Residential and outpatient treatment completion for substance use disorders in the U.S.: Moderation analysis by demographics and drug of choice
Introduction
Although more Americans suffer from addiction than from diabetes, cancer, or heart disease (CASA, 2012), only about 2.5 million people out of the estimated 22.7 million Americans aged 12 or older, or about 11% of those who need treatment, receive it at a specialty facility (SAMHSA, 2014). As the implementation of the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act continues, there is expected to be a considerable expansion of the publicly funded substance abuse treatment system (Buck, 2011) which may lead to increased access to substance use disorder treatment (Wen, Cummings, Hockenberry, Gaydos, & Druss, 2013).
In general, research on the treatment of addictive disorders has been shown to be effective (Dutra et al., 2008, Prendergast et al., 2002), with outcomes comparable to those for other chronic medical diseases, such as diabetes, asthma, and hypertension (McLellan, Lewis, O′Brien, & Kleber, 2000). Although continuing abstinence may represent the “gold standard” for a successful outcome, completion of treatment represents an important therapeutic goal and is a key indicator of treatment compliance and positive outcomes. Compared to non-completers, those who complete substance abuse treatment are more likely to remain abstinent, have fewer relapses, higher levels of employment and higher wages, fewer readmissions, less future criminal involvement, and better health (Brorson et al., 2013, Stark, 1992, The TOPPS-II Interstate Cooperative Study Group, 2003).
The substantial body of previous research on factors associated with treatment completion or dropout has generally found that different treatment settings (e.g., residential, outpatient) have differing completion rates, and that there is a great deal of uncertainty concerning which client characteristics best predict treatment completion (Brorson et al., 2013, Craig, 1985, Stark, 1992). The lack of consistent results associated with treatment completion may be due to variations in study design and criteria for treatment completion, differences in subject populations and treatment settings, restricted samples, and analyses that fail to examine interactions among predictor variables. With few exceptions, most of the published studies in this extensive literature are locally based, conducted using a single treatment facility, focused on one type of treatment setting (e.g., residential treatment), or examine a specific subgroup of clients (e.g., opiate users) (Brorson et al., 2013). One recent review suggests that it would be more useful to the field to shift research away from identifying simple demographic predictors of dropout toward a greater emphasis on a moderation analysis of treatment completion, e.g., which variables moderate the relationship between client characteristics and treatment completion (Brorson et al., 2013).
Although there is considerable evidence that treatment completion rates vary by treatment setting (i.e., outpatient, residential), demographic characteristics (eg., age, gender, racial/ethnic groups), and drug of choice (eg., cocaine, opioids, alcohol), we are not aware of any prior studies that have directly examined these interactions within a single analysis using a national dataset. The purpose of this study is to investigate the impact of residential versus outpatient treatment setting on treatment completion, and then to examine how this impact might vary by demographic characteristics and drug of choice. While it is well known that residential treatment programs have a generally higher rate of treatment completion as compared to outpatient programs (SAMHSA, 2013), we hypothesize that the positive impact of residential treatment on completion will differ across age, gender, and racial/ethnic groups. Secondly, we hypothesize that the impact of residential treatment on treatment completion will differ for different substances of abuse, where residential treatment may have a greater effect on completion for abusers of such “harder” drugs as cocaine, opioids, and methamphetamine compared to abusers of alcohol and marijuana. We reason that the efficacy of residential treatment will be greater for abusers of these harder drugs because residential treatment, compared to outpatient settings, can better mitigate exposure to the environmental and social triggers of relapse and (consequently treatment dropout), and this may be more important for users of these “harder” drugs who may be less functional than those whose primary substance is alcohol or marijuana.
Section snippets
Study sample
The present study involves a retrospective analysis using data extracted from the 2011 Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Set (TEDS-D) (SAMHSA, 2013), a federal compilation of admission and discharge data collected from state substance abuse agency administrative data systems. It includes a significant portion of all admissions in the US for treatment for substance use disorders and thus may be considered a national sample (SAMHSA, 2013).
Results
Table 1 displays the counts and frequencies for the variables used in the analysis, as well as the rates of treatment completion for the entire sample and for residential and outpatient programs separately for each variable. Outpatient treatment accounted for 84.6% of the sample, but had a lower completion rate (51.9%) as compared to residential treatment (64.5%). Outpatient treatment cases also had a higher rate of full time employment and a lower rate of homelessness as compared to the
Discussion
Generally, our results are consistent with much of the prior research on treatment completion, showing that higher treatment completion rates are associated with older age, greater education, being employed full time, more stably housed, being White, less recent substance use, alcohol as the primary substance of abuse, and being referred to treatment by employers and the criminal justice system. In general, residential treatment completion rates are usually higher compared to outpatient
Limitations
There are a number of limitations regarding this research that are important to recognize. First, these data are from a large public survey submitted by state data systems from individual programs. While there has been every effort to standardize definitions and reporting, there may still be inconsistent reporting of survey responses. The actual criteria and definitions of “successful completion” may vary across programs since what constitutes completion is left up to the individual program
Role of funding source
Nothing declared.
Contributors
All authors contributed materially and participated in the research and article preparation. All authors have approved the final article. Dr. Stahler's contributions included study concept and design, acquisition of data, interpretation of data analyses, drafting of the manuscript, revising and editing of the original manuscript, and editing the revised manuscript. Dr. Mennis's contributions included study design, statistical analyses and interpretation of findings, drafting parts of the
Conflicts of Interest
No conflict declared.
References (28)
- et al.
Reasons for dropout from drug abuse treatment: Symptoms, personality, and motivation
Addictive Behaviors
(2006) - et al.
Drop-out from addiction treatment: A systematic review of risk factors
Clinical Psychology Review
(2013) Reducing the treatment dropout rate in drug abuse programs
Journal of Substance Abuse Treatment
(1985)- et al.
The effectiveness of drug abuse treatment: A meta-analysis of comparison group studies
Drug and Alcohol Dependence
(2002) - et al.
Evaluating racial disparity in referral source and successful completion of substance abuse treatment
Addictive Behaviors
(2015) - et al.
The effect of individual, program, and neighborhood variables on continuity of treatment among dually diagnosed individuals
Drug and Alcohol Dependence
(2007) Dropping out of substance abuse treatment: A clinically oriented review
Clinical Psychology Review
(1992)Fixed Effects Regression Models
(2009)- et al.
How the states stack up: Disparities in substance abuse outpatient treatment completion rates for minorities
Drug and Alcohol Dependence
(2013) - et al.
Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: Utility of a mixed methods approach
Drug and Alcohol Review
(2010)
The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act
Health Affairs
Addiction medicine: Closing the gap between science and practice
Predicting dropout in the first 3 months of 12-step residential drug and alcohol treatment in an Australian sample
Journal of Studies on Alcohol and Drugs
A meta-analytic review of psychosocial interventions for substance use disorders
American Journal of Psychiatry
Cited by (98)
Is there a disparity in medications for opioid use disorder based on race/ethnicity and gender? A systematic review and meta-analysis
2024, Research in Social and Administrative PharmacyBarriers, perceived benefits and preferences to exercise in adults with an opioid use disorder in the U.S
2023, Preventive Medicine ReportsReview and inventory of 911 Good Samaritan Law Provisions in the United States
2022, International Journal of Drug PolicyCitation Excerpt :However, the state allows the court to offer alternative conditions, such as pretrial diversion programs or probation, if appropriate. As few as 52% of PWUDs successfully complete SUD treatment, and significant disparities persist as a function of race/ethnicity and substance (Arndt, Acion, & White, 2013; Stahler, Mennis, & DuCette, 2016). Some evidence suggests mandated SUD treatment may result in comparable (Kiluk et al., 2015) or improved outcomes (Coviello et al., 2013) over voluntary programs by retaining persons who otherwise would exit treatment, although results are limited (Werb et al., 2016).