly, in 1998, drug treatment providers offering services to women only had higher rates than all-male or mixed-gender providers of providing parenting/family services (82% versus 35% or less), services for pregnant and postpartum women (46% versus 41% or less), women’s groups (46% versus 33% or less), and domestic violence services (48% versus 16% or less) (data not displayed). AOD treatment providers showed a similar pattern regarding the provision of child-care services as alcohol and drug treatment providers. Fewer than 15 percent of male-only or mixedgender AOD treatment providers offered child-care services in any of the survey years, whereas 12 percent of women-only AOD providers offered child-care services in 1987, and this rate increased to 45 percent in 1998 (data not displayed). Similarly, there were increases from 1987 to 1991 in the proportion of AOD treatment providers that had staff specially trained to provide services to women, except among providers to women only, where the rate remained stable at 87 percent. Among all providers, the rates of J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 43 Findings having specially trained staff decreased from 1991 to 1994 (see Exhibit III-25). AOD treatment providers that had only women clients had higher rates of staff trained to provide services to women, compared to other AOD treatment providers, at all time points. EXHIBIT III-25 PERCENTAGE OF AOD TREATMENT PROVIDERS WITH SPECIALLY TRAINED STAFF FOR WOMEN'S SERVICES, BY PERCENTAGE OF WOMEN CLIENTS (SOURCE: NDATUS, 1987-1994)* 100% Percent of AOD Treatment Providers 80% 60% 40% 20% 0% 1987 (N =3,584) 1991 (N=5,534) 1994 (N=8,068) Percent of Women Clients 0% 1 - 49% 50 - 99% 100% * All differences across groups within survey years, p <.0001 Similar to drug treatment only providers, in 1998, AOD treatment providers offering services to women only had higher rates than mixed-gender or all-male providers of offering parenting/family services (76% versus 48% or less), services for pregnant and postpartum women (55% versus 26% or less), women’s groups (64% versus 36% or less), and domestic violence services (48% versus 36% or less) (data not displayed). J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 44 IV. SUMMARY AND IMPLICATIONS IV. SUMMARY AND IMPLICATIONS This analysis examined changes in the provision of substance abuse treatment to women in the United States between 1985 and 1999, when several social policies were implemented that had implications for the delivery of substance abuse treatment services to women. The findings of the analysis suggest that there were changes in service delivery over this time period consistent with these social policies. Most important, the rates of treatment utilization among women who needed treatment increased over this time, a broader range of women accessed treatment services across a wider variety of settings, and substance abuse treatment providers increased the provision of services that addressed women’s treatment needs. 1. SUMMARY AND DISCUSSION OF KEY FINDINGS FROM THE ANALYTIC QUESTIONS In the sections below, brief summaries of the key findings from the analytic questions are presented. 1.1 Changes in the Rates of Women Who Needed and Received Treatment for Alcohol and Drug Problems From 1985 to 1999 The analysis showed that there were generally decreases in the rates of need for treatment for use of alcohol or illicit drugs among women age 12 and above in the general population. It is important to note that the focus of this analysis was on changes over time in need for treatment and treatment utilization among women, and that gender comparisons were beyond the scope of the present analysis – clearly an important area for future analysis. Other surveys, however, have shown that there was an overall decrease in need for treatment among the general population over this time, and hence this finding for women parallels that of men (Office of Applied Studies, 1997). In 1985, approximately 10 million women needed treatment for either an alcohol problem or a drug problem; this number declined to approximately 9.8 million women in 1991, to 7.5 million women in 1994, and to 6.2 million women in 1999. Despite these decreases in the proportion of women in the general population who needed treatment, the actual numbers of women who needed substance abuse treatment remained substantial. The proportion of women in the general population who received substance abuse treatment declined slightly over this same time period, yet the estimated number of women who received treatment remained stable at approximately one million because of an increase in the number of women in the overall population. When utilization of treatment for either alcohol or drug problems was examined among women who needed treatment, there was a gradual increase in the rates of treatment utilization, J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 46 Summary and Implications from 10 percent in 1991 to 16 percent in 1999. In terms of numbers, in 1985, approximately 3.2 million women (3.1%) needed treatment for a drug problem, yet only approximately 134,000 of these (4.3% of those who needed treatment) reported that they had received treatment. By 1999, approximately 2.9 million women (2.6%) needed treatment for a drug problem, and the rate of treatment received among these women had increased to 23 percent, representing approximately 660,000 women. Similarly, 8.2 million women (7.7% of women in the United States) needed treatment for alcohol problems in 1991; of these, approximately 770,000 (9.4%) received treatment. This number increased to 1 million in 1994 (15.7% of those who needed treatment) and decreased to approximately 800,000 women in 1999 (18.5% of those who needed treatment). Thus, although there was a gradual decline over the time period examined in the proportion of women who needed treatment for substance use problems, there was an increase in the rate of treatment utilization among women who needed treatment. Nevertheless, the treatment gap, or lack of treatment among those who needed it, remained substantial. Indeed, in all survey years except one, less than one-fourth of the women who needed treatment for either an alcohol problem or a drug problem actually received treatment. Furthermore, other analyses conducted with NHSDA data have shown that women have lower rates of treatment utilization compared to men, even after controlling for differences in treatment need and insurance coverage for substance abuse treatment (Office of Applied Studies, 1997). In summary, although treatment utilization increased among women who needed treatment during the time period examined, which coincided with several social policy changes that promoted the expansion of treatment services for women, the majority of women with substance use problems failed to receive any kind of treatment. 1.2 Changes in the Characteristics of Women Who Received Treatment for Alcohol and Drug Problems From 1985 to 1999 The analysis showed that there were changes in the sociodemographic characteristics of women who used substance abuse treatment services over the time period examined. There were increases in the ages of women treated for substance abuse problems, decreases in the proportion of white women and increases in the proportions of women of other ethnic groups, and increases in the levels of education and rates of employment. In particular, there were increases among women with dependent children and women on Medicaid who utilized treatment. In contrast, the rate of women on welfare who received substance abuse treatment decreased dramatically from 1994 to 1999, consistent with welfare reform implemented in 1996 that reduced the rate of welfare dependence in the general population. These findings on the characteristics of women receiving substance abuse treatment, based on the NHSDA, which collects data from the general public, contrast with findings on J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 47 Summary and Implications treatment admissions from the Treatment Episode Data Set (TEDS) (Office of Applied Studies, 2001e), which reports on data collected directly from treatment centers about its clients. For example, in 1999, there were higher rates of white women who received substance abuse treatment, based on the NHSDA used in this analysis, than among treatment admissions in TEDS (72% versus 60%) and lower rates of African-Americans (15% vs. 23%) and Hispanics (8% versus 12%). This difference in characteristics may be due to several factors. The NHSDA is based on non-institutionalized respondents in the general population, whereas TEDS is based on treatment admissions (rather than discrete individuals) to substance abuse treatment facilities that serve primarily publicly funded clients (i.e., recipients of public funding). Respondents in the NHSDA reported treatment received from providers outside of publicly funded treatment settings, such as private doctors, hospital emergency rooms, and mental health centers. This difference may underlie the differences in ethnic composition and other characteristics (e.g., age distribution, rates of employment, and insurance coverage) observed in the estimates derived from the NHSDA in the current analysis and in analyses conducted with TEDS and reported elsewhere. 1.3 Changes in the Settings in Which Women Received Treatment for Alcohol and Drug Problems From 1985 to 1999 Rates of treatment received generally increased across a wide range of treatment and nontreatment settings across the survey years examined. There were increases in the rates of women who reported having received treatment for alcohol or drug problems in hospitals, mental health centers, private doctors’ offices, schools, and churches. This broad range of settings in which women received some form of treatment for substance abuse may reflect increased awareness and understanding of these problems outside of publicly funded substance abuse treatment settings. Indeed, other research conducted with data from national surveys of the general population has shown a high rate of utilization of non-publicly funded providers and combinations of formal and informal treatment among individuals with substance use problems (Kessler et al., 1999). Although the rate of self-help participation stayed the same among women with alcohol problems and decreased somewhat among women with drug problems, it remained the most frequently reported source of treatment received among women in each survey year. 1.4 Changes in the Proportion of Women Who Received Treatment in Different Types of Treatment Settings and in the Types of Services Provided in These Settings From 1987 to 1998 The proportion of women receiving substance abuse treatment across different types of treatment settings gradually increased over the time period examined, from 28 percent in 1987 to 32 percent in 1998. These estimates are based on providers surveyed by NDATUS/UFDS and J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 48 Summary and Implications correspond with data on treatment admissions from TEDS indicating that women represented about 30 percent of substance abuse treatment admissions from 1992 to 1998 (Office of Applied Studies, 2001b). In the analysis described in this report, the largest share of women clients received treatment in settings that provided residential and intensive outpatient treatment. The increased rates of women being treated in facilities that offered these more intensive forms of treatment may reflect an increased emphasis on providing treatment services specifically for women over this period and the corresponding increase in funding for these services. As noted previously, more intensive forms of treatment are vulnerable to cost containment efforts, given their generally higher costs. Yet a recent study showed that the cost savings, due to reductions in criminal behavior, was highest among pregnant women who were treated in settings providing residential treatment, compared with several forms of outpatient treatment (Daley et al., 2000). In addition, a national demonstration project showed that there were substantial reductions in the rates of infant mortality and morbidity associated with comprehensive, long-term residential treatment for substance-abusing pregnant and postpartum women (Clark, 2001). It is important to note that substance abuse treatment providers delivering services to women only comprised a small minority of all treatment providers in all years examined, ranging from 4 percent of the providers surveyed in 1987 to 7 percent of the providers surveyed in 1994 (the rate declined slightly to 6% in 1998). In contrast, the percentage of treatment providers serving males only varied between 12 and 16 percent across the survey years examined. Furthermore, given the greater number of outpatient treatment providers relative to providers of intensive outpatient or residential treatment, most women who received substance abuse treatment did so in mixed-gender settings that provided outpatient treatment. For example, in 1998, women comprised 32 percent of clients served by approximately 3,400 outpatient providers of combined AOD treatment, but only 2 percent of these providers treated women only. In the same year, women comprised 35 percent of the clients in approximately 800 therapeutic community providers of combined AOD treatment, but only 19 percent of these served women only. In summary, although there is evidence of an increased number of providers of substance abuse treatment services to women only, particularly among providers of more intensive forms of treatment, the vast majority of women who receive substance abuse treatment do not access treatment from these providers. In addition, there were increases in the proportion of women receiving substance abuse treatment, particularly for drug problems, within the criminal justice system, a finding that reflects the increased numbers of women who were incarcerated for drugrelated offenses over this time, as well as the increased availability of treatment services within criminal justice settings. Thus, although men are more likely than women to enter substance J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 49 Summary and Implications abuse treatment through the criminal justice system, it appears that women are increasingly accessing treatment through this system (Office of Applied Studies, 2001a). With regard to the types of services provided in substance abuse treatment settings, there was an increase in the proportion of treatment providers (across all types of treatment) that provided child-care services from 1987 to 1998, although the rate remained low (less than 15%) among alcohol treatment providers. As would be expected, treatment settings in which 100 percent of clients were women were more likely to have staff specially trained to provide treatment services to women, as well as to provide services that directly addressed women’s needs, as compared with all-male or mixed-gender settings. Interestingly, not all women-only providers stated that they provide these services. For example, in 1998, less than half the drug treatment providers whose clients were women only provided services for pregnant or postpartum women, child-care services, women’s groups, or domestic violence services. Also in 1998, domestic violence services were offered by fewer than half of AOD treatment providers serving women only. Thus, although there were dramatic increases over this time period in the delivery of treatment services that addressed women’s treatment needs among substance abuse providers, the availability of these services was far from comprehensive, even among providers serving only women clients. 2. IMPLICATIONS OF THE FINDINGS FOR TREATMENT PROVIDERS, POLICYMAKERS, AND RESEARCHERS/EVALUATORS The findings from this analysis have implications for treatment providers, policymakers, and researchers/evaluators, as discussed below. 2.1 Implications for Treatment Providers The findings from this analysis have implications for treatment providers, who must utilize existing resources or seek additional resources to provide needed services to their clients. Treatment providers can benefit from information on the changing characteristics of women who utilize substance abuse treatment and their service needs, such as among women with children, women of differing age and ethnic groups, women who were formerly receiving welfare, and women under criminal justice supervision. In the current analysis it was apparent that, although there have been increases in the past 15 years in the provision of services to address women’s treatment needs, not all providers, even those whose clients are primarily women, offer such services. More information is needed about how to increase the availability of services that meet women’s needs across various types of treatment settings. More information is also needed about the resources required to equip facilities to provide these services and the training required by staff. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 50 Summary and Implications 2.2 Implications for Policymakers The findings from this analysis have implications for policymakers, who need information on the potential impact that policies under consideration may have on the provision of substance abuse treatment services for women, particularly with regard to how such policies may affect treatment access and utilization. Such information is essential to ensure that decisions regarding the allocation of resources take into consideration the treatment needs of substance-abusing women and their access to appropriate treatment services. As seen in this analysis, data from national surveys like the ones utilized in this analysis can provide information on the characteristics of women who need substance abuse treatment, their rates of treatment utilization, the locations where they receive treatment, and the types of services available in different types of treatment settings. Given the limited information currently available about gender differences in this area, and the policy implications of such information, an important priority for future studies is to assess gender differences in rates of treatment need, treatment utilization, and the gap between these two. The findings from this analysis also provide policymakers with information to assess the substance abuse treatment system's adequacy for women. This important issue is often overlooked, given the larger number and often-greater visibility of male substance abusers. Policymakers may find it useful to assess the nation’s substance abuse treatment system to determine its ability to meet the needs of women who have substance abuse problems. In this regard, the findings from this analysis showed that, although there was an increase in the utilization of substance abuse treatment services over the past 15 years among women who needed treatment, a substantial gap persisted in the rate of treatment received among women who needed it. Social policies may be able to ameliorate this treatment gap among women by developing strategies for increasing the accessibility and availability of treatment services to substance-abusing women. Policymakers concerned with substance abuse treatment for women also require updated information on how the provision of these services is affected by system-level changes in other service sectors (such as criminal justice, welfare, mental health, child welfare, and health services), as well as information on the varying profiles of women who enter substance abuse treatment through these different service systems. Policymakers can use these data to assist with the prioritization of available funding for women’s treatment and to better provide services targeted to women clients. For example, the analysis showed a high rate of utilization of treatment services in settings outside of substance abuse treatment providers, such as hospitals, private doctors’ offices, and mental health clinics. Coordination of information across these service delivery systems, as well as the training of staff in these settings to enable them to assess J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 51 Summary and Implications and diagnose substance abuse disorders, would help ensure that substance-abusing women are referred to the most appropriate settings for treatment. 2.3 Implications for Researchers/Evaluators The findings of the analysis provide a foundation for future research/evaluation in the area of provision of substance abuse treatment to women in the United States, particularly research on the factors that affect women's access to and utilization of substance abuse treatment services. The analysis described in this report suggests several areas for future inquiry regarding the provision of substance abuse treatment services to women. Future analytic questions could include the following: What factors, including those at the client, program, and system levels, would increase the rate of treatment utilization among women who need treatment for substance abuse problems? Are there gender differences in the rates of treatment utilization among those who need substance abuse treatment and, if so, are these differences increasing or decreasing over time? What factors influence women to enter treatment in different types of settings? What barriers exist that result in certain forms of treatment being accessed rather then others? How do individual choice or preference, cost of treatment, location of treatment setting, and availability of treatment slots influence the type of treatment obtained? What are the benefits of treatment provided in specialized women-only versus mixedgender settings, from the perspective of treatment participants? Can treatment services that address women’s needs be integrated into mixed-gender treatment settings, or are they most effectively delivered in women-only treatment settings? Are there differences in treatment retention and outcomes among women who receive treatment in different types of treatment settings (e.g., type of substance treated, type of treatment provided, percentage of women clients in the setting) and who receive different kinds of services in these settings? What barriers (beyond the availability of resources) do providers face in developing more appropriate treatment services for women? What factors facilitate the development and implementation of treatment services that address women’s treatment needs? Future studies can build on the findings from this analysis and others by continuing to monitor changes in the rates of treatment need and utilization among substance-abusing women, the settings in which treatment is provided, and the types of services available in these settings. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 52 Summary and Implications Future analyses that examine the differences among women who access treatment in different types of treatment settings, such as differences among ethnic groups, by age, and by geographic location are areas in the literature that remain minimally explored. Ultimately, improved monitoring of access to and utilization of treatment services among substance-abusing women can reduce the costs of substance abuse to the women themselves, to their families, and to the communities in which they live. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 53 REFERENCES REFERENCES Allard, P. (2002). 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The impact of outpatient drug services on abstinence among pregnant and parenting women. Journal of Substance Abuse Treatment, 13(3), 195-202. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page 64 APPENDIX A MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS - NHSDA APPENDIX A MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS – NHSDA Construct Need for treatment for alcohol Need for treatment for marijuana Need for treatment for heroin* Need for treatment for cocaine and other stimulants 1985 Dependence or almost daily or more frequent use in past year Dependence or almost daily or more frequent use in past year Any use Cocaine: Dependence, or weekly or more frequent use in past year; or had used cocaine in the past year and had ever injected cocaine. Other stimulants: Dependence in past year Dependence in past year 1991 Dependence, almost daily or more frequent use, or treated for alcohol use in past year Same as 1985 Same as 1985 Cocaine: Dependence, or weekly or more frequent use, or injection use in past year Other stimulants: Dependence or weekly or more frequent use in past year Dependence or weekly or more frequent use in past year 1994 Dependence, almost daily or more frequent use, or treated for alcohol use in past year Dependence, almost daily or more frequent use, or treated for marijuana use in past year Same as 1985 Dependence, weekly or more frequent use, treated for that substance, or injection use in past year 1999 Dependence, use on at least 363 days, or treated for alcohol use in past year Dependence, use on at least 363 days, or treated for marijuana use in past year Same as 1985 Dependence, use on at least 52 days, treated for that substance, or injection use in past year Need for treatment for tranquilizers, sedatives, hallucinogens inhalants, analgesics Need for treatment for any drug Dependence, weekly or more frequent use, or treated for that substance in past year Dependence on any illicit drug; or frequent drug use, i.e., used marijuana almost daily or more often; used cocaine/crack, sedatives, tranquilizers, stimulants, analgesics, inhalants, or hallucinogens weekly or more often; used heroin at all; or injected any drug; or treated for any drug use in past year. Dependence, use on at least 52 days, or treated for that substance in past year Dependence on any illicit drug; or frequent drug use, i.e., used marijuana almost daily or more often; or used cocaine/crack, hallucinogens, inhalants, analgesics, sedatives, tranquilizers, or stimulants on at least 52 days; used heroin at all; or injected any drug; or treated for any drug use in past year. Dependence on any illicit drug; or frequent drug use, i.e., used marijuana almost daily or more often, used cocaine weekly or more often, or used heroin at all; or had used cocaine in the past year and had ever injected cocaine; or treated for any drug use in past year. Dependence on any illicit drug; or frequent drug use, i.e., used marijuana almost daily or more often; used cocaine, sedatives, tranquilizers, stimulants, analgesics, inhalants, or hallucinogens weekly or more often; used heroin at all; or injected any drug; or treated for any drug use in past year. *Historically, the Office of Applied Studies used “any use of heroin” as a criterion of need for treatment and this definition was retained in order to maintain consistency in deriving estimates of need of treatment for heroin across survey years. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page A-1 Appendix A APPENDIX A (CONT.) MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS – NHSDA Construct Dependence 1985 Met 3 or more of the following 6 DSM-III criteria for a substance ever, and had used that substance within the past year. − Tried to cut down on use − Needed a larger amount to get the same effects or to get high − Used almost daily or more frequently for at least two weeks in a row − Had withdrawal symptoms − Felt she needed or was dependent on the drug − Had problems in the past year with family or friends, at work, school, with police, with health, or of an emotional or psychological nature because of use 1991 Met 3 or more of the following 6 DSM-III-R criteria for a substance within the past year, and had used that substance within the past year. − Tried to cut down on use and unable to cut down − Needed a larger amount to get the same effects or to get high − Used almost daily or more frequently for at least two weeks in a row − Had withdrawal symptoms − Felt she needed or was dependent on the drug − Had problems in the past year with family or friends, at work, school, with health, or of an emotional or psychological nature because of substance use 1994 Met 3 or more of the following 5 DSM-IV criteria for a substance within the past year. − Spent a great deal of time over a period of a month getting, using, or getting over the effects of the substance − Built up a tolerance to the substance − Used the substance more often than intended − Wanted to stop or cut down on use and was unable to cut down − Had problems in the past year with family or friends, at work, school, with police, or of an emotional or psychological nature because of substance use 1999 Met 3 or more of the following 7 DSM-IV criteria for alcohol, analgesics, cocaine, heroin, sedatives, or stimulants; and 3 or more of the first 6 criteria for marijuana, tranquilizers, inhalants, or hallucinogens. − Spent a great deal of time over a period of a month getting, using, or getting over the effects of the substance − Built up a tolerance to the substance − Used the substance more often than intended − Reduced or gave up participation in important activities because of use − Had emotional, psychological, or health problems because of use − Wanted to stop or cut down on use and was unable to cut down − Reported withdrawal symptoms for alcohol, analgesics, cocaine, heroin, sedatives, or stimulants J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page A-2 Appendix A APPENDIX A (CONT.) MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS – NHSDA Construct Treatment received in past year 1985 Treatment received in past year was only available for “any drug” and not for alcohol or specific drugs. 1991 Treatment received in past year was only available for alcohol and “any drug” and not for specific drugs. 1994 Treatment for alcohol in the past year was coded if the respondent said that she had been treated for alcohol in the past year in any treatment setting or had been treated most recently and in the past year for alcohol. Treatment for any drug in the past year was coded based on whether the respondent was treated in any location for any drug in the past year. Treatment for a specific drug in the past year was coded if the respondent had been treated for any drug in the past year and the specific drug was one for which she had most recently been treated. Treatment for any substance in the past year was coded if the respondent had received treatment for either alcohol or any drug. Same as 1991, with addition of multi-ethnic category to ethnicity Coded “yes” if respondent had children less than 18 years old 1999 Treatment for alcohol in the past year was coded if the respondent said that she had been treated for alcohol in the past year and reported past-year treatment in any treatment setting. Treatment for any drug in the past year was coded if the respondent said that she had been treated for drugs in the past year and reported past-year treatment in any treatment setting. Treatment for a specific drug in the past year was coded if the respondent said that she had been treated for that substance in her last treatment and had been treated in the past year Treatment for any substance in the past year was coded if the respondent had received treatment for either alcohol or any drug. Same as 1994 Coded “yes” if respondent had at least one biological child in the household who was less than 18 years old Demographic characteristics Any dependent children Measured variables for: age, ethnicity, educational status, work status, & marital status Coded “yes” if respondent had any biological children less than 18 years old and any of her children (regardless of age) were currently living with her Same as 1985 Same as 1985 J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page A-3 Appendix A APPENDIX A (CONT.) MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS – NHSDA Construct Health insurance 1985 Not available 1991 Classified as (1) private, group, or own/family policy; (2) Medicaid; (3) Medicare, CHAMPUS, or other; (4) none Not available for a 12-month reference period Treatment received in the past year was available for any type of drug use only and coded for the following settings: 1994 Classified as (1) private, group, or paid for by self; (2) Medicaid; (3) Medicare, CHAMPUS, or other; (4) none Respondent or someone in her family received public assistance or welfare payments in past 12 months Treatment received in the past year was available for any type of substance use (i.e., alcohol, any drug) for the following settings: − Hospital/inpatient medical facility − Residential drug or alcohol rehabilitation facility − Outpatient drug or alcohol rehabilitation facility − Outpatient mental health facility − Hospital emergency room − Private doctor’s office − Criminal justice system − Self-help group − Some other place: Responses within this category were recoded, when possible, into one of the existing categories. Non-specific mentions of drug treatment or rehab centers were coded as an outpatient rehab facility. All other responses were left in the “other” category. 1999 Same as 1994 Welfare status Not available Treatment settings Not available Respondent or someone in her family received public assistance payments in previous calendar year Same as 1994, except courtmandated or -sponsored treatment was added to “criminal justice system” − Hospital/inpatient medical facility − Drug rehabilitation facility (note: no distinction was made between inpatient and outpatient facilities) − Outpatient mental health facility − Hospital emergency room − Private doctor’s office − Self-help group − Some other place: Responses within this category were recoded, when possible, into one of the existing categories. New categories were added for (1) church or school, and (2) criminal justice system. All other responses were left in the “other” category. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page A-4 APPENDIX B MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS NDATUS/UFDS APPENDIX B MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS – NDATUS/UFDS Construct Type of substance use treated 1987 If there were clients receiving alcohol treatment, but no clients receiving drug treatment, the setting was classified as an alcohol-treatment provider If there were clients receiving drug treatment, but no clients receiving alcohol treatment, the setting was classified as a drug-treatment provider If there were clients receiving alcohol treatment and clients receiving drug treatment in the same setting, the setting was classified as an AOD-treatment provider Type of treatment provided The types of treatment provided to clients in treatment settings were classified into the following mutually exclusive, hierarchical categories, based on the order of intensity of treatment, by the type of primary substance treated. Types of treatment provided for alcohol use: Criminal justice system, if the setting was located in a correctional facility Hospital inpatient, if there were hospital inpatient clients in inpatient rehabilitation/recovery or custodial/domiciliary settings 1991 If there clients receiving alcohol treatment, but no clients receiving drug- or AOD-treatment, the setting was classified as an alcoholtreatment provider If there were clients receiving drug treatment, but no clients receiving alcohol- or AODtreatment, the setting was classified as a drugtreatment provider If there were clients receiving AOD treatment, or clients receiving alcohol treatment and clients receiving drug treatment in the same setting, the setting was classified as an AODtreatment provider In this year, clients were classified in the survey according to three, mutually exclusive types of primary substance use: alcohol, drug, or AOD. The types of treatment provided to clients in treatment settings, for all three types of substances, were classified into the following mutually exclusive, hierarchical categories, based on the order of intensity of treatment: Criminal justice system, if the setting was located in a correctional facility Hospital inpatient, if the setting had hospital inpatient rehabilitation/residential clients Same as 1991 The types of treatment provided to clients in treatment settings, for all three types of substances, were classified into the following mutually exclusive, hierarchical categories, based on the order of intensity of treatment: Criminal justice system, if the setting was located in a correctional facility Alternative criminal justice system, if the setting was coded as “other criminal justice” (i.e., TASC, pretrial diversion, court referral, probation, parole, community corrections, drug courts) 1994 Same as 1991 Same as 1991 1998 J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page B-1 Appendix B APPENDIX B (CONT.) MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS – NDATUS/UFDS Construct Type of treatment provided 1987 Residential/rehabilitation, if there were non-hospital clients in inpatient rehabilitation/recovery or in inpatient custodial/domiciliary settings Outpatient, if there were outpatient/nonresidential clients in either a hospital or a non-hospital setting Types of treatment provided for drug use Criminal justice system, if the setting was located in a correctional facility Hospital inpatient, if there were maintenance or drug-free clients in a hospital inpatient setting Residential/rehabilitation, if there were maintenance or drug-free clients in a residential setting Outpatient methadone maintenance, if there were maintenance outpatient clients whose number was equal to the total number of clients in the setting Outpatient, if there were drug-free outpatient clients or fewer maintenance outpatient clients than total clients in the setting 1991 Long-term residential/rehabilitation, if the setting had long-term rehabilitation/residential clients Short-term residential/rehabilitation, if the setting had short-term rehabilitation/residential clients Intensive outpatient, if the setting had intensive outpatient ambulatory clients Non-intensive outpatient, if the setting had outpatient ambulatory clients In settings that provided drug- or AODtreatment, all outpatient clients were further classified as follows: If an outpatient setting had methadone clients in a number equivalent to the total number of clients in the setting, then the setting was classified as providing outpatient methadone maintenance treatment and removed from the outpatient category. Settings classified as providing outpatient methadone maintenance treatment were coded as drugtreatment providers. If they originated in the AOD-treatment category, they were removed from that category. 1994 1998 Hospital inpatient, if the setting had hospital inpatient rehabilitation clients Residential/therapeutic community, if the setting had residential rehabilitation clients and was located in a therapeutic community Residential/rehabilitation, if the setting had residential rehabilitation clients Intensive outpatient, if the setting had intensive outpatient clients. Non-intensive outpatient, if the setting had other outpatient clients In settings that provided drug- or AODtreatment, all outpatient clients were further examined as follows: If an outpatient setting had methadone clients in a number equivalent to the total number of clients in the setting, then the setting was classified as providing outpatient methadone maintenance treatment and removed from the outpatient category. Settings classified as providing outpatient methadone maintenance treatment were coded as drugtreatment providers. If they originated in the AOD-treatment category, they were removed from that category. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page B-2 Appendix B APPENDIX B (CONT.) MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS – NDATUS/UFDS Construct Type of treatment provided 1987 Types of treatment provided for AOD use: Criminal justice system, if the setting was located in a correctional facility Hospital inpatient, if the setting had been coded hospital inpatient for either its alcohol or its drug clients Residential/rehabilitation, if the setting had been coded residential/rehab for either its alcohol or its drug clients, it was assigned a modality of residential/rehabilitation. Outpatient, if the setting had been coded outpatient for either its alcohol or its drug clients If a setting had previously been classified as providing outpatient methadone maintenance treatment, it was reclassified from an AOD-treatment provider to a drug-treatment provider. 1991 1994 1998 J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page B-3 Appendix B APPENDIX B (CONT.) MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS – NDATUS/UFDS Construct Percentage of women clients in treatment settings 1987 Alcohol-treatment providers: The percentage of clients receiving inpatient alcohol treatment who were women was applied to settings providing hospital inpatient and residential rehabilitation treatment. The percentage of clients receiving outpatient alcohol treatment who were women was applied to settings providing outpatient treatment. The percentage of all clients who were women was applied to the total and to the criminal justice system-based treatment. Drug-treatment providers: The percentage of clients receiving inpatient drug treatment who were women was applied to settings providing hospital inpatient and residential rehabilitation treatment. The percentage of clients receiving outpatient drug treatment who were women was applied to settings providing outpatient and outpatient methadone maintenance treatment. The percentage of all clients who were women was applied to the total and to the criminal justice system-based treatment. 1991 Percentages of women were available separately for alcohol-, drug-, and AOD-treatment providers and in global treatment type categories. These categories were identical for each type of substance use treatment. For each type of substance use treatment, these global categories were applied to treatment type subcategories as follows: The percentage of substance-specific clients receiving inpatient treatment who were women was applied to settings providing hospital inpatient, long-term residential, and short-term residential treatment. The percentage of substance-specific clients receiving outpatient treatment who were women was applied to settings providing intensive and non-intensive outpatient treatment. The percentage of all clients who were women was applied to the total within each type of substance treated and overall, and to criminal justice settings and settings providing outpatient methadone maintenance treatment. 1994 Same as 1991 1998 Percentages of women were available independent of type of substance use treated and in global categories of types of treatment. For each type of substance use treatment, these global categories were applied to treatment type subcategories as follows: The percentage of clients receiving hospital inpatient treatment who were women was applied to settings providing hospital inpatient treatment for all types of substances treated. The percentage of clients receiving residential treatment who were women was applied to settings providing residential TC and other residential treatment for all types of substances treated. The percentage of clients receiving outpatient treatment who were women was applied to settings providing intensive outpatient, non-intensive outpatient, and outpatient methadone/maintenance-LAAM treatment for all types of substances treated. The percentage of total clients who were women was applied to the two types of criminal justice-based treatment, the total for each type of substance use treated, and the grand total. J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page B-4 Appendix B APPENDIX B (CONT.) MEASUREMENT AND DEFINITIONS OF KEY CONSTRUCTS – NDATUS/UFDS Construct Percentage of women clients in treatment settings 1987 AOD-treatment providers: The percentage of all clients receiving inpatient AOD treatment who were women was applied to settings providing hospital inpatient and residential rehabilitation treatment. The percentage of all clients receiving outpatient AOD treatment who were women was applied to settings providing outpatient treatment. The percentage of all clients who were women was applied to the total and to the criminal justice system-based treatment. Childcare Staff specially trained to conduct women’s programs or services Same as 1987 Same as 1987 Childcare Groups for pregnant/postpartum women Other women’s groups Parenting/family skills development Domestic violence services 1991 1994 1998 Services provided in treatment settings J:\SARE\170\170730\UCLA\UCLA _final.doc NEDS, December 2002, Page B-5