Center for Substance Abuse Treatment

www.samhsa.gov

**THE NATIONAL RURAL ALCOHOL AND DRUG ABUSE NETWORK AWARDS FOR
EXCELLENCE 2004**

**Submitted and Award-Winning Papers**

**Technical Assistance Publication (TAP) Series**

**28**

**U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES**

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857

**Acknowledgments**

The content of this document was prepared for the Substance Abuse and
Mental Health Services Administration (SAMHSA) by the American
Institutes for Research (AIR) under contract number 270-00-6400, task
order number 270-00-6403, with SAMHSA, U.S. Department of Health and
Human Services (DHHS). Hal Krause served as the Government Task Order
Officer. The publication was formatted and prepared for publication by
JBS International, Inc., under the Knowledge Application Program (KAP)
contract number 270-04-7049 with SAMHSA, DHHS. Christina Currier served
as the Center for Substance Abuse Treatment Government Project Officer
(GPO). Andrea Kopstein, Ph.D., M.P.H., served as the Deputy GPO.

**Disclaimer**

The views, opinions, and content of this publication are those of the
authors and do not necessarily reflect the views, opinions, or policies
of SAMHSA or DHHS.

**Public Domain Notice**

All papers appearing in this document are in the public domain and may
be reproduced or copied without permission from SAMHSA. Citation of the
source is appreciated. However, this publication may *not* be reproduced
or distributed for a fee without the specific, written authorization of
the Office of Communications, SAMHSA, DHHS.

**Electronic Access and Copies of Publication**

This publication may be accessed electronically through
**www.kap.samhsa.gov**. For additional free copies of this document,
call SAMHSA's National Clearinghouse for Alcohol and Drug Information at
(800) 729--6686 or (800) 487--4889 (TTD).

**Citation**

Cite individual paper and contributing author(s) as follows: Author list
(Last name, First name). "Paper Title." In *The National Rural Alcohol
and Drug Abuse Network Awards for Excellence 2004, Submitted and
Award-Winning Papers*. Technical Assistance Publication (TAP) number 28.
DHHS Publication No. (SMA) 06-4183. Rockville, MD: Substance Abuse and
Mental Health Services Administration, Center for Substance Abuse
Treatment, 2006.

**Originating Office**

Division of State and Community Assistance, Center for Substance Abuse
Treatment, Substance Abuse and Mental Health Services Administration, 1
Choke Cherry Road, Rockville, MD 20857.

DHHS Publication No. 06-4183

NCADI Publication No. BKD552

Printed 2006

**Contents**

**Foreword**

**Creating and Sustaining an Adult Drug Court: Avoiding Burial in
Grant's Tomb**

The Honorable Glade F. Roper, J.D., and Dee S. Owens, M.P.A.

**Empower for Recovery: An Innovative Approach To Assist Sustained
Recovery in Rural Iowa**

Deborah K. Rohlfs, M.A., LMHC, CADC

**Delivering a Maternal Substance Abuse Intervention Program Along the
Rural Route**

Trudee Ettlinger, Ph.D., APRN, LADC

**Socio-Demographic Profiles and Treatment Outcomes of Methamphetamine
Abusers in Rural and Urban Areas**

Kazi A. Ahmed, Ph.D., and Careema Yusuf, M.P.H.

**An Environmental Scan of Faith-Based and Community Reentry Services in
Johnson County, Iowa**

Janet C. Hartman, M.A., LMSW, Stephan Arndt, Ph.D., Kristina Barber,
M.S.M., and Thomas Wassink, M.D.

**Substance Abuse Among Rural and Very Rural Drug Users at Treatment
Entry**

Marlies L. Schoeneberger, Carl G. Leukefeld, Matthew L. Hiller, and
Michael Townsend

**Making the Addiction Severity Index User Friendly: An Electronic
Display of Client Outcomes Using Shareware**

James E. Sorensen, Ph.D., C.P.A., James Elzey, C.P.A., CMA, and Faith
Stuart, M.P.A., M.S.W., LICSW.

**Resources on Rural Substance Abuse Issues**

**Other Technical Assistance Publications**

**Foreword**

The Center for Substance Abuse Treatment (CSAT) of the Substance Abuse
and Mental Health Services Administration funded the Seventh Annual
*Call for Papers/Awards for Excellence* 2004 competition hosted by the
National Rural Alcohol and Drug Abuse Network (NRADAN). The Awards for
Excellence program was initiated by the late Larry Monson, cofounder of
NRADAN, who sought to recognize effective and innovative models of
treatment and prevention services for rural populations. The Awards for
Excellence publication seeks to promote and showcase research addressing
the unique and special challenges of providing treatment services to
individuals in rural and frontier areas who abuse substances and their
families.

In response to the CSAT/NRADAN request for papers announcement, seven
papers were submitted and subsequently reviewed by a panel of six
experts on rural/frontier substance abuse treatment services and
research. The top three papers were selected based on high panel ratings
of award criteria, including (1) focus on salient issues identified in
the Call for Papers (e.g., effective multiple agency rural partnerships;
lower cost modalities that increase access), (2) innovative or
responsive program approach, (3) potential for application and
replication, and (4) clarity of writing and exposition.

The first, second, and third place papers were recognized at the
Twentieth Annual National Rural Institute on Alcohol and Drug Abuse
(NRIADA) held in Menomonie, Wisconsin, in June 2004. The winning authors
presented highlights of their papers during a special session, and CSAT
presented nominal cash awards, certificates, and award plaques to each
researcher or research team at the Opening Plenary Session on June 14,
2004. This document contains the award-winning papers, as well as the
other submitted papers.

The first place paper, "Creating and Sustaining an Adult Drug Court:
Avoiding Burial in Grant's Tomb," describes the effectiveness of a
self-funded drug court in Tulare County, California; lessons learned;
and disadvantages and advantages of the self-funded approach.

The second place paper, "Empower for Recovery: An Innovative Approach To
Assist Sustained Recovery in Rural Iowa," describes the effectiveness of
a strength- and home-based substance abuse treatment and recovery
support program in rural Iowa, as well as the challenges, problems, and
solutions related to program implementation.

The third place paper, "Delivering a Maternal Substance Abuse
Intervention Program Along the Rural Route," describes the development
and effectiveness of an indicated-level substance abuse prevention
program for lower income mothers living in rural Vermont, as well as the
lessons learned and recommendations for improving implementation.

The other four submitted papers address demographic and treatment
outcomes of individuals who abuse methamphetamine, faith-based and
community reentry services, people in rural and very rural areas who use
drugs, and an electronic version of the Addiction Severity Index (ASI).

**Eric B. Broderick, D.D.S., M.P.H.**

Acting Deputy Administrator

Assistant Surgeon General

Substance Abuse and Mental Health Services Administration

**H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM**

Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

**Creating and Sustaining an Adult Drug Court: Avoiding Burial in
Grant's Tomb**[^1]

The Honorable Glade F. Roper, J.D.

Dee S. Owens, M.P.A.

*Contact information:*

Glade F. Roper, Judge

Superior Court

Tulare County, California

87 East Morton Avenue

Porterville, CA 93257

Phone: (559) 782--4710

Fax: (559) 782--4805

Dee S. Owens, M.P.A.

Director, Alcohol-Drug Information Center

Indiana University

705 East Seventh Street

Bloomington, IN 47408

Phone: (812) 855--5414

Fax: (812) 855--4465

*Area of focus:* Rural drug court and/or criminal justice programs that
have demonstrated effectiveness in reducing recidivism and increased
positive outcomes in key areas of life/personal adjustment.

**Abstract**

Drug Courts are effective at reducing criminal recidivism and motivating
addicted people to embrace the recovery process. State and Federal
grants have enabled jurisdictions to create and operate Drug Courts,
which have been effective in reducing drug use and crime. However, when
the grants expire, some Drug Courts close while others struggle to
obtain funds for ongoing operation. The Tulare County, California, Adult
Drug Court was created without grant funds and continues its operation
without programmatic government support by using existing resources and
requiring that participants pay the cost of treatment. Although this
seemed implausible at the outset, experience has demonstrated that
addicted people can and will pay the cost of their own treatment and
graduate successfully from a Drug Court program.

The Court encourages success with rewards and imposes penalties only as
necessary. Rewards are either donated by private individuals or groups
or purchased at very little cost; these incentives are largely symbolic
in nature but very effective. Centralized drug testing that is paid for
by the participants has been implemented for uniformity and for
consistent application to the entire population. Modifications were made
to increase the efficacy of the program without additional cost to
taxpayers. A 3-year outcome study showed that fewer than 5 percent of
graduates were convicted of new drug offenses.

Self-funding a Drug Court program requires basic, no-frills treatment;
wraparound services that could otherwise benefit participants may be
absent. Other disadvantages include reduced training, no home visits,
and dependence on treatment personnel to perform case management. These
drawbacks are offset by public support for a self-sustaining program and
freedom from worry about sources of future funding. Participants show a
high degree of investment in their recovery. Any jurisdiction, no matter
how poorly funded, can establish and operate an effective self-funded
Drug Court.

**Introduction**

The success and benefits of a specialized court process for nonviolent,
drug-addicted offenders are well documented and widely known. Numerous
studies (Belenko, 2001; Hora, Schma, & Rosenthal, 1999; Lessenger,
Lessenger, & Lessenger, 1999) have shown that when such offenders are
incarcerated after conviction, recidivism is the norm rather than the
exception. According to a U.S. Department of Justice study, in 1983
50.47 percent of drug offenders were rearrested for a new offense within
3 years of release from custody. By 1994 that number had grown to 66.7
percent (Langan & Levin, 2002, p. 11). As drug arrests and convictions
increased more than 10 times between 1980 and 1996, penal facilities
have exceeded maximum-designed capacity. (See figures 1 and 2.)
Continuing budget constraints have made construction of new jails and
prisons difficult, while the advisability of constructing them has been
actively debated. An increasingly strong voice contends that the policy
of incarcerating addicted people is not only unacceptably costly but is
also poor social policy (see **www.ncadd.org** and
**www.jointogether.org**). Otherwise nonviolent addicts may be housed
with violent antisocial offenders who teach the addicts other criminal
behaviors.

As the cost of incarceration has increased and the cost of new
construction of penal facilities becomes prohibitive in this time of
budget cutting, corrections officials have tried other methods of
punishment, including home arrest, electronic monitoring, day reporting,
and work release. Judges have also made unsupervised referrals to
addiction treatment facilities. Although these actions marginally
relieve the pressure on penal facilities, their value in either
punishing or rehabilitating offenders is questionable to the Court. When
all else fails, prisoners are simply released long before they complete
their sentences. It is unacceptable to the Court to sentence a repeat
offender to a year in custody only to have the convicted person released
after 3 months and rearrested shortly thereafter on new charges. Such
early releases send the message that there is no clear consequence for
undesirable behavior and in fact may reinforce the very behavior that
society attempts to extinguish by incarceration. This revolving door
undermines the integrity of and public confidence in the criminal
justice system.

Addiction treatment courts, commonly called Drug Courts, were created in
1989 in Dade County, Florida, as an alternative to pronouncing
unenforceable sentences of incarceration and with the goal of sending
defendants to effective addiction treatment. The success of the early
Drug Courts led to their rapid spread across the country. By November
2003, 1,093 Drug Courts were operational, including specialized courts
for juveniles and tribal members, and 414 were in planning stages
(American University, 2003). Other Family or Dependency Drug Courts have
been created for parents who have neglected or abused their children,
resulting in the children being detained by child protection agencies.
When drug use by the parents is the root of the problem, there may be
insufficient evidence to justify the filing of criminal charges, but the
drug use should be addressed or the abuse and neglect will likely
continue. Family Drug Courts allow the court to address the addiction so
that the children can ultimately be returned to a stable, drug-free
home.

**Figure 1. California Inmate Data From California Department of
Corrections, 2002**

![](media/image1.wmf)

**Figure 2. National Data From FBI Uniform Crime Reports, 2003**

![](media/image2.png)

Although specific methods vary, all Drug Courts use the same basic
approach. Offenders with drug addictions are identified by themselves,
by law enforcement, or by the court and assessed by qualified counselors
for amenability to treatment. Instead of being sent to jail or prison,
they are referred to treatment programs and closely supervised by court
personnel. Offenders may be referred to treatment prior to entering a
plea, or they may be sent to treatment as a term or probation after
pleading guilty. They are tested for drug use frequently, and sanctions
are imposed for deviating from the treatment prescribed. The judge is a
critical part of the process, and most Drug Courts require participants
to return to court frequently to report on their progress. In addition
to negative sanctions for violations, positive rewards are bestowed for
milestones of progress. Treatment providers, probation officers, county
addiction personnel, or specialized Drug Court caseworkers closely
supervise the participants. Drug Courts are regular courts that adopt
the caseloads and methodologies of addiction treatment.

Although the success of Drug Courts has been remarkable (American
University, 2003; Belenko, 2001), the cost of implementing them is
always a challenge. Placing offenders in treatment programs saves the
cost of incarceration, but the treatment cost, usually a fraction of
that for jail or prison, still must be paid. For example, in California
it costs approximately \$26,000 to incarcerate one person for 1 year in
the State prison system, whereas the cost of a year in a county jail
varies between \$12,500 and \$40,000 (California Department of Alcohol
and Drug Programs & the Judicial Council of California, 2002, p. 15).
Effective addiction treatment can cost as little as \$3,000 for 1 year.
In addition, testing and supervision are critical elements of a Drug
Court, and each incurs a significant cost.

The cost of starting a Drug Court can be considerable, and courts
commonly apply for State or Federal grants to cover costs. The U.S.
Department of Justice awards competitive grants, providing up to
\$300,000 to reimburse costs for startup, implementation, or enhancement
within the first 3 years of operation of a Drug Court. Some State
agencies have provided grants to assist in implementing or enhancing
Drug Court operations. For example, in 1995, Oklahoma established the
first State-operated Drug Court in the Nation, blending both State and
Federal funding and incorporating ASAM (American Society of Addiction
Medicine) standards into statute.

Once their grants expire, many Drug Courts are threatened with closure
because replacement funds are often not available. Some courts have
actually closed when grant funds ran out. Other jurisdictions wish to
create a Drug Court but are unable to qualify for a grant or lack the
resources to write a competitive application. The experience of the
Tulare County, California, Superior Court demonstrates that a successful
Drug Court can be created and sustained without external government
funding. More than a year after the Drug Court had been in operation,
the county did receive a Federal grant. However, the long-term
sustainability of the Drug Court was not ensured in the grant structure.
The principles discussed in this paper allowed the Drug Court to remain
in operation.

**Program Origins**

Tulare County is located in the San Joaquin Valley in the center of
California and is rural in character. It is routinely the first or
second most productive agricultural county in the Nation; in 2001,
Tulare secured the number-one position as the leading county in the
Nation and reached \$3.49 billion in agricultural value (California
Department of Food and Agriculture, 2002, p. 4). Much of the agriculture
is dependent on migrant farm workers, most of whom live at a subsistence
level of income. Many residents live in poverty, with 23.9 percent of
the population and 18.8 percent of families below the poverty line. Out
of the total number of people living in poverty, 32.6 percent are under
the age of 18 and 10.5 percent are 65 or older, leading to significant
social problems that tax county government (Tulare County, California,
2000; California Department of Finance, 2004). Rates for teenage
pregnancy are 77.2 per 1,000 teens and are the highest in the State
(California Department of Health Services, 2004, p. 51), and 8.6 percent
of residents receive public aid (U.S. Census Bureau, 2000). Unemployment
hovers around 20 percent at times, especially during economic downturns
or agricultural events, such as freezes that harm the crops and decrease
the need for agricultural workers. In March 2004, the unemployment rate
was 18.5 percent, compared to 6.7 percent for California and 6 percent
for the Nation (California Employment Development Department, 2004).

The court noticed that, beginning about 1990, Tulare County experienced
a rapid increase in arrests for drug offenses, principally due to the
influx of methamphetamine (meth) into the county. Methamphetamine, which
has numerous street names including "speed" and "crank," is an illicit
stimulant that is highly addictive. It is relatively easy to manufacture
locally with readily available chemicals, as opposed to cocaine and
heroin, which require importation of substances usually grown outside
the country. With an investment of \$5,000, meth dealers can quickly
turn a profit of up to \$100,000, according to addicts in the Drug
Court. The addictive properties of methamphetamine rapidly ensnared
people of all ages throughout the county. The courts sentenced these
drug offenders, many of whom were seriously addicted to methamphetamine,
to jail in increasing numbers. As inmate populations grew, the jail
facilities were unable to accommodate them all, and prisoners were
released early from their sentences. More serious offenders who had been
sent to the State prison were returned to Tulare County on parole,
pursuant to State law.

It is well known that many drug offenders are arrested for new
drug-related charges within 3 years of release from jail or prison; the
California arrest rate for Drug Court graduates after 2 years is 85
percent less than their arrest rate for the 2 years prior to entering
the Drug Court (California Department of Alcohol and Drug Programs & the
Judicial Council of California, 2002, p. 14). As judges became aware
that the same people were returning to court time after time, it also
became obvious that the standard practice of incarcerating addicts was a
poor use of public funds. A high-level meeting was held in 1995
involving law enforcement, judiciary, county government, and mental
health officials. A judge and officials from a neighboring county
presented the concept of a Drug Court and provided convincing
testimonials of the success of the Drug Court in their county. Many who
attended the meeting were excited about the concept, and a series of
further planning meetings was held in which there were mixed support and
opposition for establishing a Drug Court. Although there was a high
level of support from the court, the probation department, local
treatment providers, and the mental health department, the general
feeling was that no funds were available with which to implement a Drug
Court.

It was the perspective of the court that no additional judicial
resources would be required, since the defendants would be either
involved in the Drug Court or proceeding through the normal criminal
justice process. If only a few defendants opted for Drug Court by
pleading guilty without proceeding to jury trials, a great deal of court
time would be saved, not to mention the reduction in recidivism and
renewal of lives as promised by the experience of the neighboring
county. A probation officer was assigned to each division of the court,
and these probation officers were willing to take on the additional
burden of administering the Drug Court.

A major obstacle was funding treatment. Although the Tulare County
Alcohol and Other Drug Program administrators expressed support for the
concept, they indicated that they had no funds to contribute to the
provision of treatment. Despite the fact that four
alcohol-rehabilitation programs existed, providers said there was very
little expertise in treatment for non-alcohol drug addiction in the
county. The owner of the local program for
driving-under-the-influence-of-alcohol offenders was involved in the
Drug Court planning sessions and proposed that participants be sent to
this program, with some modifications made, and pay the cost of their
treatment. At first this seemed unrealistic, as many people in the
county with untreated addiction are destitute. The argument was that, if
addicts are paying up to \$200 per day for drugs, they could afford to
pay \$50 per week for treatment. The difficulty with this concept was
that they were stealing, prostituting, or selling drugs to finance their
drug use, all of which behaviors the court wanted to eradicate rather
than encourage. However, another treatment provider, himself in
recovery, indicated that such behaviors are inconsistent with the
process of recovery and that addicts would not steal, sell drugs, or
prostitute to pay for recovery. Another judge from a neighboring county
with experience in a Drug Court laughed out loud when presented with
that idea, saying, "Addicts are not going to waste their money from
stealing on treatment!"

With no other resources to draw upon, the Court was faced with the harsh
reality of either starting the program by requiring participants to pay
for their own treatment or not having a Drug Court at all. Given those
options, it seemed preferable to at least experiment with self-funded
treatment rather than abandon the concept entirely. So with some
judicial skepticism, the Drug Court began.

Potential participants were identified by the judges and referred to the
probation officer for an interview in which the program was explained
and background information about the defendant was obtained. If the
probation officer determined that the defendant was interested in
changing his or her life, would embrace recovery, and could pay the cost
of treatment, the defendant was offered the Drug Court. A set of formal
terms of probation was signed that constituted an agreement to comply
with Drug Court requirements. The defendant was then referred back to
the judge and was formally sentenced into the Drug Court.

The Court initially referred almost every participant to an outpatient
program. The very few who were deemed to be unable to benefit from
outpatient treatment were referred to existing residential programs.
Those who could not refrain from drug use after several weeks of
outpatient treatment were also referred to residential treatment.
Because of long waiting lists, those referred to residential treatment
were frequently required to wait in jail for several months until a bed
became available at the residential facility. Experience and court
records showed, however, that more than 90 percent of participants who
graduated were able to succeed with outpatient treatment alone.

The original design consisted of a 1-year program divided into three
phases. Phase 1 treatment provided two 90-minute group sessions, 1 hour
of individual counseling, and attendance at two 12-step self-help
meetings each week. Participants came to court every week and showed
proof of attending 12-step meetings on a card provided by the treatment
provider and signed by the secretary of the 12-step group. The
counselors assigned to the participants filled out a simple, one-page
form reporting their progress for the week. This form was provided to
the Court the day before a participant's scheduled hearing and placed in
the participant's file by the court clerk.

Prior to each Drug Court session, the treatment providers met with the
judge and probation officer to discuss every participant and appropriate
responses to deviations from treatment. Prosecutors and defense
attorneys were invited to attend, but because of understaffing and their
opinion that supervision of the participants was the province of the
court and probation, the district attorney and public defender chose not
to attend. During the weekly Drug Court session, each participant was
called up individually to discuss progress, make changes to the
treatment program, and receive a reward for good behavior or a sanction
for undesirable behavior. The counselors conducted drug testing as they
felt necessary.

Phase 1 lasted a minimum of 2 months. Advancement to phase 2 required at
least 30 days clean and sober and substantial compliance with all
treatment requirements. The only change in phase 2 was a 2-week interval
between court appearances. This phase lasted 3 months.

Advancement to phase 3 reduced individual counseling sessions to every
other week, with 1 month between court appearances. At the end of the 7
months of phase 3, if the participants had been clean and sober for at
least 180 days, they were graduated out of the Drug Court. They remained
on probation but were encouraged to apply for early termination of
probation pursuant to the normal statutory scheme for all criminal
cases.

Participants always had the option of voluntarily leaving the Drug Court
and accepting the court sentence that would have been imposed had they
initially decided not to participate in the Drug Court. They were not
sentenced with greater terms of incarceration because they attempted to
go through treatment. Even those who were terminated from the program
were given the same sentence that they would have received without
trying the Drug Court. Very few were terminated involuntarily, as the
goal of the Drug Court was to keep the participants engaged in treatment
as long as they were making progress. This was a subjective decision
that was made by the judge after input from the treatment program and
the probation officer. More frequently, participants voluntarily asked
to be sent to jail or prison because they were unwilling or unable to
continue to pay the cost of treatment or to abide by the program's
strict requirements. In the Court's experience, about one-quarter of
those beginning the Drug Court were terminated prior to successful
graduation.

**Subsequent Refinements and Lessons Learned**

Although there was very little prior experience with drug addiction
treatment in the county, the Drug Court in Tulare County proved
immediately effective in reducing drug use and motivating people to
accept and embrace recovery. Experience quickly taught that many changes
were necessary to improve outcomes. Because the treatment was based on
the classic 12-step model, mandatory attendance was increased to five
meetings per week until the participant acquired a sponsor and then
attendance was reduced to four meetings per week for the duration of the
program. More emphasis was placed on completion of the 12-step process,
and participants were expected to know the meaning of each step. Phase 1
was increased to 13 weeks, phase 2 remained at 13 weeks, and phase 3 was
reduced to 26 weeks.

Additional treatment providers have approached the Drug Court, wanting
to be involved. Initially, all were accepted until it became apparent to
the Court that some programs were substandard, so standards were adopted
that all participating treatment programs must meet. They must have
certified treatment counselors, and although most programs are certified
by the State, some faith-based programs participate that have chosen not
to be certified and regulated by the State. The Court and probation
department watch these programs and procedures closely.

Inconsistencies in drug testing were a concern, and different programs
tested at different frequencies. There were also allegations that some
counselors were not observing the collection of samples. In addition,
different laboratories provided reports in varying formats that proved
difficult to decipher in a court review. Differing cutoff levels among
laboratories meant that participants were treated unequally after using
drugs. To overcome this disparity, a protocol was developed and a
solicitation was issued for proposals from testing agencies. One testing
agency was selected, and now all participants are sent to a central
testing location.

For drug testing, each participant is assigned to a group based upon the
phase of treatment. Every morning, each participant is expected to call
the testing agency before 9 a.m. and listen to a recorded message that
indicates which groups are to be tested that day. The short message
lasts less than 30 seconds, so it requires only a very brief call. If
their group number is announced, participants must report to the testing
facility and leave a urine sample before 5 p.m. that same day. The hope
is that participants will begin each day focusing on what is required
for recovery that day.

Originally various sanctions were imposed for missed tests, and
according to the testing agency, up to 10 percent of participants failed
to test on designated testing days. A wide range of reasons was given
for missing tests, from death of relatives to malfunctioning vehicles to
work requirements. Because testing is such a critical part of Drug Court
supervision, the severe sanction of incarceration was finally imposed
for missing each test, and compliance increased dramatically. It is
explained to all participants that a positive test is viewed as a
clinical issue indicating that some increased treatment should be used.
Failure to test is treated as a behavioral issue, because it prevents
the treatment provider from knowing whether the participant is
responding to treatment. At present, less than 1 percent of participants
fail to test when scheduled. The Drug Court judge has joked openly that
sending people to jail for missing tests has tremendously improved the
health of the participants' relatives and their vehicles.

In addition, it is important to note that the Court views lying about
drug use as a behavior issue. In cases in which a client does not pass a
drug test, it is the act of attempting to mislead the counselor and/or
the court about recent substance use that precipitates consequences, not
the positive drug test itself.

A standard sanction list was adopted as a minimum response to deviations
from treatment. These minimum sanctions are the general rule, with some
agreed upward departure imposed for aggravated violations. The list has
been modified somewhat over time. The philosophy of the Drug Court has
been that behavioral issues are penalized, whereas abstinence and drug
use are considered treatment issues. Sanctions are intended to encourage
compliance rather than to punish participants. Importantly, sanctions
are imposed as soon as possible to relate the sanction to the
undesirable behavior. (See the list of progressive sanctions in table
1.)

It quickly became apparent to the Court that most participants responded
more favorably to rewards than to negative sanctions, and the Court
adopted the goal of helping participants feel better about themselves
when they left court than when they came in. Verbal accolades were given
freely, and small steps were recognized. For example, the courtroom
audience was encouraged to applaud for milestones of sobriety, such as
30, 60, 90, or 180 days. As a humorous interlude, one participant was
presented with a toy beach ball upon moving from phase 1 to phase 2.
Everyone laughed, but when the next participant was advanced, he asked,
"Where is my beach ball?" It became the standard protocol to award
participants small "trinkets" for milestones, most of which were
obtained without cost. For example, court personnel donate miniature
bottles of shampoo or lotion and bars of soap from hotel stays, and
these are presented to recognize periods of sobriety. Pens, pencils, key
chains, and similar useful items that are picked up on vacation trips
are given freely to recognize improvement.

**Table 1. Tulare County Adult Drug Court**

  ----------------------- ------------- ----------------------------------
  **Tulare County Adult                 
  Drug Court Minimum                    
  Sanctions**                           

  1\. Missing 12-Step     First time:   Make up meetings
  Meetings                              

                          Second time:  Sit in jury box, make up meetings

                          Third time:   Spend night in jail, make up
                                        meetings

                          Fourth time:  Spend weekend in jail, make up
                                        meetings

  2\. Missing Test or     First time:   Spend night in jail, may move back
  Taking Unauthorized                   a phase. If in aftercare, 1-month
  Medication                            extension

                          Second time:  Spend weekend in jail, move back a
                                        phase

                          Third time:   Spend week in jail, move back to
                                        phase 1

                          Fourth time:  Spend 2 weeks in jail, move back
                                        to phase 1

  3\. Missing Counseling  Pay for       
                          missed        
                          session,      
                          extension of  
                          1 week to     
                          move to next  
                          phase         

  4\. Adulteration of     30 days in    
  Test                    jail,         
                          possible      
                          expulsion     

  5\. Falsification of    First time:   14 days in jail
  Signature                             

                          Second time:  30 days in jail, move back a phase

                          Third time:   60 days in jail, move back to
                                        phase 1, likely expulsion

  6\. Missing Aftercare   Extend        
  Meeting                 aftercare 1   
                          month         
  ----------------------- ------------- ----------------------------------

As the success of the Drug Court has become apparent, other donations
have been received and used as rewards. A nonprofit foundation was
created with a board of local community leaders who support the concept
of recovery rather than incarceration. Although donations are not
actively solicited, the foundation has a balance of about \$5,000. A
business owner who employs a participant in a key position has donated
\$500 to purchase key rings with a Drug Court logo and the message
"Recovery is a process that lasts a lifetime." These are awarded to
participants moving into phase 2. The testing agency has donated mugs
with a special Drug Court logo; these are presented to participants
moving into phase 3. Rotary Clubs have donated T-shirts with a logo to
those graduating from the program. Some graduates donate to the
foundation, giving \$5 to \$100 for each year of sobriety.

The Court noted that a significant number of recent graduates
experienced relapse, and counselors indicated from interviews that many
graduates felt a sense of abandonment when involvement in the program
ended suddenly. To remedy this, a 6-month "aftercare" phase was added.
Following graduation, participants attend one aftercare group every
other week, continue testing on the same schedule, attend four 12-step
meetings every week, and come to court after 3 and 6 months, after which
they qualify for completion. The additional 6 months of involvement
reduced relapse and allowed a more gradual severance from the Drug
Court---a cushioned release rather than a hard drop.

As a further reward to the graduates, an annual graduation ceremony has
been held. Prominent figures in recovery have been keynote speakers,
including musicians David Crosby and Dallas Taylor and actors Larry
Hagman, Mackenzie Phillips, and Todd Bridges. As evidenced by a full
house, more than 1,600 people attend the annual graduations, which are
emotional events for participants, family members, and interested
members of the community. Dignitaries, including law enforcement
officials, prosecutors, legislators, city council members, and mayors,
routinely attend and shake the hands of the graduates.

The initial plan was to accept no more than 50 people into the Drug
Court and then evaluate success. Because the program's positive effect
was so immediately apparent to the Court, the population of the Drug
Court quickly rose above 50. Because participants pay their own
treatment costs, each additional participant only slightly increases the
burden on the system, principally in time needed to review their cases.
Larger populations actually improve the efficiency of the program
because of economies of scale. For example, larger numbers help keep the
cost of drug testing low, as fixed costs for the testing agency are
spread among more clients. The treatment providers are able to add more
counselors as needed to accommodate greater client bases. It has worked
so well that currently more than 500 people participate in the Tulare
County Adult Drug Court.

To have a significant impact on the county's drug problem, the Drug
Court tries to direct as many people as possible into treatment. A
system was developed whereby the prosecutors screen every offender based
on agreed criteria, and a summary sheet is filed with the criminal
complaint indicating whether the offender is eligible to participate in
the Drug Court. If eligible, the offender is offered this option at the
first pretrial conference, thereby encouraging an early settlement of
the case and avoiding additional court hearings.

The concept that was implemented with skepticism---that people can and
will pay for the cost of their addiction treatment---has flourished and
enabled hundreds of people every year to avoid incarceration, embrace
recovery, and return to a normal lifestyle. To date, there is no
evidence that any participant has committed theft, drug sales, or
prostitution to pay for treatment.

**Outcomes**

Anecdotal evidence indicated that the Tulare County Adult Drug Court was
a huge success. To verify this, a physician and a psychologist teamed up
to do an analytical study of the results of the first 3 years of
operations (Lessenger, Lessenger, & Lessenger, 1999). Everyone
considered for placement in the Drug Court was tracked from the entrance
interview to the close of the study period. Studied subjects were
divided into four groups for research purposes, depending on their
involvement in the program: those who were considered for the Drug Court
but found unsuitable, those who were found suitable and offered the Drug
Court but declined to participate, those who began participating in the
Drug Court but either voluntarily left to do custody time or were
terminated involuntarily, and those who successfully graduated from the
Drug Court.

As shown in table 2, 5 percent of the graduates were convicted of new
drug charges during the course of the 3-year study period, compared to
nearly 41 percent of those who were rejected for admission into the Drug
Court and 27 percent of those who were found suitable but declined. In
interpreting these figures it is important to note that those who
graduated were at liberty the entire 3-year period (except for some
short-term incarcerations, never more than a few days, as sanctions).
Those who were rejected or who declined spent all or a large part of the
3-year period in custody, where they were much less likely to be
arrested for new drug charges.

**Table 2. Criminal Recidivism Outcomes: Post-Drug Court in Tulare
County, California**

+------------------+-------------+-----------+-----------+-----------+
| **Outcome**      | *           | **D       | **Ter     | **Gr      |
|                  | *Rejected** | eclined** | minated** | aduated** |
|                  |             |           |           |           |
|                  | **N=111     | **N=74    | **N=122   | **N=142   |
|                  | Persons\*** | Pe        | Pe        | Pe        |
|                  |             | rsons\*** | rsons\*** | rsons\*** |
+------------------+-------------+-----------+-----------+-----------+
|                  | **Number**  | *         | *         | *         |
|                  |             | *Number** | *Number** | *Number** |
|                  | **          |           |           |           |
|                  | (Percent)** | **(P      | **(P      | **(P      |
|                  |             | ercent)** | ercent)** | ercent)** |
+------------------+-------------+-----------+-----------+-----------+
| Nondrug          | 27 (22.2)   | 15 (20.0) | 21 (16.5) | 4 (2.8)   |
| Convictions      |             |           |           |           |
+------------------+-------------+-----------+-----------+-----------+
| Drug             | 47 (40.7)   | 20 (27.0) | 27 (21.5) | 8 (5.0)   |
| Convictions:     |             |           |           |           |
+------------------+-------------+-----------+-----------+-----------+
| --- Possession   | 31 (27.9)   | 12 (16.2) | 16 (13.2) | 2 (1.4)   |
+------------------+-------------+-----------+-----------+-----------+
| --- Under        | 14 (12.6)   | 8 (10.8)  | 9 (7.4)   | 4 (2.8)   |
| Influence        |             |           |           |           |
+------------------+-------------+-----------+-----------+-----------+
| --- Transport    | 2 (1.8)     | 0 (00.0)  | 1 (0.7)   | 0 (0.0)   |
+------------------+-------------+-----------+-----------+-----------+
| --- Sales        | 2 (1.8)     | 0 (00.0)  | 3 (2.4)   | 0 (0.0)   |
+------------------+-------------+-----------+-----------+-----------+
| ---              | 6 (5.4)     | 2 (2.7)   | 3 (2.4)   | 2 (1.4)   |
| Paraphernalia    |             |           |           |           |
+------------------+-------------+-----------+-----------+-----------+
| County Jail      | 42 (37.8)   | 24 (32.4) | 30 (24.7) | 5 (3.5)   |
+------------------+-------------+-----------+-----------+-----------+
| State Prison     | 22 (19.8)   | 7 (9.5)   | 10 (8.2)  | 2 (1.4)   |
+------------------+-------------+-----------+-----------+-----------+
| Driver License   | 94 (84.7)   | 50 (67.6) | 75 (61.9) | 9 (6.4)   |
| Suspension       |             |           |           |           |
+------------------+-------------+-----------+-----------+-----------+

From Lessenger, J. E., Lessenger, L. H., & Lessenger, E. W. (1999). *An
outcome analysis of Drug Court in Tulare County, California* (p. 30).
*P*orterville, CA: Unpublished report.

\*Numbers do not match population totals and percentages may not total
100 due to multiple offenses/arrests by the same person.

As funds are not available to conduct a followup study, there is no
current information about outcomes after 7 years of operation. It is the
sense of the Drug Court team (composed of the judge, probation officers,
and treatment providers) that this trend has continued but that
recidivism of the graduates has probably doubled to about 10 percent,
which is consistent with other studies of Drug Courts around the Nation.
In California, two of three parolees are rearrested before parole is
completed, within 18 months of release (Warren, 2003). The stark
difference between a 10-percent recidivism rate for Drug Court graduates
and a high recidivism rate for incarcerated offenders demonstrates the
need for more Drug Courts.

Although adequate data to establish a direct connection do not exist, it
is interesting to note that incarceration rates for drug offenses began
a sharp drop about 1997, as shown previously in figure 1. This is about
the same time that Drug Courts began to be well established in this
country. It appears to the authors that Drug Courts have had a
strikingly salutary effect on the drug problem.

**Disadvantages of the Self-Funded Approach**

Publicly funded Drug Courts have the advantage of much greater
supervision of participants. These courts are frequently able to hire
coordinators and case managers who see the participants frequently and
make home visits to ensure that they are in full compliance. These
courts also enjoy the full participation of prosecutors and defense
attorneys, who add valuable perspectives to the Drug Court team. The
self-funded approach, as that of Tulare County, requires treatment
providers to do much of the case management, along with the probation
officers. In jurisdictions in which a probation officer is not available
to dedicate to the Drug Court, treatment providers would be required to
perform all case management functions.

The greatest disadvantage of the self-funded approach is that many
defendants who would otherwise be eligible to participate and are
desirous of doing so are excluded because they cannot bear the cost of
treatment. Many participants in the Tulare County Adult Drug Court are
personally unable to pay for treatment initially but have relatives or
other supporters who are willing to advance the cost of treatment for
some period of time, noting to the Court that it is money well spent due
to the high level of supervision provided by the court, which forcefully
encourages compliance. Many family members who said they have abandoned
hope for their relatives with addictions are willing to pay treatment
costs for several months because they know that if participants do not
comply with requirements, they will be immediately corrected. If these
relatives return to drug use, the relapse will be dealt with swiftly
before they can return to a full drug-using life. The Court expects this
support from others to end within a few months of entry into the Drug
Court because participants are required to obtain employment and become
self-supporting.

Lack of funding prevents an ongoing study of the outcomes and hinders
Drug Court administrators from substantiating its success for
policymakers who might otherwise be willing to contribute public funds.
This setback is partly offset by the annual Drug Court graduation
ceremony that celebrates the productive return to society of those who
have graduated during the past year. At the ceremony, photographs of the
participants at arrest are displayed next to current photographs,
visually and powerfully showing the changes made by participation in the
Drug Court. As related by policymakers to the judge, publicity from
these graduations has made it clear that the Drug Court is a valuable
asset to the county's criminal justice programs.

Treatment is necessarily no-frills and basic, kept as inexpensive as
possible. All counselors are State-certified and supervised by those
licensed to do so, but they need ongoing training. Inexpensive education
and training can be found at local community colleges that offer human
services degrees with an emphasis on addiction treatment and through
involvement in State continuing education programs. The counseling
provided to participants in the Tulare County Adult Drug Court is worth
far more toward recovery than the minimal costs they pay.

The lack of public funding also means that the Drug Court team is
responsible for payment of ongoing training that is specific to Drug
Courts. For example, membership in the National Association of Drug
Court Professionals requires substantial annual dues, and the cost of
attending its annual training conference is considerable. Expenses can
be offset somewhat by State associations that also provide training and
by other training opportunities. For example, the National Rural
Institute on Alcohol and Drug Abuse at the University of Wisconsin
offers annual training for Drug Courts, subsidized by the Office of
National Drug Control Policy and the U.S. Department of Justice.
Participants can receive scholarships to this training, including the
full cost of travel, lodging, and tuition.

**Advantages of the Self-Funded Approach**

Despite the disadvantages previously discussed, the self-funded approach
offers many advantages. Chief among them is the freedom from concern
about locating the next funding source. The economic downturn following
the September 11, 2001, tragedy caused some Drug Courts to close for
lack of funding. Other Drug Court coordinators have had to scramble and
spend many hours searching and applying for grants, thereby diverting
them from their intended purpose of coordinating the Drug Court. Under
the self-funded approach, economic downturns that result in government
budget cuts will not affect the operation of the Drug Court. The judge
and administrators know from where the next dollars will emanate. The
self-funded Drug Court team is free to operate its court considering
local needs and circumstances. The court can adapt quickly to local
changes, trends, and resources. There are no reports and forms that must
be submitted to grant providers or those whose political agenda does not
include Drug Courts. The most significant, overriding advantage of the
self-funded approach is that it allows any jurisdiction, no matter how
poorly funded, to have a Drug Court.

The public in Tulare County is highly supportive of the self-funded
approach. The Drug Court is not a government program that uses more
taxpayer dollars squeezed from already strapped budgets. The Drug Court
judge and other team members can proudly speak about the efficacy of the
program, all without additional cost to taxpayers. Service clubs and
other civic groups are very supportive after speeches in which the judge
relates that those who violated the law in the first place are paying
for their own treatment. A study by the California Department of Alcohol
and Drug Programs and the Judicial Council of California completed in
March 2002 showed that California Drug Courts saved taxpayers more than
\$43,400,000---more than \$200,000 for every 100 participants. These
savings are enhanced when the cost of treatment is borne by the
participants; resources can then be provided for other services (p. 15).

Many wraparound services, such as medical care, employment training,
vocational and educational counseling, housing, parenting classes, and
childcare can be provided from existing government programs. Alert team
members can make arrangements with such programs to give special
attention to Drug Court participants. For example, the Adult School and
Adult Literacy Programs in Tulare County found that the Drug Court
participants are highly motivated to succeed because, barring
disability, completion of their education is a requirement of
participation in the Drug Court. If they do not follow through on
commitments to these programs, they face expulsion from the Drug Court
and incarceration. With appropriate waivers, periodic reports can inform
the judge of progress, and any necessary corrective measures can be
applied to put the participants back on the right track.

Finally, the Court's experience has shown that participants value
something according to their investment to obtain it. The Tulare County
Adult Drug Court emphasizes to the graduates that they can be proud of
the fact that they paid for their treatment and are responsible for
their own success in achieving recovery. Graduates leave with an
unprecedented feeling of pride in their accomplishments. Many say they
have never done anything deserving of positive public recognition. For
example, one man in his 30s stood silently for more than a minute,
looking at his certificate after graduating, then looked up with tears
in his eyes and said, "This is the first thing I have ever
accomplished." Most have lengthy criminal records and suffer feelings of
worthlessness upon entry into the Drug Court. This lack of self-esteem
contributes to the cycle of helplessness and hopelessness that spirals
into ongoing and increasing drug use. Instilling a sense of pride in
accomplishment, bolstered by paying for treatment, is a key element in
participants' future sobriety. Graduates leave knowing that their
sobriety came dearly purchased, and they guard it closely.

**Conclusions**

It might well be said that those who live by the grant will die by the
grant. Whereas grants can be a useful tool in creating a Drug Court, it
is shortsighted to create a project without planning for sustainability
after the grant expires. To avoid having a successful project entombed
by the expiration of grant funds, sustainability must be considered from
the inception of Drug Court planning. Startup grants can provide much
needed resources to get a Drug Court off the ground; planning for
reliance on existing resources, rather than using grant funds to create
new ones, will ensure ongoing operation of a Drug Court.

Although Drug Courts funded with public resources can offer participants
more expansive treatment and supportive wraparound services, there are
tangible advantages to creating a self-supporting Drug Court. Basic
treatment services can be provided at a reasonable cost to most eligible
defendants, and those who graduate are highly motivated because of the
substantial commitment they have made toward their own recovery. When
economies fluctuate, there is stability in the program, and all
resources can be directed toward providing quality services directly to
the participants instead of concentrating on raising funds. Private
community resources and public--private partnerships can enhance the
program through voluntary donations and provision of many additional
services for the Drug Court.

Because participants come to court for regular reviews, the judge and
probation officer can ascertain whether participants are complying with
requirements to pursue education and employment goals. Those who
successfully complete the Drug Court leave knowing that they have
contributed the lion's share toward their own recovery, and they tend to
value it more highly than those to whom it was provided gratis. More
than 1,000 people have graduated from the Tulare County Adult Drug Court
in the past 7 years, at very little cost to the taxpayers, and a great
majority has avoided further convictions for drug offenses. For Tulare
County, the choice of whether to have a Drug Court is clear. Any
jurisdiction can create and sustain a self-supporting Drug Court with a
little ingenuity, creativity, and the political will to make it succeed.

**References**

American University. (2003). *Summary of Drug Court activity by State
and county, November 7, 2003.*
**www.american.edu/academic.depts/spa/justice/publications/drgchart2k.pdf**
\[Accessed April 30, 2004\].

Belenko, S. (2001). *Research on Drug Courts: A critical review.* New
York: The National Center on Addiction and Substance Abuse at Columbia
University.

California Department of Alcohol and Drug Programs & the Judicial
Council of California, Administrative Office of the Courts. (2002). Drug
Court Partnership Act of 1998, Chapter 1007, Statutes of 1998: Final
Report. Sacramento, CA: California Department of Alcohol and Drug
Programs.

California Department of Finance. (2002). *California statistical
abstract: Gross State product, income, and cost-of-living, section D
table D-22.* **www.dof.ca.gov/html/fs_data/stat-abs/sec_D.htm**
\[Accessed May 31, 2004\].

California Department of Food and Agriculture. (2002). *California
agricultural statistical review. Resource Directory 2002.*
**www.cdfa.ca.gov/card/card_new02.htm** \[Accessed May 31, 2004\].

California Department of Health Services & California Conference of
Local Health Officers. (2004). *County Health Status Profiles 2004* (p.
51). Sacramento, CA: California Department of Health Services.
**www.dhs.ca.gov/hisp/chs/PHweek/CProfile2004/Profile2004.pdf**
\[Accessed May 31, 2004\].

California Department of Justice, Criminal Justice Statistics Center.
(n.d.). *Incarceration rates for drug-related crimes, 1970--2002.*
**www.caag.state.ca.us/cjsc/glance/cht17.htm** \[Accessed December 4,
2003\].

California Employment Development Department. (2004). *Tulare County
industry employment and labor force data.*
**www.calmis.ca.gov/file/lfmonth/tularpr.txt** \[Accessed May 31,
2004\].

Hora, P. F., Schma, W. G., & Rosenthal, J. T. (1999). Therapeutic
jurisprudence and the drug treatment court movement: Revolutionizing the
criminal justice system's response to drug abuse and crime in America.
*Notre Dame Law Review*, 74(2), 455.

Langan, P. A., & Levin, D. J. (2002). *Recidivism of prisoners released
in 1994.* Washington, DC: U.S. Department of Justice, Office of Justice
Programs, Bureau of Justice Statistics.

Lessenger, J. E., Lessenger, L. H., & Lessenger, E. W. (1999). *An
outcome analysis of Drug Court in Tulare County, California* (p. 30).
Porterville, CA: Unpublished report.

Tulare County, California. (2004). In *Wikipedia: The free
encyclopedia.* **www.fact-index.com/t/tu/tulare_county_california.html**
\[Accessed May 31, 2004\].

U.S. Census Bureau. (2000). *Table DP-1. Profile of general demographic
characteristics: 2000 statistics for Tulare County, California.*
**censtats.census.gov/data/CA/05006107.pdf#page=2.** \[Accessed May 31,
2004\].

U.S. Department of Justice, Office of Justice Programs, Bureau of
Justice Statistics. (2003). *The estimated number of arrests for drug
abuse violations decreased slightly from 2001 to 2002: Drug arrests by
age, 1970--2002*. **www.ojp.usdoj.gov/bjs/glance/drug.htm** \[Accessed
December 3, 2003\].

Warren, J. (2003, November 14). Panel calls prison policies costly
failure. *Los Angeles Times*, p. B1.

**Empower for Recovery: An Innovative Approach To Assist Sustained
Recovery in Rural Iowa**

Deborah K. Rohlfs, M.A., LMHC, CADC

*Contact information:*

Community and Family Resources

916 Superior Street, Suite 115

Webster City, IA 50595

Phone: (515) 832--5432

Fax: (515) 832--5432

*Area of focus:* Rural strength- and home-based substance abuse
treatment and recovery support program.

**Abstract**

Empower for Recovery is a targeted treatment approach that has
demonstrated both its effectiveness and successful outcomes with
rural/frontier substance abusers, their families, and significant
others. This home-based program provides early intervention utilizing
DiClemente and Prochaska's stages of change. The program emphasizes
pretreatment, posttreatment, case management, and family services to
families in whom substance abuse has been identified as a possible
problem. Those in rural areas face unique challenges in obtaining and
maintaining sobriety. They face issues such as geographical distance
from services including Alcoholics Anonymous, Al-Anon, and Ala-Teen.
Transportation can be an obstacle to obtaining and maintaining sobriety.
Families often have very few resources for obtaining support and
education surrounding substance abuse. Other issues, such as financial
pressure, domestic violence, and Department of Human Service
involvement, can overwhelm a family. Providing a comprehensive
strength-based approach that empowers individuals in the families' home
results in positive outcomes. According to reported 1-year postdischarge
outcomes, 80 percent of substance abusers maintain sobriety with this
in-home program.

**Introduction**

Rural Iowa. The words create the image of rolling cornfields and an
idyllic lifestyle. However, a different picture is hidden behind that
image---methamphetamine labs and substance abuse. The image of an
idyllic lifestyle disguises the misery caused by substance abuse.
Treating those caught up in the web of substance abuse is challenging,
especially in rural areas. Those who seek help encounter many barriers.
Treatment facilities can be as much as 100 miles away, with no public
transportation available. Losing a driver's license or having financial
difficulties can make participating in treatment difficult if not
impossible. Services to assist families of persons involved in substance
abuse are also very limited. Even common systems such as Al-Anon and
Ala-Teen are few and far between. Most communities have Alcoholics
Anonymous (AA) groups, but they usually meet only once a week.

The challenges of achieving and maintaining sobriety are daunting.
Community and Family Resources (CFR), a State-funded treatment agency
located in rural Iowa, began to look for creative ways to overcome some
of these barriers in their catchment area.

At the same time, recognizing that solutions to problems are best
decided at a local level, State legislators created a statewide
Empowerment Board. This board provides funding for local empowerment
areas to use creative methods to address stated needs in their
communities. The target population served by these funds is families
with children up through age 5 as well as pregnant women. The goal is to
provide a safe and stable family environment so children can develop in
an appropriate manner and be prepared for school.

In 1999, the rural counties of Hamilton, Humboldt, and Wright were
declared a local empowerment area. The counties cover 1,592 square miles
and have a combined population of 40,782, or 25.6 people per square
mile. The largest population center has 8,176 residents.

In the local empowerment area, substance abuse---especially
methamphetamine use---was identified as a significant problem that
needed an additional creative approach to produce better treatment
outcomes. A new goal was set through creative planning and discussion by
a multitude of community providers, the local empowerment group, and the
executive director of the Empowerment Board, Ann Stewart. This new goal
of the local Empowerment Board was to provide in-home services for
families of substance abusers as well as those who abuse substances. The
executive director of CFR, John Hostetler, and therapist Deb Rohlfs
designed the details of the program services. These services would not
be treatment specific but would assist in case management,
premotivational services, posttreatment followup and support, and
services to the family. These services would be provided in the client's
home, making it easier for the family to access the services. This
program would work in collaboration with other in-home programs that
provide services to families.

After the first year, the local Department of Human Services (DHS) also
chose to participate in the program. By providing funding from the
Promoting Safe and Stable Families Program, services were expanded to
include children older than age 5. This expansion assisted families in
achieving reunification when children had been removed from the home
because of substance abuse.

**Purpose**

The purpose of the Empower for Recovery Program is to assist families in
which substance abuse has been identified as a risk factor for the
children in the home. Substance abuse in a home can create chaos and
instability. Many studies have shown that children raised in homes where
substance abuse occurs suffer from neglect and abuse at a higher rate
than in the non-substance-using population (Semidei et al., 2001). When
families are living in chaos related to substance abuse, helping their
children with developmental activities is not a priority. The children
are at risk of falling behind developmentally. According to Semidei et
al. (2001), children raised in homes where substance abuse is a problem
are at greater risk of experiencing adjustment disorders, behavioral
problems, conduct disorders, and Attention Deficit Disorder. When the
children enter school, these problems may continue, possibly for the
rest of their lives.

To help the children, the family must receive help with the substance
abuse issues. This program does not specifically identify the person who
is abusing substances as the "client." Instead, the program considers
the whole family as being in need of assistance. Through this process,
it is hoped that the person who is abusing substances will come to a
point of seeking help and choosing to live an abstinent life style.

**Methods**

A strength-based approach was chosen as the most effective. All families
have strengths, but often they do not recognize or use those strengths
to make changes. By first looking at their strengths, the family could
start to use both the resources they had and their natural support
systems to start to make changes. The counselor could then help them
identify what was not working and help the family to discover better
ways to achieve the change. The counselor would also act as a case
manager to help the family access resources they still needed to become
more successful. This assistance would include helping the substance
abuser to identify and find the appropriate level of substance abuse
service.

This program also incorporated two theories---stages of change (Connors
et al., 2001) and motivational interviewing (Miller & Rollnick, 2002).
Families involved with this program are at all points of the stages of
change model. Some are just starting to explore the possibility of
changing, whereas others have made a commitment to change and need
ongoing support. The concept of change as a process (Connors et al.,
2001) can be very helpful in working with families. Many people relapse
during their process of change; hope is encouraged when relapse is
explained with the stages of change model. People see that a relapse
does not necessarily constitute failure but can be used as a tool to
examine what was not working and what changes must occur. The stages of
change can also help the family understand the process people go through
when trying to change behaviors. Families can also use the stages of
change model as they try to change any enabling behaviors they may have.

Motivational interviewing also works well in the context of this
program. Part of the premise of motivational interviewing involves
joining with the clients where *they* are (Miller & Rollnick, 2002).
Joining with the family, instead of dictating what needs to occur,
empowers the family to find a way to make changes that make sense to
them.

**Subjects**

Involvement in this program requires a problem with substance abuse
within the family system. Referrals come from many agencies, primarily
the County's Public Health agencies and the DHS. If agencies are working
with a family, and substance abuse is suspected, the family can be
referred to the program. Treatment facilities also make referrals when
their clients are preparing for discharge.

The Empower for Recovery Program began early in 2000. Referrals have
continued to increase steadily over the past 4 years. Since the
program's inception, 61 families have received services. During
screening, nine of the families were in crisis situations and were
referred to more appropriate services. Thirty families have completed
the program, dropped out, or were referred elsewhere.

**Screening Tools**

After families were referred to the program, a screening tool created by
the empowerment coordinator was used to assess the family's needs. If a
person admitted having a substance abuse problem, a regular evaluation
was completed to determine the level of treatment needed. An appropriate
referral was made for any other areas of need the screening tool
identified.

**Program Description**

Every family is unique and thus has unique needs. Empower for Recovery
was developed with maximum flexibility to meet each family where they
are and to assist them in achieving their goals. The main components of
the program are intertwined and often overlap. As described below, the
program has five main parts: (1) pretreatment, (2) posttreatment, (3)
case management, (4) family issues, and (5) collaboration.

**Pretreatment**

When some families are referred to the program, the family member who is
abusing substances is not ready to admit having a problem. In the stages
of change model, this situation would be identified as a
precontemplation stage. Some characteristics of this stage include
defensiveness, resistance to the suggestion of a problem, lack of
commitment to treatment, avoidance of steps to change behavior, and
feeling coerced (Connors et al., 2001).

The rest of the family may be angry and frustrated with the substance
abuser. Often, a great deal of friction exists. In this situation, the
needs of all family members must be addressed. The substance abuser is
offered the opportunity to explore his or her substance abuse and is
given permission to feel free to examine his or her ambivalence about
stopping. According to Miller and Rollnick (2002), exploring ambivalence
is crucial in the process of change. By allowing this exploration,
resistance is lowered. When confrontation is used, the person often
becomes more resistant; he or she does not want to be told what to do.
The family is allowed to explore the benefits of the substance abuse as
well as the cost to the family. This exploration often allows the family
to make choices that will work for them.

The family is given an opportunity to express its feelings. Family
members often have conflicting feelings regarding substance abusers and
their continuing substance use. They may fear for the health and safety
of the abuser; they may feel anger, disappointment, and conflicting
degrees of love and hate. They have not always had the opportunity to
express these feelings, even to themselves. Family members are educated
regarding substance abuse and addiction. They also learn about enabling,
family systems, and the family dynamics often found where substance
abuse is a problem. Family members develop their own plan to take care
of themselves, and they learn ways to stop enabling the user. The stages
of change are also explained to the family. They explore these stages in
regard to changes the family might experience due to the absence of
substance abuse. They also examine changes they might experience
individually. Once again, the family members decide what changes they
are willing to make. The program focuses on the client and his or her
decisions, not what the counselor feels is the best choice for the
family. Referrals to Al-Anon and other similar self-help programs are
given. Unfortunately, such programs are not available in many rural
areas, so online groups may be listed as an option.

Sometimes the substance abuser chooses to continue substance abuse. In
keeping with the goals of this program, which include a safe and stable
environment for the children, family members decide whether they can
live with the ongoing substance abuse or whether they need to leave. If
they choose to leave, case management services are available to assist.
If the family chooses to stay, services are available to develop safety
plans. It is hoped the families will, at the least, change their
reactions to the substance abusers. At times, this change will also
force the substance abuser to decide what is most important---family or
substance use.

External factors---usually involvement from DHS---may make the user feel
that he or she is being forced to participate in the program. When a
family is at this point, it is important for program personnel to join
with them. This concept comes from motivational interviewing theory
(Miller & Rollnick, 2002). It is important to let the family know the
counselor is willing to start where the family members are and listen to
what they want as goals. Their first goal may be getting DHS out of
their life. If so, the counselor can discuss what would have to happen
to accomplish this goal. Although they may have to address several
issues, substance abuse is certainly one of them. Many substance abusers
are not sure they want to quit at this point. As program counselors, we
discuss with them their ambivalence. They must come to their own
conclusion that they want to quit. We then can develop goals to help
them accomplish this. Substance abusers seem less resistant to stopping
the use of drugs and alcohol if stopping is only part of the overall
plan to make the changes DHS is requesting. If substance abusers feel
that the substance abuse is the most important issue, resistance seems
to become greater. Once again, the substance abuser is given the choice
to stop or not. However, the substance abuser must also be willing to
accept the consequences of continuing use. If the person chooses to
quit, he or she is given assistance to gain entrance into an appropriate
program. Referrals to AA or Narcotics Anonymous (NA) are also given.

If substance abusers are to enter residential treatment, issues often
arise surrounding making arrangements for their families. The Empower
for Recovery Program works with families who have children. If the
children are still living in the home, arrangements must be made for
their care if the primary caretaker goes through treatment. Some
programs are available for women who want to bring their children into
treatment with them, but these programs do not work for all families.
For some families, a relative or friend must be found who will be
willing to care for the children. If the person seeking treatment is
holding a job, arrangements also must be made at work. In addition,
financial obligations must be covered while a person is in treatment.
Sometimes, substance abusers---especially those who are single
parents---can feel overwhelmed with all this preparation. Single parents
often have less support and feel all of the responsibility. For the
counselor, a fine line exists between doing too much for the client and
helping the client make the arrangements. Without some assistance,
however, some substance abusers will have a difficult time following
through with entering residential treatment.

If the children have been removed from the home already, entering
residential treatment can be less complicated. However, visitation can
become problematic, especially if the children live a long way from the
treatment facility. The substance abuser cannot leave residential
treatment to visit the children, and both the DHS and foster parents are
often reluctant to allow the children to visit the treatment center. At
the same time, it is important for clients to have visitation to promote
successful reunification of the family. The Empower for Recovery
counselor is instrumental in coordinating family visitation and
encouraging future reunification.

**Posttreatment**

This program also provides posttreatment services. As the person nears
discharge, the primary treatment counselor, the client, and the Empower
for Recovery in-home counselor will sit down and discuss the discharge
plan. Some of this discussion will become incorporated in the goals the
client sets for the Empower for Recovery Program. When a person leaves
treatment and goes home, more stress often occurs within the family. The
family has worked around the addiction for such a long period of time
that suddenly not having the addiction present can create a difficult
transition period. Families usually need assistance in working through
this transition period. Substance abusers typically become frustrated
when family members do not believe they will change. Family members, on
the other hand, do not know why they should suddenly believe someone who
has consistently lied to them. The substance abuser, however, leaves
treatment and wants to go back into the family and start taking back
responsibilities that had been ignored.

These responsibilities may include paying the bills and making decisions
that affect the family. The spouse might be resentful about this change.
The spouse may have handled all the responsibilities in the past and is
now not sure about trusting the recovering person. Disciplining children
also may be difficult, as children have learned how to manipulate the
substance-abusing parent. The substance abuser also may have
difficulties in returning to work and facing issues left behind when
entering treatment. Attendance at AA/NA meetings may also cause
conflict. The family sometimes resents the time spent at the meetings
and feels the meetings are not so necessary. The family may see only
that the substance abuser is taking time and financial resources to
drive to meetings.

All these stresses can become overwhelming and contribute to relapse.
The client might still be in outpatient or aftercare treatment, but the
counselors in this program find that the person in recovery often does
not share these issues. The counselor often does not have much access to
the family members who are not in recovery, so it is difficult for the
counselor to address issues with the couple or other family members.

For couples who are both in recovery, especially those who completed
treatment at the same time, even more issues arise. These couples must
rebuild their relationship. Often, they have not known each other as
sober persons, and they must learn different ways to communicate, have
fun, and spend time together. These issues are often brought up when the
counselor is in their home, where these couples seem more relaxed and
more open to discuss the issues.

Many other issues surround the posttreatment period. Poverty frequently
is seen in the population served by the Empower for Recovery Program.
Even in those families with employed adults, low wages make it difficult
for the family to have a balanced budget. Their substance abuse may have
interfered with education and job performance (Karoll & Poertner, 2002).
Many single parents, especially, have been on welfare for a period of
time. The recent 5-year limit on welfare is starting to affect some
persons. Many lack medical insurance. Available and affordable childcare
is difficult to find. Many former substance abusers have difficulty
finding transportation. They do not have a reliable vehicle, they do not
have a license, they cannot afford insurance, and public transportation
is very limited. All these difficulties pose challenges to their finding
employment, because they are often limited to small towns that have few
available positions (Karoll & Poertner, 2002). The Empower for Recovery
Program can assist clients in examining these issues and resolving the
problems. For example, some programs offer short-term assistance, but
families are often not aware of these programs; therefore, referrals can
be very helpful.

Many of the women have been involved in abusive relationships. Surviving
in these relationships is often more important to them than maintaining
sobriety. The women feel trapped due to economic situations (Dore &
Doris, 1998). Again, referrals made by the Empower for Recovery
counselor can be beneficial.

Frequently, a history of child abuse, both physical and sexual, has
occurred and results in ongoing mental health issues.

Persons in recovery often have not had positive models for parenting and
therefore lack parenting skills (Karoll & Poertner, 2002). When DHS
becomes involved and either removes their children or adjudicates their
children as Children in Need of Assistance, women may become overwhelmed
and find it difficult to maintain sobriety. Part of the Empower for
Recovery Program is assisting these families, as discussed in the next
component of the program---case management.

**Case Management**

A study conducted by Dore & Doris (1998) suggests that achieving and
maintaining sobriety requires extensive support over a long period of
time. Part of the problem in a rural area is finding that type of
support. Groups in most communities can offer support, though sporadic
and limited, for maintaining sobriety. However, issues other than not
drinking or using occur, such as those mentioned in the previous section
(poverty, DHS involvement, court involvement, insurance, transportation,
and parenting). Usually, the persons' families have struggled with these
issues for years. While persons were abusing substances, they tended not
to worry about paying bills, found illegal ways to support themselves,
or ignored the problems. Other family members were left to try to deal
with these issues on their own. Now that the persons in recovery are
trying to develop a sober lifestyle, they tend to feel overwhelmed by
all the issues they are facing. The case management component of the
Empower for Recovery Program assists families in this area.

One goal of the program is family financial independence. The family
must work through this process and often needs assistance in reaching
that goal. Some families have used every resource they could find in
their area and thus have exhausted any further assistance. These
families need help in learning how to develop a budget and to find ways
to make enough money to follow the budget. They may need to learn living
skills, such as learning to cook instead of depending on fast food. They
may need to learn how to shop more effectively. They may need to look at
getting job training or more education to obtain better paying
employment. Some people do not have sufficient skills to maintain
employment. For instance, they may not have learned good communication
skills or may have difficulty in managing their emotions. After the
persons return to the home setting, these issues become more evident
than they were during treatment. Not addressing these issues can lead to
failure in employment and/or personal relationships. Any failure at this
point in their recovery can lead to relapse. These issues can be
addressed best in the home situation. Referrals can be made to provide
more assistance with areas in which a person lacks skills. At times,
just offering support is helpful for the family.

Families who are struggling financially can be referred to appropriate
agencies. Not all families are aware of all the programs for which they
qualify. These programs can assist the family to become financially
stable and move forward.

Parenting is another issue that commonly is important early in recovery.
Many families in the Empower for Recovery Program are involved with DHS.
But even in the families without DHS involvement, difficulties often
arise in parenting while sober. By providing services in the home, a
program can address parenting issues in the family's normal setting and
normal circumstances. Referrals can also be made to collaborating
agencies that provide parenting programs in the home.

The Empower for Recovery Program often discovers mental illness within
the family. Mental health services are limited in the rural area and can
be difficult for the families to obtain. Many families do not know where
to start looking for help. Paying for medications may also be difficult.

Case management services assist in finding resources that enable
families to receive the care they need. It is important for the Empower
for Recovery counselor to have a background in mental health. The
counselors involved in the CFR Empower for Recovery Program have a
master's degree in mental health services and are Certified Substance
Abuse Counselors.

Health insurance is another important issue. Many families do not have
health insurance and are not aware of the programs that offer low rates
for children. Referrals can also be made to some free clinics. The
Empower for Recovery counselor can assist clients in finding appropriate
health care for the family.

Transportation issues can hinder a family's recovery. If families do not
have access to transportation, they cannot attend outpatient services.
They often have a difficult time making appointments with DHS, housing
assistance, and other agencies. These services may be as much as 40
miles away. Families may have difficulty in finding someone who has 3--4
hours to spend bringing the family to the appointment, waiting, and
coming back. Through the Empower for Recovery counselor, persons can
receive assistance with transportation or find other transportation
resources through local volunteer agencies. The families are often
unable to access these resources directly because an agency must make
referrals.

Families learning new ways of coping in the early stages of recovery
often find themselves in crisis. These crises can usually be dealt with
during a phone call. All families are given a phone number for such
crisis situations. At times, families will need to schedule an extra
appointment to deal with a crisis.

A wide variety of other issues are brought up by families. By having the
program services provided in the home and readily available, referrals
can be made quickly, and assistance is readily available.

**Family Issues**

Family issues can be difficult for those in recovery. Family members are
often left out of the treatment process. The Empower for Recovery
Program has found that other members of the family often are angry and
frustrated. Providing services in the home provides an opportunity for
dealing with these family issues. Issues surrounding family roles and
the unspoken rules often found in the homes of substance abusers are
discussed and resolved. Family members can gain an understanding of
their enabling behaviors and learn ways to offer healthy support.

Older children often have much built-up anger, both toward the substance
abuser for continuing to use and toward the other parent for staying in
the situation. For example, one teen had been referred to the Empower
for Recovery Program because of the poor choices she was making. As she
started to improve, she expressed her anger toward her father for his
continued promises to stop using and his continued return to drugs and
alcohol. She reported being tired of "being the parent" in her family
and wanted to be a "normal" teenager. She was also angry at her mother
for refusing to leave her father and start a new life. Finally, she was
placed in foster care at her request.

Another component of the family-centered services is Family Team
Conferencing. This concept was adapted from the model used by The Child
Welfare Policy and Practice Group (Vincent, 2003). First, the Family
Team concept is explained to the client. They can then choose whether to
participate. If they chose to use a Family Team Conference, they decide
who their support system includes---usually family members, friends, and
service providers. If DHS is involved, they are also included. Those
persons identified by the client are notified and invited to a meeting.
During this time, family strengths are identified. Those invited can
bring up concerns they have regarding the substance abuse and related
issues. The entire group then develops a plan to assist the family in
reaching the family's goals and identifies who will provide what
assistance. Safety plans are developed in case of relapse. This approach
has proved to be extremely helpful. Those invited tend to become more
involved because they have participated in developing the plan. The
client also feels more of a sense of ownership.

**Collaboration**

A very important component of the Empower for Recovery Program is
collaboration with other agencies. To ensure nonduplicated services and
provide coordinated case management, a strong collaborative network has
been developed. This collaboration eliminates fragmented services and
ensures that all programs provided to the family are working toward the
same goal. Developing a strong, collaborative, well-working relationship
with other agencies is a process that takes time, patience, and
persistence when starting a program like Empower for Recovery.

To provide helpful collaboration, meetings are often set with the family
and all providers involved with the family. This is a more informal,
smaller version of the Family Team Meeting. Releases of information are
signed, allowing service agencies involved with the family to share
information. The family is asked to share its goals. Any problems with
the goal are discussed at this time. The family is asked what assistance
it will need to achieve its goals. The providers then make suggestions
on ways they believe they could help. A plan is created that identifies
which providers will do what. The meeting also helps the providers speak
with each other when working with families they all serve. Review
meetings are set up on a regular basis so that movement toward the goals
can be examined and any changes can be made. As a very strong component
of the Empower for Recovery Program, collaboration not only helps
address substance abuse issues but helps the family deal with underlying
issues that might contribute to relapse. Involving service agencies in
an integrated approach provides families with the tools needed for
successful recovery.

**Discharge**

Discharge planning begins after any initial crisis period has passed.
Often, if the referral is made during a crisis episode, this crisis must
be resolved first. The family and the counselor discuss what goals the
family would like to set. They also discuss what the family would look
like when services are discontinued. This goal is reviewed periodically.

Dependency on the counselor is always a risk in this program. The
counselor must be aware of interactions with the family and encourage
autonomy. If a counselor notices dependency starting to develop, it is
appropriate to discuss it with the family and incorporate a goal of
family autonomy. Weekly review of the cases by a supervisor and/or peer
counselor will help the therapist to remain objective and focused on the
mission of the program.

**Counselor Safety**

When counselors go to a family's home, the counselor's safety is always
in question. In the Empower for Recovery Program, this aspect is
addressed by training the counselors. Basic training for safety includes
a variety of approaches, such as safety information from other providers
and referral sources. Also, having specific training in mental health
and substance abuse makes the counselor more aware of common
characteristics of those who use specific drugs and individuals who may
be under the influence. This training helps the counselor identify when
not to stay and provide services. As in all situations, "gut instincts"
are good indicators of what to do or not to do. Every counselor in the
program has total control of engagement and disengagement as well as
modifying interactive approaches.

This program also has very few first contacts in which the counselor
does not have information from another agency. Almost all clients have
been referred. Releases are obtained, and the family's situation is
discussed with the referral agency. Any safety issues are brought up at
that time. Each counselor also carries a cell phone at all times. Any
time a counselor feels uncomfortable or unsafe, he or she can leave the
situation.

**Challenges, Problems, and Solutions**

One of the biggest challenges in developing Empower for Recovery was
establishing collaborative relationships. According to the original
grant, the Empower for Recovery Program was to work with the
Hopes/Building Families Programs in all three counties. Public Health
nurses carry out these programs with families with children who are
prenatal through age 5. The nurses work with the children's health
issues as well as with child development and appropriate parenting
skills. The initial collaborative efforts were awkward and challenging.
No agency was sure how this process should work or how the Empower for
Recovery Program would fit in with current programs. The programs Public
Health was working with were also somewhat new. They were not sure how
to present the Empower for Recovery Program to their clients. Persons in
all agencies spent time getting to know each other, developing a common
language, and being open to trying some new approaches. Cross-trainings
helped to create a common language and approaches. As the program
developed, the helpfulness of the collaboration became apparent.
Families achieved better outcomes in a shorter amount of time. Although
the Public Health nurses had some knowledge of substance abuse, and the
staff of Empower for Recovery understood child development, by using our
strengths and trusting the other agency to work from its strengths, the
work with the family was both more effective and easier for the staff.
As the collaboration between Public Health and Empower for Recovery
developed, other agencies began to be drawn in to the collaborative
process (such as advocates against domestic violence, social workers
from DHS, school counselors, and persons from other agencies providing
family-centered services). During the past 4 years, the agencies
involved in collaborative processes have gained overall strength and
become more effective in providing services.

Another challenge Empower for Recovery encountered was the expense of
the program. Providing in-home services over a large geographical area
has proved to be expensive. Much time is spent driving. However, when
comparing the expense of a family's completing the program versus the
long-term cost to the community of continued substance abuse, the cost
does not seem so high. For example, helping a young, pregnant woman
abstain during her pregnancy reduces her chances of having a child with
Fetal Alcohol Syndrome (FAS). A child born with FAS can cost a county
more than \$3 million over a lifetime (Fetal Alcohol Syndrome, 2003).
The program may also save the cost of foster care---approximately \$900
per month in Iowa (Doug Koons, personal communication, January 2001). In
addition, substance abusers who are in recovery are not reentering the
legal system. Because these are long-term costs, they are often
overlooked. In fact, persons who are in recovery are usually employed
and contributing by paying taxes.

**Outcomes of the Program**

Families who participated in the program were involved for an average
period of 6 months to 1 year. The program has tracked several specific
outcomes, including maintained sobriety, measured at 6 months and at 1
year; founded charges of child abuse after entry into the program; and
an increase in community involvement.

Thirty families have been discharged from the program. Of these
families, nine were crisis situations and received services only two to
three times. During these visits, the family situation was evaluated,
and more appropriate sources of assistance were found. Six families
dropped out of the program. Fifteen families have completed the program.
At the end of 1-year postdischarge, eight substance abusers have
maintained sobriety. One has reached 6 months. Four families have left
the substance abuser, because the substance abuser has refused to stop
using at this time; thus, the children are now in a safer situation. Two
substance abusers have relapsed, but they have accessed services sooner
than during previous relapses.

**Case Study**

**Amy**

Amy was a methamphetamine user who was failing in treatment due to
continued use. She had had several previous treatment episodes. She was
currently living with her husband, their common child (a 3-year-old
son), her 18-year-old child from a previous marriage, and his two
children from a previous marriage. Animals accessed the home through
holes. The couple had debts of approximately \$60,000. Amy's husband was
manufacturing meth in the garage, although she denied knowing where he
was manufacturing the drug. A history of domestic violence included
several threats on her life. Amy also suffered from depression but was
not being treated.

Amy was referred to the Empower for Recovery Program. When the Empower
for Recovery counselor visited the home, she found the water and
electricity had been disconnected. Amy had stopped opening the mail 3
months earlier, because she did not want to deal with any more bills.
Therefore, the family had not received their food stamps and had not
completed paperwork to receive any further assistance.

With assistance from the counselor, the local Domestic Violence Center,
and Public Health, Amy was able to leave her husband. She felt this was
the only way to maintain her sobriety, as he was not willing to stop
using or manufacturing methamphetamines, nor was he willing to meet with
the Empower for Recovery counselor. Amy obtained suitable housing, has
been drug free for more than 2 years, and has completed some vocational
technical education. She is employed and has followed through with
treatment for her depression. Amy also paid off her share of their debt
after the divorce.

**Recommendations**

This program began as part of an innovative program through the local
Empowerment Board. At first, it was not known exactly how this program
would fit with the other programs in existence. Through the work of Deb
Rohlfs, this program has been refined and developed over the past 4
years. It would be beneficial to perform a formal research project on
this program at this time.

Other screening tools are currently being examined to provide even
better screenings and referrals. Motivational interviewing is a large
component of the program's approach. However, at this time no formal
tools are used to assess the clients' motivation. Addition of such a
tool might prove advantageous. Exploring the use of mental health
screening tools also might be useful.

The program has demonstrated some promising outcomes. Further study and
refinement of the program might provide a more helpful approach in
working with rural and frontier substance abusers.

**References**

Connors, G. J., Donovan, D. M., & DiClemente, C. C. (2001). *Substance
abuse treatment and the stages of change.* New York: Guilford Press.

Dore, M. M., & Doris, J. M. (1998). Preventing child placement in
substance-abusing families: Research informed \[Electronic Version\].
*Child Welfare, 77*, 407--427. Retrieved October 17, 2003, from
Professional Development Collection database.

Fetal Alcohol Syndrome. Retrieved November 10, 2003 from
**www.acbr.com/fas/fasmain.htm**.

Karoll, B. R., & Poertner, J. (2002). Judges', caseworkers', and
substance abuse counselors' indicators of family reunification with
substance-affected parents \[Electronic Version\]. *Child Welfare, 81*,
249--260. Retrieved October 17, 2003, from Professional Development
Collection database.

Miller, W. R., & Rollnick, S. (2002). *Motivational interviewing* (2nd
ed.). New York: Guilford Press.

Semidei, J., Radel, L. F., & Nolan, C. (2001). Substance abuse and child
welfare: Clear linkages and promising responses \[Electronic Version\].
*Child Welfare, 80*, 109--129. Retrieved October 17, 2003 from
Professional Development Collection database.

Vincent, P. (2003). Training from The Child Welfare Policy and Practice
Group. Montgomery, AL. Phone: (334) 264--8300.

**Delivering a Maternal Substance Abuse Intervention Program Along the
Rural Route**

Trudee Ettlinger, Ph.D., APRN, LADC

*Contact information:*

Trudee Ettlinger

P.O. Box 85

Underhill Center, VT 05490

Work: (802) 485--2612

Home: (802) 899--3737

Fax: (802) 899--3677

E-mail: trudeern@earthlink.net

*Area of focus:* Rural mothers/women and alcohol and other drugs.

**Abstract**

We sought to design and deliver an indicated-level substance abuse
prevention program for lower income mothers living in rural Vermont. The
Rocking Horse program employed best practices for working with rural
mothers, used sensitive outreach, and built the program in the
community. This 10-week psychoeducation group modality, led by a
maternal/child specialist and a licensed substance abuse treatment
professional, provided education about the risks of alcohol and illegal
drugs for women's health during pregnancy, and for young children living
in substance-abusing families. Health education was delivered in a
highly supportive format that emphasized building personal competencies.
The short-term results suggest that this program is increasing knowledge
of the harms caused by substance abuse and bolstering personal capacity
to move away from this behavior.

**Introduction**

According to the National Household Survey on Drug Abuse (Substance
Abuse and Mental Health Services Administration, 2002), the estimated
rates of problem drinking and illegal drug use for women are climbing,
and rural women are included in these trends (Rural Women's Work Group,
2000). Yet getting rural mothers the help they need to move away from
this harm is challenging because they often hesitate to admit problems
(Boyd, 1998). For many, revealing heavy drinking and drug use in the
family may bring threats from close family members (Booth & McLaughlin,
2000); carry community disapproval toward them for behavior unbecoming a
mother (Ettlinger, 2000); and capture attention from child welfare
authorities. The limited availability of treatment services (Fortney &
Boothe, 2001), the hurdles barring access to the programs, and the need
for childcare and transportation (Bushey, 1997) further discourage them
from seeking help early. For poor and nearly poor rural mothers involved
with substance abuse firsthand or secondhand, the rural poverty
hardships they face may loom larger in their lives than the destructive
nature of substance abuse. All too often, cultural norms, access
barriers, and personal issues keep these women from getting help until
they are in crisis. These observations, and the absence of
prevention-level programs for this population, prompted a Vermont group
of maternal/child professionals and substance abuse specialists to
develop an alcohol and other drugs (AOD) intervention that might keep
low-income mothers out of harm's way.

The Rocking Horse (RH) program attempts to intervene with these at-risk
mothers before their circumstances escalate into a treatment crisis. The
program was designed as an indicated-level prevention effort to
interrupt the progression of risk. During the past 2 years, this Vermont
program has served an estimated 225 lower income rural mothers who are
at risk of substance abuse. Our evaluation suggests that this program is
helping mothers build knowledge and skills to repair the personal and
family harm that results from problem drinking and illegal drug use.

**Getting Started: Designing the Rocking Horse Program**

The RH program realizes that substance abuse is a part of our world and
strives to reduce its tragic effects on maternal health by intervening
early, both to decrease the vulnerability to this health threat and to
increase the capacity to move away from this risky behavior. The program
believes that changing risky behaviors depends on strengthening
knowledge and skills through a caring approach that respects the women's
culture and their traditions. The program also recognizes the harms from
alcohol and illegal drug use that are specific to women's experiences
(Ramlow, White, & Watson, 1997). Central to the program's framework are
the concepts found in effective prevention efforts. Effective prevention
at the individual level is based on building mastery, self-worth, and
life skills and establishing rewarding relationships (Schinke,
Brounstein, & Gardner, 2002).

Four main principles guided program development. First, the RH program
recognizes that these mothers are nested in a background where sets of
social and cultural factors may place them at risk for substance use. RH
helps them recognize risk factors and provides strategies to reduce the
harm. Second, RH also understands that substance abuse has grave
consequences during pregnancy, and parental substance abuse places young
children at risk. The program provides education on the serious outcomes
of substance abuse during pregnancy and teaches skills to bolster safe
and nurturing care of the young child. Third, the program realizes that
these mothers face hardship, and their support networks may not be
dependable. RH underscores substance abuse as a major factor in
destabilizing personal development, family strength, and reliable
friendships. The program model highlights setting goals, making
decisions, managing stress, and recognizing healthy, rewarding
relationships. Fourth, the RH program recognizes that these mothers are
cautious and guarded for many reasons. Reaching and engaging these women
call for using culturally matched approaches and sensitive outreach and
lowering the barriers to access.

**Delivering and Managing the Program**

The RH program is a group modality that follows a 10-week curriculum.
The content of the weekly groups has four major domains. Guided
discussion explores substance abuse and women's health, substance abuse
and relationships, substance abuse and young children, and substance
abuse and life troubles. A maternal/child specialist and a licensed
substance abuse treatment professional lead the weekly groups. These
leaders are women who live and work in the same rural communities and
have a deep understanding of the culture and lives of the women they
serve. The groups are conducted in nonagency community settings, and
onsite childcare and transportation are provided. A particular feature
of this program is providing the mothers with a small incentive at each
weekly meeting. These small gifts recognize that being a mother is hard
work and reward their efforts to solve problems. Additionally, special
emphasis is placed on making the climate inviting and caring. The
setting is private and comfortable, and snacks are provided for the
mothers and their children.

The group process is sensitive to the culture of the mothers. Group
leaders are mindful of the intergenerational patterns of substance abuse
in families; often, healthy role models are lacking. The leaders
function as teachers, mentors, and role models. They are very supportive
and encourage the women to support one another in rewarding ways.
Relational approaches and thoughtfulness are the key processes in group
interaction. The groups close each meeting with a ritual that emphasizes
self-care.

The mainstay of the RH program is its community aspect. It is not seated
in any agency, nor is it part of an outpatient or residential substance
abuse treatment program. Professionals from the network of programs that
serve the local population collaborate to deliver the program.
Multidisciplinary community teams of maternal/child, substance abuse,
early childhood, mental health, and child protection workers, as well as
family visitors, manage the program in their community. The group
leaders who coordinate the groups receive supervisory and administrative
oversight. The supervisory level maintains program integrity and gathers
feedback from the field to refine the program. The administrative level
concentrates on program accountability.

**Program Evaluation Methods**

The RH program was piloted for 3 years (1997, 1998, and 1999) in rural
Vermont locations and served an estimated 60 women. The observational
data from pilot groups in two communities suggested that the program was
both reaching and engaging an at-risk group of younger mothers. The
group leaders' findings suggested that the women were responsive, their
attitudes were changing, and their binge drinking patterns decreased. In
2000, RH groups were implemented across the State, and an objective,
measurable, evaluation component was developed.

Three methods are used to evaluate the program. The women complete a
preparticipation and postparticipation survey and add narrative
comments, and the leaders also complete a focused questionnaire. The
preprogram and postprogram surveys are self-administered at the first
and last group sessions. Each survey uses forced choice questions that
are scored on a Likert scale. The 23 items are measures from the Center
for Substance Abuse Prevention Core Measures Initiative (1999). These
measures look for shifts in perception of handling stress, managing
parenting, self-esteem, and establishing supportive relationships. The
measures seek changes in perception about the risks of alcohol, tobacco,
and illegal drugs in relation to women's health and pregnancy as well as
their effects on young children. The tool gathers demographic data from
the mothers and asks questions about their personal alcohol consumption
and illegal drug use and that of their partner(s).

The leaders complete a log that records the number of women served and
notes the time needed for program management. This log also records the
number of women referred for treatment services. The postprogram survey
that leaders complete elicits leaders' impressions about conducting the
program, observations of the women attending, and comments about both
the program's strengths and areas for improvement.

**Results from Year 1 and Year 2**

The data were analyzed using a t-test for matched pairs of preprogram
and post-program surveys. The following results are based on 124
completed sets of questionnaires (from a total of 167 surveys returned
from the field) for groups conducted in 14 towns across the State in
2001 and 2002. Missing data reflect incomplete forms and unmatched
surveys. The data suggest that 29 percent of the women do not complete
the 10-week program, and more than one-third are repeating the program.

The demographic data show that the majority of the women are 22--35
years old, and two-thirds are single parents. Sixty-eight percent had
their first baby during their teenage years; half of these women had not
completed a high school education. More than 80 percent of the women had
children under age 5, and 36 were pregnant. More than 60 percent of the
mothers were not working and receiving Temporary Assistance for Needy
Families benefits. About 25 percent of the women reported heavy
drinking, and 40 percent reported that their partners were heavy
drinkers. Almost 80 percent of the women stated that they had used
illegal drugs in the past.

Data from year 1 and year 2 suggest several significant changes: a shift
in perception of handling stress more effectively (p = .008), increased
perception of risk from alcohol for women's health and during pregnancy
(p = .01), increased perception of strong interpersonal support (p =
.003), and an increased perception of self-worth (p = .01). Although not
statistically significant, the data also suggest an increased perception
of parenting skills and an increased understanding of substance abuse
behavior patterns. The results show a reported 9 percent decline in
their own binge-drinking behavior. The women's narrative comments are
consistent across the 2 years with four major perceptions: The women
report a very strong positive opinion of the group experience; they cite
the importance of having a trusted space where they can talk about the
effects of alcohol and drugs on their lives; they state that they have
built new ways to manage their lives and feel more capable taking care
of their babies and children; and they want to see this program continue
because it is "worthwhile."

The leaders reported that they observed uninterrupted attendance; the
women dressed up to come to the group; the group was referred to as
"class"; dropping out was influenced more by the partner than by the
attendee; the women often commented on being afraid to talk about AOD
for fear of retribution; and the women had a startling lack of knowledge
about sexually transmitted infections. The leaders suggested that 10
group meetings were not enough and recommended that the program be
extended. The leaders also commented that this program was serving as an
entry point for bridging many of the mothers into other services. The
group leaders reported personal satisfaction in conducting these groups.
They expressed alarm, however, about the norm of heavy drinking among
these younger mothers and their great vulnerability to the mounting
presence of drugs in the rural towns.

Despite the data suggesting that this program is having positive
results, the findings must be viewed with caution. The evaluation design
is empirically weak with only a preprogram and postprogram survey of the
attending women. The results may be biased because the women are alerted
to the postprogram survey questions by taking the initial questionnaire.
No control of confounding variables was attempted. Additionally, missing
data may have affected the results.

**Discussion**

Although the evaluation process has weaknesses, we nonetheless believe
that the RH program is leaving an imprint. The program is reaching and
engaging a population that is at increased risk for substance abuse. The
findings from this prevention effort suggest that the program is
effectively delivering health education about the risks of substance
abuse and helping the mothers increase their awareness about how AOD
jeopardizes themselves, their pregnancies, and their young children. The
women in the program also appear to be building coping skills and
gaining self-confidence to manage their lives. The experience of genuine
support also seems to help them identify healthy, rewarding
relationships.

The group leaders and other professionals involved with the program view
the program as greatly needed by this population of mothers. Until this
program was launched, prevention efforts were absent. The treatment
network stepped in when the women were in crisis---a demanding and often
unfriendly entry point for treatment. The community teams note that
early intervention may have interrupted a crisis situation for some of
the mothers; for others, the program sparked recognition that they
needed treatment. The community teams commented positively on their
personal satisfaction in delivering this program. As well, the community
teams have found that the structure of the program (not nested within an
agency) has promoted shared ownership among the service providers.

**Program Lessons Learned and Recommendations**

We set out to address a profound maternal health risk for a population
that usually keeps this risk well hidden. We discovered that "country
mothers" are at risk of AOD and in need of prevention programming. We
also learned that matching approaches to the intended population is an
important key to engage people in helper programs. We believe that the
strength and followthrough in the RH program rests with the
collaborative efforts of the community teams. This program was based on
grassroots participation of the many providers who work with these
mothers. As this program was developed and discussed, these
professionals came forward to head up implementation in their
communities. It is clear that involving others from the beginning is a
critical part of a program's success.

All programs need to be evaluated, and the methods and processes of the
evaluation must be sound and objective. We have come to realize that
field evaluation processes must be stringent. During the past 2 years,
approximately 48 groups have been conducted in 14 communities by 11
teams of group leaders. Data accuracy problems have prompted a more
structured and monitored data gathering process. Additionally, a strong
evaluation design is needed to better determine the effectiveness of a
program. Presently, we are moving ahead with a stronger experimental
design that will include a comparison group and measure results of the
comparison group against results of the intervention group. Without such
a comparison, program outcomes are questioned.

**Summary**

Poor and nearly poor rural mothers face a collection of health threats.
We encourage all professionals who work with these women not to overlook
the possible presence of substance abuse in their lives. During the past
2 years we have found that we are drawing to the attention of the
service system the issues of substance abuse among this population. The
program is gaining recognition, and the referrals are growing.

Is the RH program making a difference? The short-term outcomes support
the conclusion that we are engaging our intended population and helping
these mothers increase their knowledge of AOD abuse and build skills to
move away from AOD.

Equally important, the program is highlighting, at both program and
system levels in our State, the presence of substance abuse for this
group.

Finally, our findings support the need for both substance abuse
treatment programs for rural mothers and further research into the
strategies that will provide effective interventions for this
population. We advance the notion that all efforts, from prevention to
treatment, recognize that AOD is interwoven in the life fabric of these
women. Therefore, addressing this problem must include attention to all
the background influences that place these women at risk. Additionally,
initiatives must recognize the strengths that these women possess as
well as their attachments to their families. We also suggest that
incorporating treatment programs into various community provider teams
may create a spirit of engagement and promote shared ownership. These
collaborations are often the key to a program's sustainability and
growth.

**References**

Booth, B., & McLaughlin, Y. (2000). Barriers to and need for alcohol
services for women in rural populations. *Alcoholism: Clinical and
Experimental Research, 24*, 1267--1275.

Boyd, M. (1998). Substance abuse in rural women. *Nursing Connections*,
*11*(2), 33--45.

Bushey, A. (1997). Mental health and substance abuse: Challenges to
providing services to rural clients. *Bringing excellence to substance
abuse services in rural and frontier America*. Technical Assistance
Publication (TAP) number 20. DHHS Publication No. (SMA) 97-3134.
Rockville, MD: Substance Abuse and Mental Health Services
Administration, Center for Substance Abuse Treatment.

Center for Substance Abuse Prevention. (1999). *Core Measures Initiative
Phase I Recommendations*. Rockville, MD: Substance Abuse and Mental
Health Services Administration.

Ettlinger, T. (2000). In harm's way: Recognizing and addressing alcohol
risk for rural disadvantaged pregnant mothers. *Public Health Nursing,
17*(3), 207--210.

Fortney, J., & Boothe, B. (2001). Access to substance abuse services in
rural areas. *Recent Developments in Alcoholism, 15*, 177--197.

Ramlow, B., White, A., & Watson, D. (1997). The needs of women with
substance abuse problems: An expanded vision for treatment. *Substance
Use & Misuse*, *32*(10), 1395--1404.

Rural Women's Work Group. (2000). The behavioral health care needs of
rural women. In *Report of the Rural Task Force of the American
Psychological Association*. New York: American Psychological
Association.

Schinke, S., Brounstein, P., & Gardner, S. (2002). *Science based
prevention programs and principles*. DHHS Publication No. (SMA) 03-3764.
Rockville, MD: Substance Abuse and Mental Health Services
Administration, Center for Substance Abuse Prevention.

Substance Abuse and Mental Health Services Administration. (2002).
*Summary of the findings from the 2001 National Household Survey on Drug
Abuse*. DHHS Publication No. (SMA) 02-3759. Rockville, MD: Substance
Abuse and Mental Health Services Administration, Office of Applied
Studies.

**Socio-Demographic Profiles and Treatment Outcomes of Methamphetamine
Abusers in Rural and Urban Areas**

Kazi A. Ahmed, Ph.D.

Careema Yusuf, M.P.H.

*Contact information:*

Corresponding Author: Kazi A. Ahmed, Ph.D.

JBS International, Inc.

8630 Fenton Street, 12th Floor

Silver Spring, MD 20910

Phone: (301) 495-1080

*Area of focus:* Socio-demographic characteristics of methamphetamine
abusers in rural and urban areas.

**Abstract**

This study compares methamphetamine abusers in rural and urban areas,
specifically their socio-demographic characteristics, actual use
behavior, and drug use and nondrug treatment outcomes. Data are derived
from a larger dataset that is part of the Treatment Outcomes and
Performance Pilot Studies Enhancement Inter-State Study. This larger
study measured functioning or behavior of substance abuse treatment
clients at admission, discharge, and posttreatment (6 months
postdischarge or 9 months postadmission).

Both urban and rural methamphetamine abusers were predominately white
and male. In urban areas, however, nonwhite methamphetamine abusers were
more racially and ethnically diverse. More methamphetamine abusers
sought treatment in urban areas, and these clients were more likely to
be homeless. The average age of methamphetamine abusers was lower in
rural areas, and these clients also had significantly more dependent
children living with them. Posttreatment data showed that both rural and
urban methamphetamine abusers saw significant decrease in number of
arrests and significant improvement in employment status (full-time and
part-time), independent living, and abstinence from methamphetamine use
over the past 30 days. This study brings to light the shift in
socio-demographic characteristics of methamphetamine abusers (e.g., from
only white, blue-collar males) and also highlights the increase of
methamphetamine use in rural areas. Prevention and treatment initiatives
need to focus on these changes to better target the groups who need
these services.

**Introduction**

Methamphetamine is an odorless, white crystalline powder---a powerfully
addictive stimulant that can be snorted, smoked, injected, or taken
orally. It dramatically affects the central nervous system, and
long-term abuse can lead to aggression, violence, memory loss, psychotic
behavior, and cardiac damage (NIDA, 2000; Volkow et al., 2001a; Volkow
et al., 2001b). Because it can be synthesized using relatively
inexpensive over-the-counter ingredients, methamphetamine can be made
and subsequently distributed easily (NIDA, 2002).

In the 1950s, in the United States, methamphetamine was manufactured
legally as tablets for medical use. However, nonmedical use spread among
college students, truck drivers, and athletes. In the 1960s, with the
introduction of injectable methamphetamine, this pattern changed and in
1970, the Controlled Substances Act severely restricted the legal
production of injectable methamphetamine. Methamphetamine often goes by
such street names (slang) as "crank," "chalk," "meth," "speed,"
"crystal," "ice," "sparkle," "clear," and "peanut butter" (ONDCP, 2001;
NIDA, 2002).

Methamphetamine abuse has been the dominant drug problem in the San
Diego, California, area for a long time (NIDA, 2002). However,
methamphetamine abuse has now spread across the United States, no longer
concentrated in California. It has spread to other sections of the West
and Southwest, and Midwest portions of the country. Methamphetamine
abuse has also spread from urban to rural areas, and the users
themselves are no longer purely white, male, blue-collar workers (NIDA,
2002). The National Institute on Drug Abuse's Community Epidemiology
Work Group reported in June 2001 that treatment admissions showed that
methamphetamine was the leading drug of abuse among treatment clients in
the San Diego area and Hawaii, which differs from treatment admissions
in areas in most Midwestern and Eastern States, for example,
Minneapolis-St. Paul and St. Louis, where methamphetamine abuse
accounted for about 3 percent of total admissions, and Baltimore, where
no stimulant-related admissions were reported for the first half of 2000
(NIDA, 2002). In 1999, 15 of the 50 States and the District of Columbia
reported that 6 to 25 percent of the total substance abuse clients
admitted for treatment identified methamphetamine as the primary
substance of abuse. Of the 15 States, 7 were Midwestern States with
admission rates between 6 and 16 percent (SAMHSA, 2001). The number of
methamphetamine laboratory seizures in California reported to the Drug
Enforcement Administration in 1997 increased to 1,273 from 879 in 1996.
During that time period a significantly higher number of methamphetamine
laboratories were also seized in the Midwestern States of Arkansas,
Kansas, Missouri, and Oklahoma (California Border Alliance Group, 1998).
This trend reflects the widespread proliferation of methamphetamine
manufacture, trafficking, and use across the West and Midwestern States.

The shift in methamphetamine abuse from California to other sections of
the country and the change in the demographic profile of the
methamphetamine abuser are further supported by the results provided in
this paper. Treatment samples from across the country provide clear
evidence of the geographical spread pattern of methamphetamine abusers
in the country. Treatment data from a representative sample of treatment
centers from 19 States collected under the Treatment Outcomes and
Performance Pilot Studies Enhancement (TOPPS II) Inter-State Study
provide direct evidence of a general pattern of diffusion of this drug
from its West Coast origin to Midwestern and Southern States (see table
1). Whereas methamphetamine abuse is highest in the West and Southwest,
it is conspicuously absent or insignificant in East Coast States.
Prevalence of methamphetamine abuse in the Midwestern and Southern
States also signals the spread of the abuse into rural communities.

**Table 1. Sample Rates of Clients Seeking Treatment for Any
Methamphetamine Use**

**(Primary, Secondary, or Tertiary Presenting Problem) in 19 TOPPS II
States**

+----------------+-----------------+-----------------+-----------------+
| **States**     | **Percentage of | **States**      | **Percentage of |
|                | Treatment**     |                 | Treatment**     |
|                |                 |                 |                 |
|                | **Clients       |                 | **Clients       |
|                | Reporting**     |                 | Reporting**     |
|                |                 |                 |                 |
|                | **              |                 | **              |
|                | Methamphetamine |                 | Methamphetamine |
|                | Use**           |                 | Use**           |
|                |                 |                 |                 |
|                | **(Primary,     |                 | **(Primary,     |
|                | Secondary, or** |                 | Secondary, or** |
|                |                 |                 |                 |
|                | **Tertiary      |                 | **Tertiary      |
|                | Problem) (n)**  |                 | Problem) (n)**  |
+----------------+-----------------+-----------------+-----------------+
| California     | 48.8 (13,381)   | New Hampshire   | 2.8 (389)       |
+----------------+-----------------+-----------------+-----------------+
| Utah           | 43.3 (667)      | Massachusetts   | 1.6 (442)       |
+----------------+-----------------+-----------------+-----------------+
| Arkansas       | 34.2 (1,206)    | Illinois        | 1.2 (1,569)     |
+----------------+-----------------+-----------------+-----------------+
| Oklahoma       | 24.5 (1,144)    | Virginia        | 1.0 (955)       |
+----------------+-----------------+-----------------+-----------------+
| Arizona        | 24.4 (512)      | New York        | 0.6 (855)       |
+----------------+-----------------+-----------------+-----------------+
| Washington     | 22.9 (14,977)   | Rhode Island    | 0.8 (353)       |
+----------------+-----------------+-----------------+-----------------+
| Iowa           | 17.3 (400)      | Connecticut     | 0.8 (385)       |
+----------------+-----------------+-----------------+-----------------+
| Missouri       | 15.4 (475)      | Maryland        | 0.4 (10,090)    |
+----------------+-----------------+-----------------+-----------------+
| Texas          | 10.3 (892)      | New Jersey      | 0.3 (1,002)     |
+----------------+-----------------+-----------------+-----------------+
| Kentucky       | 7.1 (604)       |                 |                 |
+----------------+-----------------+-----------------+-----------------+

**Purpose**

As indicated above, the abuse of methamphetamine is not limited to urban
areas only; it has spread to rural communities as well. Because very
little systematic research has been done to document the abuse of this
drug within rural populations, this study attempts to fill this
knowledge gap by focusing on the socio-demographic characteristics of
rural methamphetamine abusers who entered a substance abuse
rehabilitation program. The study also describes the actual use behavior
of treatment clients and their drug use and nondrug treatment outcomes.
The study compares these results to characteristics of urban
methamphetamine abusers. Specifically, the study addresses the following
exploratory research questions:

> • Do socio-demographic characteristics of methamphetamine abusers in
> rural areas differ significantly from those of methamphetamine abusers
> in urban areas?
>
> • Do the two user groups vary in frequency of use and the route of
> administration of the drug?
>
> • Is there a significant difference in the drug treatment outcomes
> (abstinence from using methamphetamine) and nondrug treatment outcomes
> (posttreatment employment status, criminal justice involvement, and
> living arrangement) of the two user groups?

**Methods**

**Program and the Research Description**

This study is part of a larger study (TOPPS II Inter-State Study)
conducted under a cooperative agreement grant funded by the U.S.
Department of Health and Human Services, Substance Abuse and Mental
Health Services Administration in September 1998 with 19 States (see
table 1 for a complete list of TOPPS II participating States). A major
purpose of the TOPPS II Inter-State Study was to develop an integrated
picture of substance abuse treatment effectiveness in the participating
States. To achieve this purpose, a prerequisite was to define common
measures of client status and substance abuse treatment effectiveness
and apply them to the data collected by participating States. The
Inter-State Study used a single-group quasi-experimental
pretest--posttest design with measures at three defined time periods. By
measuring functioning or behavior at admission, discharge, and
posttreatment (6 months postdischarge or 9 months postadmission), the
design allowed consideration of posttreatment changes and their temporal
stability. Sixteen States collected primary data, while three States
extracted records of comparable data elements for the same time period
from their existing Management Information System (MIS).

**Sampling Strategies**

The 16 Primary Data States (PDS) employed a two-stage sampling design to
collect the data for the study. At stage one, the States selected a
sample of treatment providers that constituted a good representation of
the four modalities: intensive outpatient/standard outpatient,
inpatient/residential rehabilitation, methadone, and other (such as case
management, community living, continuing care, and extended care). Then,
at stage two, the States sampled the clients receiving treatment from
the selected treatment providers.

The States provided data that correspond to the standardized TOPPS II
31-item core dataset. Repeated measures were taken for most of the items
at postdischarge followup from a sample of adult (18 years or older)
clients. Data were collected by treatment center staff at admission and
discharge. The 9-month postadmission followup data were collected by
independent research organizations hired by the TOPPS II States.

Data were sent to the TOPPS II Technical Assistance Center for the
Inter-State Study analysis. The PDS provided a sample of 24,087 clients.
Posttreatment followup completion rates ranged from a low of 17.1
percent to a high of 92.38 percent, with an average of 62.15 percent. A
limited number of the core data items were collected at discharge. The
Secondary Data States provided records for 38,187 clients from their
MISs. These States were able to extract from their interagency databases
a limited number of core dataset items pertaining to posttreatment
outcomes. The two sources generated a total of 62,274 cases. The study
protocols of participating States were reviewed and approved by an
Institutional Review Board.

A subset of the larger dataset was used for this study. This study is
based on a total of 17,588 samples submitted by 142 treatment providers
from 7 States (Arkansas, California, Iowa, Kentucky, Missouri, New York,
and Utah). Samples from the seven States were used in this study because
they had either the most methamphetamine users or provided the larger
proportion of rural clients. Approximately 7 percent of the samples
(n=1,182) were clients receiving services from providers in rural
settings.

**Variables of Interest**

Variables used in this study are a subset from the larger TOPPS II
Inter-State Study. Variables were selected based on their predictive
value as well as substantive value. The importance of these variables
has been very well documented by previous studies in the substance abuse
field (McLellan, Belding, McKay, Zanis, & Alterman, 1997; Hubbard,
Mardsen, Rachal, Harwood, Cavanaugh, & Ginzburg, 1989; Hubbard,
Craddock, Flynn, Anderson, & Etheridge, 1997; Aglin & Hser, 1990;
Hubbard, 1992; McLellan, Woody, Metzger, McKay, Durrell, Alterman, &
O'Brien, 1996; Mirin, Gosset, & Grob, 1991; Ball & Ross, 1991; D'Aunno &
Vaughn, 1992; McLellan, Alterman, Cacciola, Metzger, & O'Brien, 1992;
Ahmed, Yusuf, Hussain, Cacciola, Foltz, McKay, & Weiss, 2003).

Three types of variables were included in this study---a set of
socio-demographic variables, methamphetamine use-related variables, and
methamphetamine treatment outcomes variables. The socio-demographic
variables included gender, age (18--20, 21--29, 30--39, and 40 or
older), race (American Indian/Alaska Native, Asian, African American,
Native Hawaiian/Pacific Islander, white, Hispanic, other, and
multiracial), marital status (married/remarried/widowed,
separated/divorced, and never married/ single/cohabitating), employment
status (full-time \[30 hours or more per week\], part-time, not working
but looking for a job, and not in the labor force), education (\< high
school, high school degree, and some college or college degree),
dependent children (no children, one child, and two or more children),
and living arrangement (homeless, living with someone as a dependent,
and living independently).

There were three methamphetamine use-related variables: age at first use
of methamphetamine (\<11, 11--17, 18--20, 21--34, 35--44, and 45+),
frequency of methamphetamine use (no use in the past month, 1--3 times
in the past month, 1--2 times per week, 3--6 times per week, and daily),
and the route of administration (oral, smoking, inhalation, injection
\[IV/Intramuscular\], and other).

Methamphetamine treatment outcomes variables included treatment
completion status, rate of change in use behavior from admission to 9
months postadmission (frequency of use variable at the three time
periods used), rate of change in arrest rate from admission to 9 months
postadmission, rate of change in employment from admission to 9 months
postadmission, and rate of change in living arrangement from admission
to 9 months postadmission.

Methamphetamine was one of the 18 specified drugs for which a client at
intake was asked to provide frequency of use, age at first use, and
route of administration. The response regarding frequency of use of a
particular drug helped the counselor or data collector determine whether
that drug use was a primary, secondary, or tertiary drug problem. In
this study, all three types of drug problems were included in the
analysis.

**Designation of Rural and Urban Areas**

A provider is designated as rural if the county in which it is located
has a population of fewer than 50,000; otherwise it is designated as
urban. The population size of counties is based on 2000 Census
information. Because a majority of clients reside in the area in which
they are receiving treatment, they are accordingly described as rural or
urban clients. Kentucky, Arkansas, California, Iowa, and Utah
contributed most of the sample of rural clients in the study.
Approximately 7 percent (n=1,182) of the study sample was rural clients.

**Data Analyses and Statistical Procedures**

As mentioned previously, a subset of a larger dataset was selected for
the purpose of this study. Descriptive analysis was used to obtain the
frequencies and percentages. The chi-square significance test was used
to test for statistical significance of two categorical variables (e.g.,
gender of methamphetamine abuser by rural-urban setting). The
independent t-test was also used to test for significant differences in
continuous variables (e.g., age). Finally, McNemar's chi-square test for
a 2 x 2 contingency table was used to test for the significance of the
differences of repeated measures (e.g., use or abstinence at admission
versus use or abstinence at followup).

**Socio-Demographic Characteristics of Rural and Urban Clients**

Descriptions of the socio-demographic characteristics of the rural and
urban clients in the sample follow.

**Gender**

In both rural and urban locations, treatment clients were predominantly
male. However, there were proportionately more male rural clients (68
percent) than urban clients (59 percent).

**Race and Ethnicity**

The majority of the clients were white, with 56 percent receiving
treatment in an urban setting and 85 percent in a rural setting. Some
other rural racial groups abusing methamphetamine were African Americans
(3 percent), Hispanics (2 percent), and American Indians (2 percent).
The proportion of Hispanics and African Americans was much higher in the
urban sample---15 percent and 18 percent, respectively. In both
settings, a significant proportion identified themselves as
multiracial---3 percent in rural areas and 5 percent in urban areas. In
the urban sample, 20 percent listed their ethnic origin as Hispanic or
Latino, compared to 5 percent in the rural sample. Ninety-six percent of
the clients who were multiracial were of Hispanic origin.

**Age at Admission**

There was a small but statistically significant difference in the
average ages of rural and urban clients in the sample. The average age
of rural clients was 33 years, whereas the average age of urban clients
was 35 years. The median ages were 34 and 38 years, respectively.

**Education**

In both settings, 34 percent of the clients had no high school
education. The percentage of clients with high school degrees was
slightly higher in the rural areas---47 percent versus 44 percent. This
distribution indicates that the majority of the clients had a high
school or college education.

**Employment Status**

The employment rate was higher among rural clients. In the rural sample,
more than 43 percent of the clients were employed either full time or
part time, compared to 35 percent in the urban sample. Consequently, far
fewer rural clients reported not being in the labor force---29 percent
versus 40 percent for rural and urban clients, respectively. However,
the unemployment (looking for job) rate was slightly higher among rural
clients (28 percent versus 25 percent).

**Marital Status**

The proportion of married, remarried, or widowed clients was higher in
the rural sample (27 percent versus 21 percent). The majority of the
clients had either never married or were separated/divorced. Although
the divorced rate was higher among rural clients (26 percent), the
prevalence of never married/single status was much higher among urban
clients, with 46 percent compared to 36 percent in the rural areas.
Rural clients had a higher percentage of cohabitation (2 percent) than
urban clients (less than 1 percent).

**Number of Dependent Children**

The number of dependent children (no child or one or more children) was
virtually the same for the rural and urban clients (41 percent with no
children, 21 percent with one child, and 37 percent with two or more
children).

**Living Arrangement**

Homelessness among the clients was more prevalent in the urban areas.
Only 3 percent of the rural clients were homeless, compared to 15
percent of the urban clients. When the homelessness category is merged
with those living as dependents, the percentage of clients at risk of
being homeless (i.e., homeless and dependent) increases to 33 percent
among urban clients, compared to 19 percent among rural clients.

**Major Findings**

**Socio-Demographic Characteristics of Methamphetamine Users in Rural
and Urban Areas**

The study sample revealed differences in the prevalence rates of
methamphetamine abuse among rural and urban clients. For example, in the
urban sample, more than 43 percent reported that they were in treatment
for using methamphetamine (primary, secondary, or tertiary drug
problem), as compared to 28 percent in the rural sample. This difference
was statistically significant.

No significant difference was observed in the number of male and female
methamphetamine abusers in the two settings. In each case, a little more
than half of the users were male.

The average age of rural methamphetamine abusers was slightly lower than
that of urban users---30 years compared to 33 years. This difference was
statistically significant.

More than 90 percent of the rural methamphetamine abusers were white.
Hispanics (3 percent) and American Indians (3 percent), however, were
also using the drug. There were virtually no African American users in
the rural areas in the sample. On the urban side, although the majority
of urban clients were white, the rate was much lower than in rural
areas---only 67 percent white. The urban sample included 17 percent
Hispanics, 4 percent African Americans, 3 percent American Indians, and
3 percent Asians. The racial mix of urban abusers was more diverse than
that of rural abusers (see table 2).

The marital status of rural and urban methamphetamine abusers did not
vary significantly. Approximately 20--22 percent were
married/remarried/widowed, 34--36 percent were separated/divorced, and
42--47 percent were never married/single or cohabitating.

Users did vary significantly in the number of dependent children living
with them. Thirty to thirty-six percent of rural and urban abusers did
not have any children living with them. Twenty to twenty-three percent
had one child living with them. Half of the rural clients, compared to
42 percent of the urban clients, had two or more children living with
them.

Homelessness among methamphetamine abusers was much more prevalent among
urban clients than among rural clients. In rural settings, 5 percent of
the methamphetamine abusers were homeless, compared to 15 percent in
urban settings. Users in a dependent living status, however, were more
likely to be rural clients. One-quarter of the rural clients reported a
dependent living arrangement, compared to 19 percent of the urban
clients. In both settings, the majority of the users were living
independently: 71 percent for rural and 66 percent for urban. When
controlling for gender, female methamphetamine users (55 percent) were
more likely to be homeless or at risk of being homeless than male users
(39 percent). The pattern for urban areas was similar, with a slightly
lower rate than that in rural areas.

Roughly one-third of the clients in both rural and urban areas were
employed: 34 percent of the rural clients and 28 percent of the urban
clients reported being unemployed or looking for a job. One-third of the
rural clients were not in the labor force, compared to 39 percent of the
urban clients. The differences are statistically significant.

Methamphetamine users in rural and urban areas did not differ
significantly in their educational status. Approximately 34--37 percent
had no high school education, 47--49 percent had a high school degree,
and 16 percent had some college or a higher degree.

**Table 2. Socio-Demographic Characteristics of Rural and**

**Urban Methamphetamine Abusers and Nonabusers**

+------------+-------------+-------------+---------------+------------+
| **Socio-** | *           |             |               |            |
|            | *Location** |             |               |            |
| **Dem      |             |             |               |            |
| ographic** |             |             |               |            |
|            |             |             |               |            |
| **Charact  |             |             |               |            |
| eristics** |             |             |               |            |
+============+=============+=============+===============+============+
|            | **Rural**   |             | **Urban**     |            |
+------------+-------------+-------------+---------------+------------+
|            | **Not a**   | **Metham    | **Not a**     | **Methamp  |
|            |             | phetamine** |               | hetamine** |
|            | **Metham    |             | **Meth        |            |
|            | phetamine** | **Abuser %  | amphetamine** | **Abuser % |
|            |             | (n)**       |               | (n)**      |
|            | **Abuser %  |             | **Abuser %    |            |
|            | (n)**       |             | (n)**         |            |
+------------+-------------+-------------+---------------+------------+
| **Race**   |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| American   | 56 (14)     | 44 (11)     | 50 (176)      | 50 (178)   |
| Indian/    |             |             |               |            |
|            |             |             |               |            |
| Alaska     |             |             |               |            |
| Native     |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Asian      | 100 (2)     | 0 (0)       | 45 (162)      | 55 (196)   |
+------------+-------------+-------------+---------------+------------+
| African    | 99 (80)     | 1 (1)       | 91 (2,735)    | 9 (268)    |
| American   |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Native     | 100 (2)     | 0 (0)       | 39 (28)       | 61 (43)    |
| Hawaiian/  |             |             |               |            |
|            |             |             |               |            |
| Pacific    |             |             |               |            |
| Islander   |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| White      | 70 (700)    | 30 (296)    | 48 (4,356)    | 52 (4,748) |
+------------+-------------+-------------+---------------+------------+
| Hispanic   | 45 (9)      | 55 (11)     | 54 (1,308)    | 46 (1,105) |
+------------+-------------+-------------+---------------+------------+
| Other      | 80 (4)      | 20 (1)      | 51 (100)      | 49 (97)    |
+------------+-------------+-------------+---------------+------------+
| M          | 80 (32)     | 20 (8)      | 50 (427)      | 50 (430)   |
| ultiracial |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| **Marital  |             |             |               |            |
| Status**   |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Married/   | 77 (242)    | 23 (74)     | 61 (2,070)    | 39 (1,325) |
| Remarried/ |             |             |               |            |
|            |             |             |               |            |
| Widowed    |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Separate   | 70 (283)    | 30 (120)    | 56 (3,013)    | 44 (2,376) |
| d/Divorced |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Never      | 68 (299)    | 32 (140)    | 55 (4,108)    | 45 (3,324) |
| Marri      |             |             |               |            |
| ed/Single/ |             |             |               |            |
|            |             |             |               |            |
| Co         |             |             |               |            |
| habitating |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| **         |             |             |               |            |
| Employment |             |             |               |            |
| Status**   |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Employed   | 81 (295)    | 19 (69)     | 60 (2,325)    | 40 (1,521) |
| Full Time  |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Employed   | 71 (98)     | 28 (39)     | 57 (1,068)    | 43 (820)   |
| Part Time  |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| U          | 65 (213)    | 35 (115)    | 52 (2,088)    | 48 (1,959) |
| nemployed, |             |             |               |            |
| Looking    |             |             |               |            |
| for a Job  |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Not in     | 67 (221)    | 33 (111)    | 58 (3,826)    | 42 (2,776) |
| Labor      |             |             |               |            |
| Force      |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| *          |             |             |               |            |
| *Dependent |             |             |               |            |
| Children** |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| No         | 79 (364)    | 21 (98)     | 64 (4,302)    | 36 (2,431) |
| Children   |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| One Child  | 73 (177)    | 27 (65)     | 53 (1,849)    | 47 (1,624) |
+------------+-------------+-------------+---------------+------------+
| Two or     | 62 (260)    | 38 (160)    | 50 (3,027)    | 50 (2,983) |
| More       |             |             |               |            |
| Children   |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| **Living   |             |             |               |            |
| Arr        |             |             |               |            |
| angement** |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Homeless   | 56 (19)     | 44 (15)     | 57 (1,372)    | 43 (1,023) |
+------------+-------------+-------------+---------------+------------+
| Dependent  | 57 (105)    | 43 (80)     | 54 (1,516)    | 46 (1,317) |
+------------+-------------+-------------+---------------+------------+
| I          | 75 (682)    | 25 (231)    | 57 (6,201)    | 43 (4,628) |
| ndependent |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| **E        |             |             |               |            |
| ducation** |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Less than  | 71 (286)    | 29 (115)    | 53 (2,979)    | 47 (2,601) |
| High       |             |             |               |            |
| School     |             |             |               |            |
|            |             |             |               |            |
| (\<12      |             |             |               |            |
| Years)     |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| High       | 70 (387)    | 30 (165)    | 53 (3,774)    | 47 (3,334) |
| School     |             |             |               |            |
| Degree     |             |             |               |            |
|            |             |             |               |            |
| (12 Years) |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| Some       | 74 (160)    | 26 (55)     | 69 (2,497)    | 31 (1,132) |
| College or |             |             |               |            |
| Higher     |             |             |               |            |
| Degree     |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| **Age      |             |             |               |            |
| Ca         |             |             |               |            |
| tegories** |             |             |               |            |
+------------+-------------+-------------+---------------+------------+
| 18--20     | 65 (76)     | 35 (41)     | 53 (500)      | 47 (435)   |
+------------+-------------+-------------+---------------+------------+
| 21--29     | 66 (229)    | 34 (120)    | 44 (1,804)    | 56 (2,266) |
+------------+-------------+-------------+---------------+------------+
| 30--39     | 68 (272)    | 31 (125)    | 52 (3,041)    | 48 (2,826) |
+------------+-------------+-------------+---------------+------------+
| 40+        | 84 (268)    | 16 (50)     | 72 (3,980)    | 28 (1,551) |
+------------+-------------+-------------+---------------+------------+

**Drug Use and Nondrug Outcomes in Rural and Urban Areas**

The rate of completion of treatment was slightly lower among rural
clients (37 percent) than among urban clients (39 percent). In rural
areas, the percentage of clients not completing treatment due to
incarceration was slightly higher (6 percent versus 3 percent in urban
areas). The rate of clients leaving treatment against professional
advice, however, is higher in the urban settings (43 percent versus 39
percent in rural settings).

There was no significant difference in the average age at first use of
methamphetamine between rural and urban clients---20 years (see table
3).

Although smoking methamphetamine was the most common route of
administration for both rural and urban clients, urban clients (51
percent) used it more often than the rural clients (37 percent). The
percentage of users inhaling the drug was slightly higher among rural
clients (29 percent) than among urban clients (26 percent). Similarly,
the percentage of users injecting methamphetamine was higher among rural
clients (28 percent) than among urban clients (18 percent). Also a
higher percentage of rural clients (7 percent) than urban clients (4
percent) were taking the drug orally.

**Table 3. Age at First Use, Frequency of Use, and Route of
Administration**

**for Rural and Urban Methamphetamine Abusers**

  -----------------------------------------------------------------------
  **Use-Related         **Rural % (n)**        **Urban % (n)**
  Variables**                                  
  --------------------- ---------------------- --------------------------
  **Age at First Use**                         

  \<11                  1 (4)                  1 (73)

  11--17                47 (153)               43 (3,001)

  18--20                20 (67)                21 (1,443)

  21--34                27 (90)                30 (2,116)

  35--44                4 (14)                 5 (373)

  45+                   0.3 (1)                0.2 (12)

  **Frequency of Use**                         

  No use in past month  58 (193)               59 (4,188)

  1--3 times in past    19 (64)                16 (1,142)
  month                                        

  1--2 times per week   8 (25)                 8 (544)

  3--6 times per week   7 (24)                 9 (615)

  Daily                 8 (28)                 8 (581)

  **Route of                                   
  Administration**                             

  Oral                  7 (22)                 4 (275)

  Smoking               37 (118)               51 (3,619)

  Inhalation            29 (97)                26 (1,797)

  Injection             28 (91)                18 (1,289)
  (IV/intramuscular)                           

  Other                 0.9 (3)                1 (77)
  -----------------------------------------------------------------------

The frequency of use among rural and urban clients was almost identical.
Approximately 60 percent of both rural and urban clients reported at
intake no use of methamphetamine in the 30 days prior to admission. It
may be noted that no use in the past 30 days could be attributed to
several factors, including living in a controlled environment (e.g.,
jail), a treatment provider's requirement of no use for a certain amount
of time before treatment could begin, or other external pressures (e.g.,
monitoring by the criminal justice system through probation or parole).
Of those who reported using the drug at the time of admission, 16--19
percent were using it 1 to 3 times per month, 8 percent were using it 1
to 2 times per week, 7--9 percent were using it 3 to 6 times per week,
and 8 percent were using it on a daily basis.

Treatment outcomes for methamphetamine abuse in both rural and urban
settings were virtually identical. In both locations, 92--93 percent of
the treatment clients reported abstinence from methamphetamine abuse for
the past 30 days at the posttreatment (9 months postadmission) followup
(see table 4).

The three nondrug outcomes measured were arrest records, living
arrangements, and employment. In rural settings, at admission 53 percent
of the clients reported having been arrested in the past 6 months. At
posttreatment followup this percentage was 22 percent. In urban
settings, at admission 40 percent of the clients reported having been
arrested during the past 6 months, and at followup the rate was 16
percent.

At admission 22 percent of the rural methamphetamine treatment clients
were either homeless or at risk of being homeless. At followup, this
figure dropped to 17 percent. In urban settings the percentage of
homeless or at risk of being homeless clients was 30 percent at
admission. At followup the figure had dropped to 24 percent.

In urban settings, the full-time and part-time employment status of
clients increased from 33 percent to 56 percent from admission to
followup. The employment rate among rural treatment clients increased
from 31 percent at admission to 64 percent at followup.

**Table 4. Drug Use and Nondrug Treatment Outcomes of Rural and Urban
Clients**

  --------------------------------------------------------------------------
                  **Rural %                    **Urban %      
                  (n)**                        (n)**          
  --------------- ------------- -------------- -------------- --------------
                  **At          **At           **At           **At
                  Admission**   Followup**     Admission**    Followup**

  **Frequency of                                              
  Use**                                                       

  No Use in Past  60 (59)       93 (92)        56 (644)       92 (1,073)
  Month                                                       

  1--7 Times/Week 40 (40)       7 (7)          44 (517)       8 (88)

  **Arrest                                                    
  Incidence**                                                 

  No Arrest       47 (71)       78 (118)       60 (915)       84 (1,283)

  Arrested        53 (81)       22 (34)        40 (612)       16 (245)

  **Employment                                                
  Status**                                                    

  Not Employed    69 (150)      36 (55)        66 (1,000)     44 (699)

  Employed        31 (47)       64 (97)        33 (524)       56 (855)

  **Living                                                    
  Arrangement**                                               

  Homeless        22 (34)       17 (26)        30 (452)       24 (352)

  Independent     77 (116)      83 (124)       70 (1,046)     76 (1,146)
  --------------------------------------------------------------------------

**Conclusion and Discussion**

Judging from the use behavior of treatment clients, methamphetamine is
very much an urban phenomenon. Almost half of the treatment clients in
the urban setting presented methamphetamine as their primary, secondary,
or tertiary problem. The use of methamphetamine among rural populations,
however, has become very common too. In some States (California and
Utah), almost half of the drug users are methamphetamine abusers. One of
the major reasons cited for the spread of methamphetamine in the rural
areas and deserts is the ease with which it can be manufactured there
(because the telltale odors of the production process are less likely to
be detected). Mobile labs in campers and vans have been reported on some
major highway routes. In addition to increased manufacture of
methamphetamine in rural settings, there is increased usage of
methamphetamine by rural populations, as this study has shown.

The socio-demographic profile reveals that methamphetamine abusers in
rural settings are younger than their urban counterparts. Although rural
methamphetamine abusers have similar educational background, marital
status, and gender distribution when compared to urban methamphetamine
abusers, they do vary significantly in their racial makeup, family size,
and employment status. Whereas smoking is the most common route of
administration for both groups, rural methamphetamine abusers are more
likely to be injecting or inhaling the drugs. Regarding treatment
outcomes, rural clients have a slightly higher probability of
involvement with criminal justice and have a higher treatment dropout
rate. With regard to the rate of posttreatment abstinence from using
methamphetamine, the treatment outcomes were the same for the two
groups. In general, the nondrug treatment outcomes (employment status,
arrest rate, and living arrangements) showed significant positive
results for both groups. However, the rate of change varied by location:
the decrease of arrest incidents in the past 6 months was much higher in
the rural areas, the decline of homelessness was slightly higher in the
rural areas, and the recovery from unemployment at posttreatment is much
slower in the rural areas.

This study has potential limitations that may require the results to be
interpreted with some caution. The designation of rural or urban status
was assigned poststudy based on the location of the treatment center.
There is a possibility that this assignment might lead to some
misspecification of the clients' residential status. Although the
overall size for the rural sample was adequate, some estimates of rates
may be biased due to small cell size for certain categories. Also, the
treatment outcomes of clients should be used with caution. The attrition
rate of samples at 9 months postadmission was rather high, leading one
to wonder what type of bias may have been introduced in the sample due
to the absence of input from nonrespondents.

An important treatment implication of the findings of this study is the
association of treatment completion with positive outcomes. As has been
documented in the larger TOPPS II study, treatment completion was
associated at followup not only with abstinence, but also with
employment and independent living. Treatment completion appears to be a
reasonable overarching treatment goal that providers can help clients
achieve. The study has shown that the rate of dropout from treatment is
higher for rural clients. This implies that unless treatment providers
can help decrease the dropout rate of rural clients, treatment outcomes
such as abstinence, employment, and independent living will be
negatively impacted. Because treatment completion is important, it may
be helpful to focus on enhancing motivation or other strategies of
treatment engagement to support the likelihood of both treatment
completion and abstinence. Abstinence prior to admission was related to
treatment completion and to abstinence at discharge and followup.
Specifically, clients who achieved a period of abstinence (30 days in
this case) prior to entering a substance abuse rehabilitation program
were more likely to complete treatment and maintain abstinence. This
suggests that initial abstinence for whatever reason, such as recent
time spent in a controlled environment or internal or external pressures
(e.g., monitoring by the criminal justice system through probation or
parole), provides the clinician with an opportunity to support and build
on positive behavioral change that already has been initiated.

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**An Environmental Scan of Faith-Based and Community Reentry Services in
Johnson County, Iowa**

Janet C. Hartman, M.A., LMSW

Iowa Consortium for Substance Abuse Research and Evaluation

University of Iowa

Stephan Arndt, Ph.D.

Iowa Consortium for Substance Abuse Research and Evaluation and
Department of Psychiatry, College of Medicine and Department of
Biostatistics

College of Public Health

University of Iowa

Kristina Barber, M.S.M.

Iowa Consortium for Substance Abuse Research and Evaluation

University of Iowa

Thomas Wassink, M.D.

Department of Psychiatry

College of Medicine

University of Iowa

*Contact information:*

Corresponding Author: Stephan Arndt, Ph.D.

Iowa Consortium for Substance Abuse Research and Evaluation

University of Iowa

100 Oakdale Campus

Iowa City, IA 52242--5000

Phone: (319) 335--4488

E-mail: Stephan-Arndt@Uiowa.edu

*Area of focus:* Community corrections, substance abuse treatment
providers and faith-based organizations supporting reentry clients.

**Abstract**

Although the numbers are often ignored, each year nearly 500,000 people
are released from incarceration in the United States and this number
continues to grow. During 2001, one in four probationers failed in the
community because of a drug law violation, and another 18 percent failed
due to a charge of driving while intoxicated. Many offenders also are
estranged from family, jobs, and other social support systems. Rural
communities are burdened uniquely because lack of transportation and
childcare challenge accessibility to resources located in larger
communities. Individuals are left to their own means and must seek
whatever services they can find within their local rural communities.

Establishing connections with a crime- and substance abuse-free
community is critical to success. Faith-based organizations are
frequently a point of contact for rural adults and families experiencing
problems. Faith-based organizations have unique strengths in providing
services and assistance to those in most need. However, little is known
about the kinds of services and the tremendous amount of support they
provide.

Three groups were identified to provide information regarding community
outreach in Johnson County, Iowa: community corrections; substance abuse
treatment providers; and 13 faith-based organizations, each having a
unique mission to serve those in need. Face-to-face interviews and focus
groups assessed the services in Johnson County that might be beneficial
to reentry clients either coming home to communities or relocating to
new ones.

Faith-based organizations provide both a wide variety of direct
practical services and the opportunity to establish a sense of community
belonging. Both corrections and substance abuse treatment
representatives reported that faith-based communities might benefit from
training concerning reentry clients. Improved communication among these
groups would improve the faith-based communities' capacity to deal with
reentering adults. Training, support, and a small infrastructure would
vastly increase groups' capacity to provide benefits to larger numbers
of reentering individuals.

**Introduction**

Over the past 2 years, the State of Iowa has experienced severe budget
cuts. Budget shortfalls directly affect human service agencies across
the State. Rural communities experience the greatest effect of the cuts,
because many human services in these small towns are eliminated.
Barriers to accessibility to services in larger communities are lack of
transportation and lack of childcare. Individuals are left to their own
means and must seek services within their communities. A common belief
is that faith-based organizations are frequently the first point of
contact for rural people and families experiencing problems. Faith-based
organizations have a long history of reaching and aiding individuals and
families in need, and these organizations often fill service gaps in
public support.

Special population segments---such as ex-offenders or individuals
leaving substance abuse treatment who are attempting to reenter their
communities---require support and safety mechanisms to facilitate
reintegration. Little attention and few resources have been given to
assist systematically and comprehensively with the successful reentry
transition for people released from incarceration. Faith-based and
community-based organizations have unique strengths in providing
services and assistance to those most in need. They have a strong
understanding of the needs of a community; however, we know little about
the kinds of services and the tremendous amount of support they provide.

Nationally, more than one half million (561,020) sentenced prisoners
were released from State or Federal correctional institutions in 1998
(Bureau of Justice Statistics, 2000). Nearly one half of all released
offenders fail to reenter the community successfully, and they return to
prison within 3 years (Langan & Levin, 2002). Increasing an offender's
chance to integrate successfully back into the community would have
substantial and widespread benefits.

In Iowa, 4,342 reentered the community in 1998. As shown in figure 1,
the number of released prisoners has grown steadily over the last two
decades (Bureau of Justice Statistics, 2000). In 2001, Iowa's prison
population reached 8,116, along with 26,670 offenders who were being
supervised by Community Corrections. In 2001, 5,250 left prison and
reentered the community (Harrison & Karberg, 2003). Each month, more
than 400 offenders enter Iowa's prison system and more than 400 leave
for reentry. The Iowa Department of Corrections plans to increase its
use of community corrections; thus even more offenders will be
struggling to integrate into the community (Iowa Department of
Corrections, 2002).

**Figure 1. Number of Sentenced Prisoners Released From State or**

**Federal Jurisdiction: Iowa 1977--1998**

![](media/image3.wmf){width="5.7625in" height="3.4069444444444446in"}

Most reentering offenders face many barriers to successful integration.
A large number of people in prison (Mumola, 1999) and on probation
(Mumola & Bonczar, 1998) have a history of drug and alcohol abuse and
dependence. During 2001, one in four probationers failed in the
community because of a drug law violation, and another 18 percent failed
due to a charge for driving while intoxicated (Glaze, 2002). Many
offenders are also estranged from family, jobs, and other social support
systems. The above factors make integration into the community
difficult. Connections with a crime- and substance abuse-free community
are critical to their success. Faith-based communities offer just such a
combination.

Faith-based communities also offer other services to individuals and
groups. These range from free lunch programs, to smaller, less formal
services, spiritual counseling, and use of the organization's property
to host Alcoholics Anonymous meetings. Additionally, these organizations
offer opportunities to integrate into a community and a social support
network. Given the variety of such possible services, the need for
multiple supports for reentering offenders, and the lack of information
about such offerings, we decided to initiate an environmental scan of
these types of activities in Johnson County. We also were interested in
how faith-based organizations would react to government grant support
for their efforts. In addition, we contacted community corrections
(probation and parole) officers and a local substance abuse treatment
and prevention agency for their views and perceptions of client needs
and their relations, and we examined their current relationships with
local faith-based organizations.

**Method**

The Consortium identified three target groups with a potential to
provide information regarding community outreach in this area:

\(1\) Sixth Judicial Correctional Services, Coralville, Iowa, is the
Johnson County community-based organization providing correctional
supervision for probation and parole clients reentering the community.

\(2\) The Mid-East Council on Chemical Abuse (MECCA) in Iowa City is the
local community-based organization that provides treatment and
prevention services to adults, children, and families in Johnson County.
MECCA's input is valuable because the majority of its residential
clients are correctional clients as well. Such an agency can provide
information about faith-based connections that are currently available
and assist in assessing the needs of clients reentering the community.

\(3\) Johnson County faith-based organizations have developed their own
unique outreach missions, and several organizations are part of an
interchurch coalition that addresses larger issues on a countywide
basis.

The Consortium developed a template for a semistructured interview
process to gather specific information concerning corrections, substance
abuse prevention and treatment, and faith-based organizations. Phone
calls, face-to-face interviews, and focus groups were conducted to
collect assessment data regarding the services in Johnson County that
might be beneficial to reentry clients either coming home to communities
or relocating to new ones.

The Consortium conducted a 1-hour focus group with five staff members
from the Sixth Judicial District parole/probation unit. The group
included administrators, supervisors, parole/probation officers, and
counselors. A 1-hour face-to-face interview with the Director of
Services at the Sixth Judicial District also was completed. The 1-hour
focus group session with six members of the MECCA staff included
counselors, case managers, clinical supervisors, and residential support
technicians.

Efforts to survey faith-based organizations in Johnson County in regard
to their outreach and community service work were initiated by
contacting a convenience sample of 15 rural and urban organizations. The
organizations approached were diverse in size and included Christian,
Jewish, and Muslim faiths. The phone contact invited participation in a
45-minute interview with Consortium representatives. The

Consortium staff completed 11 face-to-face interviews from April 8
through May 27, 2003.

**Results**

**1. Sixth Judicial District Community Corrections**

The administrators, supervisors, parole/probation officers, and
counselors from the Sixth Judicial's focus group identified several
challenges facing clients as they work to reenter the community after
incarceration. Information from the focus group session is summarized
below:

The group estimates that 80--85 percent of its probation and parole
clients also are working to remain clean and sober while they seek a
more supportive community structure. The group noted that clients must
work hard to change their associations and their community support in
relation to criminal behavior and substance abuse.

Appropriate jobs are much less available than 4 or 5 years ago, and the
hourly wage has also decreased. Many clients do not have driving
privileges and/or cannot afford vehicles or insurance. Medical services
are often unavailable because of unsettled debts from back bills left
unpaid, lack of insurance, and inability to pay hospital fees. Unless a
crisis situation demands emergency care, mental health waiting lists
through local community mental health systems are backlogged 12--16
weeks for assessment/ evaluation. Limited beds for detox are a huge
problem as relapse occurs. At times, relapsing adults end up
reincarcerated or are sent home with family members who are not skilled
in provision of safe care, simply because detoxification services or
immediate treatment is not available.

Interview respondents reported that their client assessments include
questions about interest in church or other spiritual avenues. When a
client expresses an interest in faith-based support, however,
correctional staff members often feel they do not have enough
information to be of assistance. No formal organizational links exist
between faith-based initiatives and corrections, but several staff
members, as individuals, have referral ideas for clients interested in
faith-based support.

Johnson County has a Circles of Support and Accountability Group which
follows a restorative justice model that asks clients who are about to
reenter the community to make a commitment to a self-selected support
group. This "circle" meets regularly with the individual to hold him or
her accountable for remaining crime free, drug free, and alcohol free,
as well as to provide support when the individual faces difficult times
and challenges. Circles of Support and Accountability programs are in
their infancy in Johnson County.

Focus group respondents expressed interest in improving the linkages
with faith-based initiatives. They think their clients would respond in
a positive way. Community churches and synagogues would be a positive
place to begin the long road to establishing or reuniting the individual
with a supportive, healthy community.

The parole and probation officers suggested that some assistance would
be helpful, such as brochures that list county faith-based initiatives,
referral contact information, and a brief description of what it would
be like to go to a service. Clients often report hesitation about
starting over at a church, wondering what they would need to wear, and
having many fears about what others will think "when people find out
what they have done and where they have been."

"Going to a new church is a great vulnerability for most of the
clients.... It would help me to know I was sending them to a welcoming
place."

Respondents also felt that educational assistance would be beneficial
for community volunteers who want to serve this reentry population.
Often the best of intentions in volunteers can lead to frustration due
to lack of understanding about how many obstacles reentry adults face
and how addiction recovery plays a significant role in their success. It
would be important for the collaboration and communication between faith
and mandated services to be open and clear so that Sixth Judicial
Services could help volunteers understand what needs to happen from a
community corrections perspective. The group felt that, through
education, people could truly help and not enable reentry persons to
continue to take advantage of a system that is not effectively linked.

Respondents concluded by stressing that sustainability of community
support is the answer to success. Band-aid services and professional
organizations that assist in early reentry are great for short-term
support, but the long hard work of staying free of crime and substances
is dependent on how supportive the community is long after the
professionals are no longer providing services. To ensure that, years
down the road, a reentry client has the support needed to be successful,
the service provision for support must come to the neighborhood and not
the reverse. Faith-based initiatives could start small with social
meetings that allow people to meet and learn about one another.
Faith-based organizations are viewed as an excellent way for clients to
begin to make new supportive choices for themselves and as a chance for
them to contribute rather than just benefit from outreach services.

**2. MECCA Substance Abuse Services**

Counselors, case managers, residential support technicians, and clinical
supervisors who participated in the focus group reported the following
criminal justice involvement for clients receiving services:

  ---------------------- ------------------------ ------------------------
                         Outpatient Clients       Residential Clients

  Probation/Parole       50--60%                  40--50%
  Involved                                        

  Criminal Justice       95%                      70%
  Involved, Including                             
  DUI                                             
  ---------------------- ------------------------ ------------------------

The group was asked to list the greatest obstacles facing recovering
reentry adults who are reestablishing themselves in the community. The
responses included:

• Clients must establish a new community that supports their new choices
to be substance free.

• Johnson County has an affordable housing shortage. A shortage of beds
for the homeless and transition shelter beds is also a problem.

• Limited employment options for reentry clients place a tremendous
strain on clients. If there is a job, the wage is often not enough to
get clients out the financial hole most find themselves in when leaving
treatment.

• Clients face transportation barriers in seeking and maintaining
employment---they have no driver's license or vehicle.

• Social Security Disability program qualification procedures are too
difficult for most clients with co-occurring disorders to move through
to get disability status, even though they need it. For example, a
client with schizophrenia may have a difficult time following through on
a required series of appointments and tasks long enough to qualify for
the assistance to receive needed medication.

• Most clients have no insurance.

• Mental health service access is a substantial problem. The waiting
time for mental health evaluation referrals from MECCA is 8--10 weeks
right now, except for a crisis or emergency.

• Clients have little ability to pay for medications that may be
prescribed after the evaluation.

• Clients sometimes do not fit the parameters for assistance and fall
through the cracks when attempting to qualify for services.

• Mental health transition resources are very hard to find, and delays
in service can lead to relapse.

• Respondents working with adolescent clients expressed frustration with
how difficult it is to get schools to see the amount of substance use in
schools as well as how difficult reentry to school is for clients.

MECCA employs case managers who work to set up client reentry. Their job
is to establish relationships for the client with community resources.
Case management success is driven by how effectively a case manager
develops relationships and learns about available resources. Case
management and client success are also affected by the effectiveness of
the relationship between these individuals and how successfully the
client's motivation for change is identified.

Respondents reported that physicians often are hard to work with because
they do not have the training they need to value the importance of
probing questions to assess addiction in clients. Physicians may
dispense addictive medications and/or may switch an antidepressant the
client is using and never know that the prescribed medication is not
working because of daily alcohol or marijuana use.

Respondents would like community leaders to know that the community
still has much to learn about how substance abuse affects every part of
an individual's life as well as the cost of substance abuse to society
in every layer of social structure.

Spiritual wholeness is part of the education process for clients in
treatment as case managers inform clients of the need for physical,
mental, emotional, and spiritual health. Discussions are open and
nondenominational. MECCA is considering reincorporating a chaplain into
the treatment setting, but no funding is available at this time. If a
client's particular motivation is toward faith and church options, that
client is encouraged to see whether that faith-based organization could
be a place where he or she could establish a new community.

Neither MECCA nor faith-based organizations contact one another formally
regarding clients. Only an interested client initiates any contact.
MECCA is concerned that some faith-based organizations are used by some
clients who network with each other to take advantage of free
assistance. Although they are grateful that community faith-based
services are available to help, respondents thought that volunteers in
various organizations need education to better understand substance
abuse and how to best offer help to clients. All respondents agreed that
both the potential for a new community and support for the needed life
changes could naturally emerge from an enhanced network between agencies
providing treatment services and local faith-based activities.

**3. Faith-Based Organizations**

Eleven ministerial, rabbinical, and administrative respondents who
participated in the individual face-to-face interviews represented both
rural and urban settings in Johnson County. The range of 40--650 members
provided information on small churches getting started and renting
worship space as well as large congregations that have been established
in Johnson County for decades. Smaller organizations were mostly
dependent on the member volunteers for service and mission offerings,
while larger churches had associate ministers and support staff working
to provide services to the congregation and the general community.
Regardless of size or economics, all agreed that faith-based
organizations could easily provide a perfect fit for someone needing to
establish new friends, new community ties, and new support for their
reentry into a life free of substance abuse and criminal activity.
Although only three interviews described specific activities or missions
geared to reentry concerns, all were certain that the regular program
offerings for their memberships would equally serve any population,
regardless of situation. The basis of their service is to provide for
anyone in need. As one respondent said, "Everyone is looking for a place
to belong. In one sense, we are a big anonymous support group. There is
no requirement to reveal your history at our door in order to come in
and be welcome."

Particular activities and endeavors that would assist an adult looking
for a new start include the following listed by the organizations
interviewed:

• Study groups

• Weekly services

• Choir and music ministry

• Social justice and peace groups

• Mentoring youth

• Moms' groups

• Men's groups

• Bible or scripture study groups

• Sports leagues

• Spiritual retreats

• Journey-in-faith groups

• Basic faith education classes

Respondents reported offering or supporting a variety of outreach and
service provisions that are available to clients in need, including:

• Rental assistance

• Emergency housing support

• Food and clothing banks

• Transportation assistance

• Conflict resolution education

• Free lunch programs

• Free medical clinics

• Yard work assistance

• Elderly assistance projects

• College student services/counseling

• Daycare for those who cannot afford it

• Open and affirming support for the gay, bisexual, lesbian, and
transgender communities

• Circles of Support and Accountability groups

• Various 12-Step meetings

All respondents recognized the existence of adults struggling with
substance abuse issues within their memberships, whether the adults are
concerned family and friends or congregation members. Three of the
faith-based organizations have active programs to assist recovery
clients in spiritual growth. They provide the support needed to
understand how an affirming spiritual faith can enhance and enrich an
individual's desire to remain in recovery. Those respondents suggested
that education regarding substance abuse, addiction treatment processes,
and correctional procedures would be helpful to volunteers who are
working with this particular population.

All respondents reported general satisfaction with Johnson County's
referral network. All believed they had sufficient access to find
resources to help anyone who came to them with a particular need,
substance abuse included. Most respondents have developed an extensive
informal system for making referrals. For instance, if someone requested
a referral for substance abuse treatment, a minister might ask another
member of the congregation who, the minister knew, had received
treatment.

According to those interviewed, no formal organizational contacts
currently exist between MECCA, Sixth Judicial Services, and faith-based
organizations. Respondents interviewed generally agreed that such
networking would improve the opportunities for adults who are reentering
the community and express interest in connecting or reconnecting to a
faith-based group. One respondent strongly suggested that treatment
agencies improve their process of releases. Agencies need to make sure
that clients receiving treatment, who are active in a church and request
such help, are allowed to pursue the consents and releases of
information necessary to have clergy involved and active in their
treatment transition. Several respondents indicated that misperceptions
regarding the separation of church and State have created barriers to
working together.

Almost unanimously, Johnson County faith-based organizations want the
community to know that they are open, accepting, more welcoming, and
less judgmental than their counterparts of 20--30 years ago. The
respondents were asked to comment on Federal support for faith-based
initiatives that serve those in most need. Most respondents reported
curiosity, but they had little confidence that the Government would be
able to offer funding without compliance and accountability issues so
rigid that the money could not be accepted. Varied comments and concerns
included:

• We need staffing money to continue what we already do.

• We don't need to start something new here; we have plenty going on; we
simply need better financial support.

• Our faith community has grave concerns that competition for funding
would disrupt an already successful collaborative effort.

• Society should provide a baseline of care regardless of faith, and our
current administration is shirking that responsibility and putting it on
us.

• If the government would effectively fund the mandated programs for
children, the disabled, the mentally ill, and those addicted, we could
do our spiritual work with no funding needed.

• Some expressed concerns that the funding provisions would be for
Christians only.

• This type of funding is viewed as just one more costly layer of
bureaucracy.

• Some are concerned about "coercion to convert before service
provision."

• More money should be channeled to families, peace efforts, and not the
military war machine.

• Give the money to those who have a good service track record, and let
them continue or expand what they are doing.

• Federal money would restrict and deny our religious freedom rights as
well as our work with substance-abusing adults. Some consider addiction
a spiritual issue that can be solved by accepting and following Christ.

• Some doubt that the government could give money without demanding an
impossible return.

• Outreach is service---what we do, how we live---not a reason to apply
for money or count how many and whom we serve.

• A longstanding antichurch bias has changed the United States from a
nation based on "freedom of religion" to a nation based on "freedom from
religion."

**Summary and Recommendations**

Faith-based organizations in Johnson County provide a wide variety of
services to the community. Some services are direct giving (e.g.,
housing assistance, yard work assistance, clothing, food, and
transportation), either by the organization or by smaller groups of
people within the community. Other services are less direct but offer
support to the community, such as housing Alcoholics Anonymous meetings
and supporting free lunch programs and medical clinics. The service
provision also varies widely, ranging from a formalized free lunch
program to individual members working together to assist an individual.
The informal nature of many services makes it difficult to determine the
exact numbers of individuals served, how often, or how many services are
provided.

Both the correctional staff and the substance abuse treatment staff felt
that faith-based communities need some education to deal with the
reentry population. Several topics mentioned would protect both the
faith-based community and the person seeking integration from
potentially unrealistic expectations. For example, substance abuse
treatment professionals and the probation/parole officers did not want
the faith-based community to burn out or have a sense of failure when an
individual relapsed to substance abuse, particularly because substance
abuse is a chronic disease with a continual chance of relapse.

Improved communication among the Department of Corrections, substance
abuse treatment providers, and the faith-based community would improve
the faith-based community's capacity to deal with reentering people.
Because much of the faith-based community's referral network is based on
informal knowledge and word of mouth, individualized and personal
contacts would likely be the most effective and self-sustaining.

This project provides a first look at the role faith-based organizations
play in assisting people reentering the community. We suspect that these
organizations play a much greater role than our introductory scan
suggests, because the informal nature of their assistance is not well
documented. Given the opportunity, these communities could do even more
to enhance people's chances for successful reintegration and to reduce
recidivism. Training, support, and even a small infrastructure would
vastly increase these organizations' capacity to provide these benefits
to a larger group of reentering individuals.

**References**

Bureau of Justice Statistics, U.S. Department of Justice. (2000). *Total
sentenced prisoners released from State or Federal jurisdictions*.
Washington, DC: Bureau of Justice Statistics, National Prisoner
Statistics Data Series (NPS-1). (Web site:
**www.ojp.usdoj.gov/bjs/dtdata.htm#corrections**,
filename:corpop22.wk1.)

Glaze, L. E. (2002). *Probation and parole in the United States, 2001*.
NCJ 195669. Washington, DC: U.S. Department of Justice, Bureau of
Justice Statistics.

Harrison, P. M., & Karberg J. C. (2003). *Prison and jail inmates at
midyear 2002*. NCJ 198877. Washington, DC: U.S. Department of Justice,
Bureau of Justice Statistics.

Iowa Department of Corrections. (2002). *Strategic plan 2002*. Des
Moines, IA: Iowa Department of Corrections.

Langan, P. A., & Levin, D. L. (2002). *Recidivism of prisoners released
in 1994*. NCJ 193427. Washington, DC: U.S. Department of Justice, Bureau
of Justice Statistics. (Web site:
**www.ojp.usdoj.gov/bjs/pub/pdf/rpr.pdf**.)

Mumola, C. J. (1999). *Substance abuse and treatment, State and Federal
prisoners, 1997*. NCJ 172871. Washington, DC: U.S. Department of
Justice, Bureau of Justice Statistics.

Mumola, C. J., & Bonczar, T. P. (1998). *Substance abuse and treatment
of adults on probation, 1995*. NCJ 166611. Washington, DC: U.S.
Department of Justice, Bureau of Justice Statistics.

**Substance Abuse Among Rural and Very Rural Drug Users at Treatment
Entry**[^2]

Marlies L. Schoeneberger, Ph.D.

Carl G. Leukefeld, D.S.W.

Matthew L. Hiller

Michael Townsend

Center on Drug and Alcohol Research

University of Kentucky Medical Center

Lexington, KY

*Contact information:*

Corresponding Author: Marlies Schoeneberger, Ph.D.

2868 Central Park Boulevard

Denver, CO 80238

Phone: (303) 371--8155

Fax: (303) 307--2514

E-mail: maria.schoeneberger@doc.state.co.us

*Area of focus:* Rural and very rural drug users' demographics and drug
use patterns.

**Abstract**

Historically, researchers and policymakers concerned with the problems
of substance abuse have focused their attention almost exclusively on
urban America. However, this focus now includes the special needs of
rural areas. In the past, rural areas were more sheltered from the
problems of mainstream America, but now mass communication has decreased
the isolation of rural areas. This study examines *rural and very rural
drug users*. The distinction between *rural* and *very rural* is
discussed in this paper, acknowledging that there are different
definitions. This paper classified *rural* areas as those with
populations between 2,500 and 19,999 people and *very rural* areas as
those with populations fewer than 2,500 people. Topics include: (1)
demographic and other selected background characteristics of *rural* and
*very rural* drug users admitted to substance abuse treatment, (2)
lifetime drug use patterns, (3) current drug use, (4) age of first drug
use, (5) recognition of drug abuse as a problem, and (6) correlates of
drug use behavior to identify potential predisposing factors. It was
hypothesized that drug users from *very rural* areas would be more
sheltered and that the severity of their involvement with drug use would
be less than that of drug users from *rural* areas. Between November 15,
1999, and January 31, 2001, face-to-face interviews were conducted in
three geographic regions of Kentucky (N = 604): in Eastern Kentucky (n =
206) and in South Central Kentucky (n = 165)---both frequently
considered rural (N = 371)---and in Western Kentucky (N = 233)---which
is considered more urban. More than one half (57 percent) of the
participants were admitted to outpatient treatment. The majority of
participants were male (75 percent), were white (94 percent), had no
religious preference (51 percent), and had been referred to by the
criminal justice system (64 percent); 55 percent had a prior history of
substance abuse treatment. Findings indicate that being from very rural
areas may be somewhat protective, with lower current drug use and older
age at drug use initiation. While alcohol remains the most used
substance in terms of lifetime and current use, cocaine use was three
times higher in *rural* areas than in *very rural* areas. Implications
are discussed and recommendations are presented for substance abuse
treatment providers and policymakers.

**Introduction**

Historically, researchers and policymakers who were concerned with
substance abuse problems focused their attention almost exclusively on
urban America. More recently, however, this focus shifted to include the
special needs of people in rural areas. For example, chronic economic
disadvantages in rural areas have been highlighted as one of the main
reasons for persons in those areas having increased health risks, which
include emotional, behavioral, and substance use problems (Conger &
Elder, 1994). In the past, rural areas may have been more sheltered from
the problems of mainstream America. Because of mass communication,
however, rural areas are no longer isolated.

Evidence is increasing of a symbiotic relationship between urban and
rural drug traffickers, as urban drug dealers find new drug markets in
rural areas, and rural drug manufacturers sell in urban areas (O'Dea et
al., 1997). This symbiosis is also visible in the substance abuse
prevalence rates in urban and rural areas. Epidemiological trends show
that substance abuse in urban and rural areas of the United States has
become similar (Wagenfeld et al., 1994), although the drugs of choice
vary somewhat. For example, in earlier studies comparing urban and rural
treatment populations, marijuana, amphetamines, and sedatives were the
preferred drugs among rural clients, whereas urban clients preferred
opiates (Brown et al., 1977; NASADAD, 1991).

The rural environment has changed the fortunes in rural America.
Although some rural people are wealthy, most of rural America has
experienced devastating economic setbacks in the farming, manufacturing,
and mining industries (Conger, 1997) during the past two decades. As a
result, the myth of rural America as a stress-free bastion of serenity
and health has been dispelled. Indeed, research has shown that rural
Americans suffer socioeconomic disadvantages similar to persons living
in poor urban neighborhoods (O'Hare & Curry-White, 1992). Furthermore,
economic stress is associated with a greater risk for mental disorders
and functional impairment in rural as well as urban settings (Brody et
al., 1994; Conger et al., 1994; Kessler et al., 1994; McLoyd et al.,
1994).

Chronic economic stress has had a long history in many parts of the
rural South. Among the manifestations of economic stresses in rural
areas is what Davidson (1996) called "America's Rural Ghetto."
Characteristically, such areas have the most disadvantaged and elderly
proportion of the population---due to the out-migration of the most
affluent, educated, and younger rural people---not unlike inner-city
urban areas (Wilson, 1996). Whether such rural economic stresses are
chronic or recent, economic deprivation is a common characteristic of
social environments that increase the risk for substance abuse (Conger,
1997).

In an effort to establish criteria for what they called "the
underclass," O'Hare and Curry-White (1992) used census data to define
four common characteristics of this group. They tend to (1) have not
completed high school, (2) receive public assistance, (3) be single
mothers, or (4) be long-term unemployed males. O'Hare and Curry-White
(1992) also found that in 1990, 3.4 percent of inner-city residents
could be categorized as underclass, compared to 2.4 percent of rural
residents. Only 1.1 percent of urban residents not in the inner-city met
the underclass criteria. These findings demonstrate differences within
urban populations. If these kinds of distinctions occur in urban
populations, it could be hypothesized that similar distinctions will
occur in rural populations. If inner-city and not-inner-city populations
are different, then perhaps rural populations can be compared by
examining *rural* areas and *very rural* areas.

In 1990, according to the Bureau of the Census (1993), about 62 million
Americans (24.8 percent of the total population) lived in rural areas;
the other 75.2 percent resided in places defined as urban. Implicit in
the above comparison is that the definitions of rural and urban are not
entirely clear. For example, the definition of "rural" has been applied
to places with populations of less than 20,000 as well as to populations
of less than 2,500 (Conger, 1997; Dahmann & Dacquell, 1992; Edwards,
1997; Patton, 1989). Places with 50,000 or more inhabitants are often
referred to as urban (Hewitt, 1989; Leukefeld et al., 2002; Ricketts,
Johnson-Webb, & Taylor, 1998; Warner & Leukefeld, 2001). According to
these definitions, rural areas are areas not considered urban. The
problem with this dichotomy is that it leaves a large gray area often
not captured when this definition is used for individuals living in
areas with populations of more than 2,500 but fewer than 50,000
inhabitants. This omission is important, as rural residents represent
about one-fourth of the total U.S. population (Bureau of the Census,
1993) and one-third of the country's poor (Rural Clearinghouse, 1993).
About a decade ago, in an effort to be more inclusive of rural
populations, Leukefeld and colleagues (1992) applied a very conservative
definition to the term rural, which they termed "very rural" (p. 103).
In their research on rural drug use, based on the 1985 National
Household Survey on Drug Use, "rural" was defined as "unincorporated
areas of under 2,500 residents" (p. 103). More recently, Warner and
Leukefeld (2001) examined differences in substance use and treatment use
among prisoners within rural populations. They defined "rural" as places
with a 1990 population of 2,500--49,999 not within an urbanized area;
"very rural" was defined as places with populations of less than 2,500
persons outside a census-defined urbanized area (p. 269).

Like the rest of the United States, rural America is multiethnic.
Although they are heterogeneous in ethnic composition, rural Americans
share common characteristics, such as *individualism* (associated with
feelings of self-sufficiency and strong ties to family and clan),
*isolation* (associated with limited access to role models for
individual and group behavior and meeting community needs), *intense
religiosity* providing rigid norms and the potential for normative
conflict), *conservatism* (in a form that is, however, tolerant of
bizarre behavior that fits into the community framework), *distrust
toward newcomers* (anyone who might challenge their way of life by
introducing new ideas or new technologies), and *economic deprivation*
(a consequence of labor market trends and technological advances)
(Beltrome, 1978). These characteristics represent research barriers in
rural areas, and they are common to these populations. In the context of
substance abuse, issues such as isolation (as a function of location)
and limited employment opportunities (due to accessibility) may
contribute to problems, such as mental health problems, as well as
increased poverty (Leukefeld et al., 1992). To be more specific, people
living in rural areas represent a multitude of ethnic and cultural
traditions, ranging from Native Americans to Hmong tribespeople from
Southeast Asia in rural Iowa and to African Americans in the rural South
(Conger, 1997). As a function of this diverse background, rural America
is characterized by varying histories of discrimination, disadvantage,
and cultural practices, which, in turn, can affect attitudes toward the
use of illegal substances and alcohol.

Using data from the 1985 National Household Survey on Drug Abuse,
Leukefeld and colleagues (1992) pointed out that across all age groups,
marijuana and cocaine use in "truly" rural areas was at lower levels
than in large metro, small metro, or nonmetro areas. Although they found
that rural drug use was extensive and that alcohol use in rural areas
was similar to that in urban areas, they indicated rural residents'
reported illegal drug use, while lower than their urban counterparts',
was at an unacceptable level.

Other studies have examined drug use preferences among urban and rural
substance abuse treatment populations. These studies revealed that the
drugs of choice for clients in rural treatment programs were marijuana,
amphetamines, and sedatives and for urban clients, opiates (Brown et
al., 1977; NASADAD, 1991). A recent study by Leukefeld and colleagues
(2002) showed that use of marijuana and sedatives was more frequently
reported by rural respondents, and use of cocaine by urban respondents.
On the basis of these studies, alcohol use was clearly identified as the
substance of choice (Leukefeld et al., 1992, 2002).

The current study uses data from drug users entering treatment to
contribute to the limited knowledge on rural drug use. Specifically, we
compare drug use patterns between *rural* and *very rural* drug users
entering substance abuse treatment in Kentucky---a predominantly rural
State. Along with providing a more comprehensive understanding of rural
drug use in general, differentiating between *rural* and *very rural*
clients could have important implications for identifying factors
associated with risk for substance abuse as well as with the success of
substance abuse treatment programs in rural locations. This study
therefore examines: (1) demographic and other selected background
characteristics between *rural* and *very rural* drug users admitted to
substance abuse treatment, (2) lifetime drug use patterns, (3) current
drug use, (4) age of first drug use, (5) whether drug use is recognized
as a problem, and (6) correlates of drug use behavior to identify
potential predisposing factors. The study's hypothesis is that drug
users from *very rural* areas are more sheltered and the severity of
involvement with drug use is lower than in drug users from *rural*
areas.

**Method**

Participants for this study were recruited into a Center for Substance
Abuse Treatment (CSAT)-sponsored cooperative agreement project titled
*Treatment Outcomes and Performance Pilot Studies Enhancement* (TOPPS
II). Participants were drug users admitted to publicly funded treatment
programs in three regions in Kentucky. Between November 15, 1999, and
January 31, 2001, data were collected in face-to-face interviews by
trained data collectors using a structured questionnaire. Interviews
were held in three geographic regions of Kentucky (N = 604): Eastern
Kentucky (n = 206) and South Central Kentucky (n = 165)---both
considered rural (N = 371)---and Western Kentucky (N = 233)---which is
considered more urban. Although the majority of subjects (N = 199, 85
percent) from the urban programs were admitted to residential treatment,
the majority of participants (N = 273, 74 percent) from the rural sites
were admitted to outpatient treatment facilities.

The current study includes drug users who were admitted to one of the
three participating treatment centers and who agreed to participate in
the TOPPS II study.

Eligibility criteria included (1) having been admitted to substance
abuse treatment, (2) being at least 18 years of age, (3) not being
admitted only for education purposes (e.g., for driving under the
influence), and (4) not being admitted only for mental health or mental
retardation treatment. Dual diagnosis with substance abuse was an
acceptable criterion for eligibility.

Baseline data were collected through face-to-face structured interviews
lasting an average of 30 minutes (with a range between 10 and 67
minutes). The Addiction Severity Index (ASI) Lite (modified) was used as
the baseline questionnaire. The ASI Lite was modified to meet the needs
of the CSAT cooperative agreement. The questionnaire included measures
from the ASI (McLellan et al., 1980; McLellan et al., 1992), the TOPPS
II Core Data Items, as well as the Treatment Event Data Set Items. In
addition to demographic and other relevant background information, data
were collected on the following six domains: medical status,
employment/support status, alcohol/drug use, legal status, family/social
status, and psychiatric status. Demographic locator data, including the
city and county that participants considered their "home base," were
also obtained to allow for a series of followup interviews after their
treatment episodes had ended.

**Measures**

**Rural and Very Rural**

The definition of urban and rural is somewhat ambiguous. Although some
define *rural* simply as non-metropolitan areas, others define rural as
places having a population of fewer than 20,000 people; still others
describe as rural areas having fewer than 2,500 people (Bureau of the
Census, 1993; Edwards, 1997; Luekefeld et al., 1992; Robertson &
Donnermeyer, 1997). Recently, a case has been made for using an
urban--rural continuum instead of the rather crude urban--rural
dichotomy, which does not seem to capture urban--rural differences
adequately (Conger, 1997; Patton, 1989; Hewitt, 1999). A recognized
research practice for defining such a continuum is the application of
rural--urban continuum codes (Beale & Johnson, 1995; Butler & Beale,
1994). This classification scheme distinguishes metropolitan counties by
size and non-metropolitan counties by degree of urbanization and
proximity to metro areas. The standardized Office of Management and
Budget metro and non-metro categories have been subdivided into four
metro and six non-metro categories, resulting in a 10-part county
codification (Ricketts et al., 1998). As Leukefeld and colleagues (2002)
pointed out, this differentiation has limited utility for practitioners
and policymakers. Therefore, the intent of this study was to define
further the rural dimension. For this purpose, we applied Beale codes to
county of residence, which was identified by participants as their "home
base," captured in the question: "What town, county, and State do you
consider your home base or permanent residence?"

Because the focus of this study was to examine and describe differences
in substance abuse as a function of rurality, the total sample (N = 604)
was reduced to those participants with a home county that was classified
by the rural--urban continuum codes of Beale and Johnson (1995), ranging
from 6 to 9 (N = 478). The selection criteria for the Rural group (N =
310) included home county codes of 6 and 7, representing a population of
between 2,500 and 19,999. The selection criteria for the Very Rural
group (N = 168) included home county codes of 8 and 9, representing a
completely rural population of fewer than 2,500 people in an area. Thus,
drug users at substance abuse treatment entry from rural areas
(population more than 2,500 but less than 20,000) were compared with
those from very rural areas (population less than 2,500).

**Sample**

Demographic and other relevant background characteristics of the study
participants are summarized in table 1. More than one-half of the
participants were admitted to outpatient treatment (57 percent). The
majority of participants were male (75 percent), were white (94
percent), had no religious preference (51 percent), had been referred to
treatment by the criminal justice system (64 percent), and had a history
of prior substance abuse treatment (55 percent). Although 54 percent had
a high school education or more, 61 percent were not employed. The
median age of the study population was 32 (ranging from age 18 to age
74), and the median current *nonemployment income* was \$280 per month
(ranging from \$0 to \$10,000 per month).

**Table 1. Characteristics of a Rural Population Entering Substance
Abuse Treatment**

+----------------------------+--------+--------+-------+---+----+-----+
| **Variables**              | **R    | **Very | **    |   |    |     |
|                            | ural** | R      | Total |   |    |     |
|                            |        | ural** | (N =  |   |    |     |
|                            | **(n = |        | 4     |   |    |     |
|                            | 310)** | **(n = | 78)** |   |    |     |
|                            |        | 168)** |       |   |    |     |
+============================+========+========+=======+===+====+=====+
|                            |        |        | *     | * | ** | **  |
|                            |        |        | *Perc | * | *X | Sig |
|                            |        |        | ent** | d | *^ | (p  |
|                            |        |        |       | f | 2^ | )** |
|                            |        |        |       | * | or |     |
|                            |        |        |       | * | F  |     |
|                            |        |        |       |   | ** |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Program Modality           |        |        |       | 1 | 1  | .   |
|                            |        |        |       |   | .5 | 216 |
|                            |        |        |       |   | 34 |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Residential                | 45%    | 39%    | 43%   |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Outpatient                 | 55%    | 61%    | 57%   |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| **Average Age (Range       | **3    | **3    | **33  | * | *  | **  |
| 18--74) in Years**         | 2.69** | 4.60** | .36** | * | *4 | .04 |
|                            |        |        |       | 1 | .1 | 3** |
| **Median Age in Years**    | **32** | **33** | *     | * | 30 |     |
|                            |        |        | *32** | * | ** |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Male                       | 75%    | 77%    | 75%   | 1 | .3 | .   |
|                            |        |        |       |   | 02 | 583 |
+----------------------------+--------+--------+-------+---+----+-----+
| **Race/Ethnicity**         |        |        |       | * | *  | **  |
|                            |        |        |       | * | *7 | .02 |
|                            |        |        |       | 2 | .0 | 9** |
|                            |        |        |       | * | 53 |     |
|                            |        |        |       | * | ** |     |
+----------------------------+--------+--------+-------+---+----+-----+
| White                      | 94%    | 94%    | 94%   |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Black                      | 5%     | 2%     | 4%    |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Other                      | 1%     | 4%     | 2%    |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Religious Preference       |        |        |       | 2 | 4  | .   |
|                            |        |        |       |   | .8 | 090 |
|                            |        |        |       |   | 07 |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Protestant/Catholic        | 33%    | 24%    | 30%   |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Other                      | 19%    | 21%    | 19%   |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| None                       | 48%    | 55%    | 51%   |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Marital Status             |        |        |       | 2 | .3 | .   |
|                            |        |        |       |   | 08 | 857 |
+----------------------------+--------+--------+-------+---+----+-----+
| Married/Remarried          | 27%    | 29%    | 27%   |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Widowed, Separated,        | 40%    | 40%    | 40%   |   |    |     |
| Divorced                   |        |        |       |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Never Married              | 33%    | 31%    | 33%   |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| High School or Above       | 57%    | 49%    | 54%   | 1 | 2  | .   |
|                            |        |        |       |   | .1 | 140 |
|                            |        |        |       |   | 78 |     |
+----------------------------+--------+--------+-------+---+----+-----+
| **Not Employed**           | *      | *      | **    | * | *  | **  |
|                            | *57%** | *70%** | 61%** | * | *7 | .00 |
|                            |        |        |       | 1 | .7 | 5** |
|                            |        |        |       | * | 22 |     |
|                            |        |        |       | * | ** |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Average Current            | \$440  | \$551  | \$479 | 1 | 1  | .   |
| Nonemployment              |        |        |       |   | .7 | 189 |
|                            | \$230  | \$324  | \$280 |   | 32 |     |
| Income (Range              |        |        |       |   |    |     |
| \$0--\$10,000)             |        |        |       |   |    |     |
|                            |        |        |       |   |    |     |
| Median                     |        |        |       |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Admission Suggested by     | 65%    | 63%    | 64%   | 1 | .1 | .   |
| Criminal Justice System    |        |        |       |   | 02 | 750 |
+----------------------------+--------+--------+-------+---+----+-----+
| Had Prior Substance Abuse  | 58%    | 49%    | 55%   | 1 | 2  | .   |
| Treatment                  |        |        |       |   | .9 | 086 |
|                            |        |        |       |   | 54 |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Prescription Medication    | 45%    | 39%    | 43%   | 1 | 1  | .   |
| for                        |        |        |       |   | .3 | 242 |
| Psychological/Emotional    |        |        |       |   | 72 |     |
| Problems: Lifetime         |        |        |       |   |    |     |
+----------------------------+--------+--------+-------+---+----+-----+
| Has Chronic Medical        | 31%    | 32%    | 32%   | 1 | .0 | .   |
| Problems                   |        |        |       |   | 37 | 848 |
+----------------------------+--------+--------+-------+---+----+-----+

\*Items in **bold** are significant at the .05 level.

**Dependent Variables**

Because most treatment-seeking models suggest that the severity of the
problem is an important outcome predictor (Andersen, 1995; Anderson &
Newman, 1973; Hartnoll, 1992), the dependent measures used in this study
were the number of years any drugs had been used, drug use in the 30
days prior to treatment entry, the age at which drug use was initiated,
and problem recognition.

**Lifetime Drug Use**

To examine lifetime drug use, we asked participants how many years they
had ever used 1 or more of 11 substances and substance categories as
well as about how many years they drank alcohol to the point of
intoxication (key for intoxication: females = 2 or more drinks, males =
4 or more drinks). Lifetime drug use was assessed asking the question:
"In your lifetime, how many years did you use \[*specific drug*\] at
least 3 times a week?" This question was repeated for alcohol, heroin,
methadone, other opiates/ analgesics, barbiturates, other
sedatives/hypnotics/tranquilizers, cocaine/crack, amphetamines,
marijuana/hashish/THC, hallucinogens, and inhalants.

**Current Drug Use**

To examine current drug use, participants were asked about their use of
the 11 substances and substance categories listed above during the
previous 30 days and whether they had used multiple substances per day,
including alcohol. Current drug use was assessed by asking the question:
"In the past 30 days, on how many days did you use \[*drug*\]?"

**Age at First Drug Use**

To examine the age of drug use initiation, participants were asked: "How
old were you when you first used \[*drug*\]?" This question was repeated
for alcohol, opiates, tranquilizers/sedatives, cocaine/crack,
stimulants, marijuana, hallucinogens, and inhalants.

**Problem Recognition**

To examine problem recognition, participants were asked whether they had
experienced (1) alcohol and (2) drug problems, whether these problems
troubled or bothered them, whether they thought they needed treatment
for these problems, and how often had they recently attended self-help
groups. Problem recognition was assessed asking the questions: "How many
days in the past 30 days have you experienced (1) alcohol, (2) drug
problems?"; "How troubled or bothered have you been in the past 30 days
by these (1) alcohol, (2) drug problems?" (0 = not at all, 1 = slightly,
2 = moderately, 3 = considerably, 4 = extremely); "How important to you
now is treatment for these (1) alcohol, (2) drug problems?" (0 = not at
all, 1 = slightly, 2 = moderately, 3 = considerably, 4 = extremely); and
"How many days have you attended self-help groups (Alcoholics Anonymous,
Narcotics Anonymous, Cocaine Anonymous) in the past 30 days?" The
effects of rurality were examined by entering a dummy variable "very
rural" (0 = rural, 1 = very rural). Internal consistency reliability for
this problem recognition index was good (Cronbach's Alpha = .77).

**Other Variables**

To gain a better understanding of participants' life circumstances,
which may have either protective or facilitating effects on substance
abuse among *rural* and *very rural* drug users, we analyzed variables
related to demographic characteristics, economic stresses, substance
abuse treatment availability and utilization, health, and criminal
justice system involvement. To examine *demographic characteristics*, we
included the following variables: *age: median split* (0 = younger than
age 32, 1 = age 32 or older); *gender* (0 = female, 1 = male); *race* (0
= white, 1 = black); *religion* (0 = has no religious affiliation, 1 =
has religious affiliation); *marital status* (0 = not single, 1 =
single, never married); *education* (0 = less than high school, 1 = high
school or above). To examine *economic stresses*, we included the
following variables: *employment* (0 = not employed, 1 = full- or
part-time employed); *nonemployment income*. To examine *substance abuse
treatment availability and utilization*, the following variables were
included: *treatment modality* (0 = residential, 1 = outpatient);
s*ubstance abuse treatment history* (0 = had no prior substance abuse
treatment, 1 = had prior substance abuse treatment). To examine
*health*, the following variables were included: *chronic medical
problems* (0 = no, 1 = yes); *prescribed medications regularly for
physical and/or psychological problems: lifetime* (0 = no, 1 = yes). To
examine *criminal justice system involvement*, the following variable
was included: *admission suggested by criminal justice system* (0 = no,
1 = yes). To identify the effects of being either from *rural* or *very
rural* areas, a dummy variable was included (rural = 0, very rural = 1).

**Analytic Plan**

Differences in demographic and other background characteristics between
*rural* and *very rural* drug users were identified by using chi-square
analyses for categorical variables and by using analysis of variance
(ANOVA) for continuous variables. Ordinary Least Squares regressions
were performed to further explore the impact of rurality on (1)
substance abuse problem recognition and (2) drug use. Dependent
variables were determined by conducting independent *t*-tests on all
relevant substance abuse variables and comparing *rural* and *very
rural* areas. Those variables which produced significant differences
were then entered as dependent variables in the regression model. This
was the case for lifetime use of methadone, other opiates, sedatives,
cocaine/crack, marijuana, or multiple drugs; treatment for drug abuse;
and attendance at self-help groups in the last 30 days.

**Results**

**Demographic Characteristics**

Examination of demographic and other background characteristics of
participants from *rural* and *very rural* areas showed that
participants from both areas were similar in terms of the proportions of
program modality, gender, marital status, religious preference,
education, admission suggested by the criminal justice system, substance
abuse treatment history, taking any prescription medication for
psychological/emotional problems, and chronic medical problems. However,
African-American subjects were significantly (p \<.05) more likely to be
from *rural* areas (5 percent vs. 2 percent), and those of "other"
racial or ethnic background were more likely to be from *very rural*
areas (1 percent vs. 4 percent). Also, significantly more subjects who
were unemployed were from the *very rural* areas (57 percent vs. 70
percent). On average, subjects from *very rural* areas tended to be
significantly older (34.60 years) than those from *rural* areas (32.69
years).

**Substance Abuse Among Rural and Very Rural Drug Users**

Tables 2 and 3 summarize differences in drug use prevalence---expressed
in percent---of lifetime as well as of current (last 30 days before the
interview) drug use between *rural* and *very rural* drug areas. Table 2
shows that *very rural* lifetime drug users were significantly less
likely to report using other opiates (39 percent vs. 27 percent),
cocaine/crack (34 percent vs. 20 percent), marijuana (61 percent vs. 46
percent), and multiple drugs (57 percent vs. 42 percent). Furthermore,
very rural lifetime drug users were marginally less likely to report
using methadone (6 percent vs. 2 percent), barbiturates (9 percent vs. 4
percent), and amphetamines (23 percent vs. 16 percent).

**Table 2. Lifetime Drug Use: Rural vs. Very Rural**

+--------------------+--------+--------+-------+----+----+----+------+
| **Variables**      | **R    | **Very | **To  |    |    |    |      |
|                    | ural** | R      | tal** |    |    |    |      |
|                    |        | ural** |       |    |    |    |      |
|                    | **(n = |        | **(N  |    |    |    |      |
|                    | 310)** | **(n = | =     |    |    |    |      |
|                    |        | 168)** | 4     |    |    |    |      |
|                    | **Per  |        | 78)** |    |    |    |      |
|                    | cent** | **Per  |       |    |    |    |      |
|                    |        | cent** |       |    |    |    |      |
+====================+========+========+=======+====+====+====+======+
|                    |        |        | *     | ** | ** | *  | **Fi |
|                    |        |        | *Perc | df | *X | *S | sher |
|                    |        |        | ent** | ** | *^ | ig | 's** |
|                    |        |        |       |    | 2^ | ** |      |
|                    |        |        |       |    | ** |    | *    |
|                    |        |        |       |    |    |    | *Exa |
|                    |        |        |       |    |    |    | ct** |
|                    |        |        |       |    |    |    |      |
|                    |        |        |       |    |    |    | *    |
|                    |        |        |       |    |    |    | *(2- |
|                    |        |        |       |    |    |    | Side |
|                    |        |        |       |    |    |    | d)** |
+--------------------+--------+--------+-------+----+----+----+------+
| Alcohol            | 81     | 86     | 83    | 1  | 1  | .1 |      |
|                    |        |        |       |    | .7 | 91 |      |
|                    |        |        |       |    | 11 |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| Alcohol to         | 73     | 78     | 75    | 1  | 1  | .2 |      |
| Intoxication       |        |        |       |    | .4 | 35 |      |
|                    |        |        |       |    | 09 |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| Heroin             | 4      | 2      | 3     | 1  | 1  | .1 |      |
|                    |        |        |       |    | .9 | 62 |      |
|                    |        |        |       |    | 52 |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| Methadone^\*^      | 6      | 2      | 4     | 1  | 3  | .0 |      |
|                    |        |        |       |    | .7 | 54 |      |
|                    |        |        |       |    | 17 |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| **Other Opiates**  | **39** | **27** | *     | *  | *  | ** |      |
|                    |        |        | *35** | *1 | *6 | .0 |      |
|                    |        |        |       | ** | .5 | 11 |      |
|                    |        |        |       |    | 07 | ** |      |
|                    |        |        |       |    | ** |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| Barbiturates^\*^   | 9      | 4      | 7     | 1  | 3  | .0 |      |
|                    |        |        |       |    | .4 | 65 |      |
|                    |        |        |       |    | 03 |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| Other Sedatives    | 30     | 23     | 28    | 1  | 3  | .0 |      |
|                    |        |        |       |    | .2 | 72 |      |
|                    |        |        |       |    | 35 |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| **Cocaine/Crack**  | **34** | **20** | *     | *  | *  | ** |      |
|                    |        |        | *29** | *1 | *9 | .0 |      |
|                    |        |        |       | ** | .8 | 02 |      |
|                    |        |        |       |    | 19 | ** |      |
|                    |        |        |       |    | ** |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| Amphetamines^†^    | 23     | 16     | 20    | 1  | 3  | .0 |      |
|                    |        |        |       |    | .4 | 64 |      |
|                    |        |        |       |    | 26 |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| **Marijuana**      | **61** | **46** | *     | *  | *  | ** |      |
|                    |        |        | *56** | *1 | *8 | .0 |      |
|                    |        |        |       | ** | .9 | 03 |      |
|                    |        |        |       |    | 22 | ** |      |
|                    |        |        |       |    | ** |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| Hallucinogens      | 14     | 9      | 12    | 1  | 2  | .1 |      |
|                    |        |        |       |    | .4 | 14 |      |
|                    |        |        |       |    | 96 |    |      |
+--------------------+--------+--------+-------+----+----+----+------+
| Inhalants^‡^       | 3      | 3      | 3     | 1  | .0 | .9 | 1    |
|                    |        |        |       |    | 02 | 64 | .000 |
+--------------------+--------+--------+-------+----+----+----+------+
| **Multiple Drug    | **57** | **42** | *     | *  | *  | ** |      |
| Use**              |        |        | *52** | *1 | *9 | .0 |      |
|                    |        |        |       | ** | .4 | 02 |      |
|                    |        |        |       |    | 50 | ** |      |
|                    |        |        |       |    | ** |    |      |
+--------------------+--------+--------+-------+----+----+----+------+

^\*^Items in **bold** are significant at the .05 level.

^†^Borderline significance.

^‡^1 cell (25%) has expected count less than 5. The minimum expected
count is 4.92.

Table 3 shows that for *current* drug use, participants from *very
rural* areas were significantly less likely to be using cocaine/crack
(10 percent vs. 3 percent). Although no statistically significant
differences were found between the two groups in the use of other types
of drugs examined, it is interesting that current use of alcohol,
barbiturates, and inhalants was marginally higher in *very rural* areas.

**Differences in Age of First Drug Use Among Rural and Very Rural Drug
Users**

Table 4 shows that participants from very rural areas were older when
they first used drugs (except for inhalants). This difference in the age
of drug use initiation was significant for those who used tranquilizers
or sedatives (rural: age 20.66 vs. very rural: age 22.95) and for those
who used cocaine/crack (rural: age 20.63 vs. very rural: age 22.36).

**Table 3. Current Drug Use: Rural vs. Very Rural**

+-------------------+--------+--------+-------+----+----+----+------+
| **Variables**     | **R    | **Very | **To  |    |    |    |      |
|                   | ural** | R      | tal** |    |    |    |      |
|                   |        | ural** |       |    |    |    |      |
|                   | **(n = |        | **(N  |    |    |    |      |
|                   | 310)** | **(n = | =     |    |    |    |      |
|                   |        | 168)** | 4     |    |    |    |      |
|                   | **Per  |        | 78)** |    |    |    |      |
|                   | cent** | **Per  |       |    |    |    |      |
|                   |        | cent** |       |    |    |    |      |
+===================+========+========+=======+====+====+====+======+
|                   |        |        | *     | ** | ** | *  | **Fi |
|                   |        |        | *Perc | df | *X | *S | sher |
|                   |        |        | ent** | ** | *^ | ig | 's** |
|                   |        |        |       |    | 2^ | ** |      |
|                   |        |        |       |    | ** |    | *    |
|                   |        |        |       |    |    |    | *Exa |
|                   |        |        |       |    |    |    | ct** |
|                   |        |        |       |    |    |    |      |
|                   |        |        |       |    |    |    | *    |
|                   |        |        |       |    |    |    | *(2- |
|                   |        |        |       |    |    |    | Side |
|                   |        |        |       |    |    |    | d)** |
+-------------------+--------+--------+-------+----+----+----+------+
| Alcohol           | 31     | 35     | 32    | 1  | .6 | .4 |      |
|                   |        |        |       |    | 31 | 27 |      |
+-------------------+--------+--------+-------+----+----+----+------+
| Alcohol to        | 24     | 27     | 25    | 1  | .6 | .4 |      |
| Intoxication      |        |        |       |    | 49 | 20 |      |
+-------------------+--------+--------+-------+----+----+----+------+
| Heroin            | 0      | 0      | 0     | -- | -- | -- |      |
+-------------------+--------+--------+-------+----+----+----+------+
| Methadone^†^      | 1      | .6     | 1     | 1  | .5 | .4 | .661 |
|                   |        |        |       |    | 09 | 76 |      |
+-------------------+--------+--------+-------+----+----+----+------+
| Other Opiates^‡^  | 21     | 14     | 19    | 1  | 3  | .0 |      |
|                   |        |        |       |    | .4 | 61 |      |
|                   |        |        |       |    | 98 |    |      |
+-------------------+--------+--------+-------+----+----+----+------+
| Barbiturates^¶^   | 2      | 4      | 3     | 1  | .7 | .3 | 1    |
|                   |        |        |       |    | 10 | 99 | .000 |
+-------------------+--------+--------+-------+----+----+----+------+
| Other Sedatives   | 15     | 12     | 14    | 1  | .7 | .3 |      |
|                   |        |        |       |    | 88 | 75 |      |
+-------------------+--------+--------+-------+----+----+----+------+
| **Co              | **10** | **3**  | **7** | *  | *  | ** |      |
| caine/Crack**^\*^ |        |        |       | *1 | *7 | .0 |      |
|                   |        |        |       | ** | .2 | 07 |      |
|                   |        |        |       |    | 10 | ** |      |
|                   |        |        |       |    | ** |    |      |
+-------------------+--------+--------+-------+----+----+----+------+
| Amphetamines^†^   | 5      | 4      | 5     | 1  | .1 | .7 |      |
|                   |        |        |       |    | 12 | 38 |      |
+-------------------+--------+--------+-------+----+----+----+------+
| Marijuana         | 27     | 22     | 25    | 1  | 1  | .2 |      |
|                   |        |        |       |    | .1 | 85 |      |
|                   |        |        |       |    | 42 |    |      |
+-------------------+--------+--------+-------+----+----+----+------+
| Ha                | .6     | .6     | .6    | 1  | .0 | .9 | 1    |
| llucinogens^\*\*^ |        |        |       |    | 04 | 47 | .000 |
+-------------------+--------+--------+-------+----+----+----+------+
| Inhalants^\*\*\*^ | 0      | .6     | .2    | 1  | 1  | .1 | .351 |
|                   |        |        |       |    | .8 | 74 |      |
|                   |        |        |       |    | 49 |    |      |
+-------------------+--------+--------+-------+----+----+----+------+
| Multiple Drug Use | 22     | 19     | 21    | 1  | .4 | .4 |      |
|                   |        |        |       |    | 64 | 96 |      |
+-------------------+--------+--------+-------+----+----+----+------+

^\*^Items in **bold** are significant at the .05 level.

^†^2 cells (50%) have expected count less than 5. The minimum expected
count is 1.76.

^‡^Borderline significance.

^¶^1 cell (25%) has expected count less than 5. The minimum expected
count is 4.57.

^\*\*^2 cells (50%) have expected count less than 5. The minimum
expected count is 1.05.

^\*\*\*^2 cells (50%) have expected count less than 5. The minimum
expected count is 0.35.

**Table 4. Age of First Drug Use: Rural vs. Very Rural**

+-----------------------------+--------+--------+-----+----+----+---+
| **Variables**               | **R    | **Very | **T |    |    |   |
|                             | ural** | R      | ota |    |    |   |
|                             |        | ural** | l** |    |    |   |
|                             | **(n = |        |     |    |    |   |
|                             | 310)** | **(n = | *   |    |    |   |
|                             |        | 168)** | *(N |    |    |   |
|                             | **     |        | =   |    |    |   |
|                             | Mean** | **     | 478 |    |    |   |
|                             |        | Mean** | )** |    |    |   |
+=============================+========+========+=====+====+====+===+
|                             |        |        | **  | ** | *  | * |
|                             |        |        | Mea | df | *F | * |
|                             |        |        | n** | ** | ** | S |
|                             |        |        |     |    |    | i |
|                             |        |        |     |    |    | g |
|                             |        |        |     |    |    | * |
|                             |        |        |     |    |    | * |
+-----------------------------+--------+--------+-----+----+----+---+
| Alcohol                     | 15.34  | 15.76  | 15  | 1  | 1  | . |
|                             |        |        | .49 |    | .0 | 2 |
|                             |        |        |     |    | 96 | 9 |
|                             |        |        |     |    |    | 6 |
+-----------------------------+--------+--------+-----+----+----+---+
| Opiates                     | 22.74  | 23.36  | 22  | 1  | .3 | . |
|                             |        |        | .95 |    | 40 | 5 |
|                             |        |        |     |    |    | 6 |
|                             |        |        |     |    |    | 0 |
+-----------------------------+--------+--------+-----+----+----+---+
| **Tranquilizers,            | **2    | **2    | **2 | *  | *  | * |
| Sedatives\***               | 0.66** | 2.95** | 1.4 | *1 | *5 | * |
|                             |        |        | 5** | ** | .6 | . |
|                             |        |        |     |    | 47 | 0 |
|                             |        |        |     |    | ** | 1 |
|                             |        |        |     |    |    | 8 |
|                             |        |        |     |    |    | * |
|                             |        |        |     |    |    | * |
+-----------------------------+--------+--------+-----+----+----+---+
| **Cocaine/Crack\***         | **2    | **2    | **2 | *  | *  | * |
|                             | 0.63** | 2.36** | 1.1 | *1 | *4 | * |
|                             |        |        | 6** | ** | .8 | . |
|                             |        |        |     |    | 10 | 0 |
|                             |        |        |     |    | ** | 2 |
|                             |        |        |     |    |    | 9 |
|                             |        |        |     |    |    | * |
|                             |        |        |     |    |    | * |
+-----------------------------+--------+--------+-----+----+----+---+
| Stimulants                  | 19.78  | 19.88  | 19  | 1  | .0 | . |
|                             |        |        | .81 |    | 18 | 8 |
|                             |        |        |     |    |    | 9 |
|                             |        |        |     |    |    | 2 |
+-----------------------------+--------+--------+-----+----+----+---+
| Marijuana                   | 15.56  | 15.98  | 15  | 1  | .9 | . |
|                             |        |        | .70 |    | 38 | 3 |
|                             |        |        |     |    |    | 3 |
|                             |        |        |     |    |    | 3 |
+-----------------------------+--------+--------+-----+----+----+---+
| Hallucinogens               | 18.46  | 19.56  | 18  | 1  | 2  | . |
|                             |        |        | .77 |    | .5 | 1 |
|                             |        |        |     |    | 09 | 1 |
|                             |        |        |     |    |    | 5 |
+-----------------------------+--------+--------+-----+----+----+---+
| Inhalants                   | 14.50  | 14.00  | 14  | 1  | .1 | . |
|                             |        |        | .38 |    | 70 | 6 |
|                             |        |        |     |    |    | 8 |
|                             |        |        |     |    |    | 1 |
+-----------------------------+--------+--------+-----+----+----+---+

^\*^Items in **bold** are significant at the .05 level.

**Substance Abuse Problem Recognition Among Rural and Very Rural Drug
Users**

Table 5 examines substance abuse problem recognition among drug users
from *rural* and *very rural* areas. The relationship was significant
(*ß* = .520, p\<.001) between the number of days participants reported
currently having alcohol problems and the degree to which they were
troubled by them. The relationship was also significant (*ß* = .641,
p\<.001) between the number of days participants reported currently
having drug problems and the degree to which they were troubled by them.
However, the model revealed no significant relationships in the degree
participants thought treatment for alcohol or drugs was important, their
recent attendance of self-help groups, or rurality. Overall, in terms of
recognition of their substance abuse problems, the variation for alcohol
(27 percent) and drug (41 percent) problems was explained by the degree
to which participants were troubled by them.

**Correlates of Substance Abuse Among Rural and Very Rural Drug Users at
Treatment Entry**

To gain a more comprehensive understanding of the impact of rurality on
substance abuse, the variables age, gender, religion, marital status,
education, employment, income, substance abuse treatment history,
admission by criminal justice system, taking prescription drugs, and
having chronic medical problems were included in a model to examine
demographic characteristics, economic stresses, substance abuse
treatment availability and utilization, health, and criminal justice
system involvement. Table 6 shows that, for these *rural* and *very
rural* drug users, admission to substance abuse treatment suggested by
the criminal justice system (*ß* = --.104, p\<.05) and being from very
rural areas (*ß* = --.092, p\<.05) were negative correlates for any
methadone use. Being employed full or part time (*ß* = --.094, p\<.05)
and admission to substance abuse treatment suggested by the criminal
justice system (*ß* = --.143, p\<.01) were negative correlates for any
opiate use, while taking prescribed medications regularly for physical
and/or psychological problems (*ß* = .128, p\<.01) was a positive
correlate. Having had any prior substance abuse treatment (*ß* = .117,
p\<.05) and taking prescribed medications regularly for physical and/or
psychological problems (*ß* = .139, p\<.01) were positive correlates for
any use of sedatives, and being from very rural areas (*ß* = --.094,
p\<.05) was a negative correlate. Having had any prior substance abuse
treatment (*ß* = .186, p\<.001) was a positive correlate for any
cocaine/crack use, but being from very rural areas (*ß* = --.119,
p\<.01) was a negative correlate. Being treated as an outpatient (*ß* =
--.133, p\<.01) was a negative correlate for any marijuana use, and
being male (*ß* = .123, p\<.01) and having had any prior substance abuse
treatment (*ß* = .158, p\<.001) were positive correlates. Being treated
as an outpatient (*ß* =

--.220, p\<.001) was a negative correlate for any multiple drug use,
while being age 32 or older (*ß* = .109, p\<.05), having had any prior
substance abuse treatment (*ß* = .158, p\<.001), and taking prescribed
medications regularly for physical and/or psychological problems *ß* =
.096, p\<.05) were positive correlates. Being employed full or part time
(*ß* = --.106, p\<.05), admission to substance abuse treatment suggested
by the criminal justice system (*ß* = --.115, p\<.01), and being from
very rural areas (*ß* = --.114, p\<.05) were negative correlates for
having been in any treatment for drug abuse, whereas having had prior
substance abuse treatment (*ß* = .300, p\<.001) and having chronic
medical problems (*ß* = .109, p\<.05) were positive correlates. Having a
religious affiliation (*ß* = .105, p\<.05), having had prior substance
abuse treatment (*ß* = .146, p\<.01), and having chronic medical
problems (*ß* = .118, p\<.05) were positive correlates for recent
attendance at self-help groups. No relationship was found between
race/ethnicity, marital status, education, nonemployment income, and any
of the examined drug use variables.

**Table 5. Substance Abuse Problem Recognition Among *Rural* and *Very
Rural* Drug Users**

+-------------------------------+-------------------+-----------------+
| **Dependent Variables**       | **Had Alcohol     | **Had Drug      |
|                               | Problems**        | Problems**      |
|                               |                   |                 |
|                               | **(No. of Days    | **(No. of Days  |
|                               | Last 30 Days)**   | Last 30 Days)** |
+-------------------------------+-------------------+-----------------+
| **Independent Variables**     | **Beta**          | **Beta**        |
+-------------------------------+-------------------+-----------------+
| **Troubled by Recent Alcohol  | **.520**^†^       | .077            |
| Problems\***                  |                   |                 |
+-------------------------------+-------------------+-----------------+
| **Troubled by Recent Drug     | .210              | **.641**^†^     |
| Problems\***                  |                   |                 |
+-------------------------------+-------------------+-----------------+
| Importance of Treatment for   | .177              | --.096          |
| Recent Alcohol Problems\*     |                   |                 |
+-------------------------------+-------------------+-----------------+
| Importance of Treatment for   | .148              | --.192          |
| Recent Drug Problems\*        |                   |                 |
+-------------------------------+-------------------+-----------------+
| Recent Attendance at          | --.040            | .217            |
| Self-Help Groups              |                   |                 |
|                               |                   |                 |
| (No. of Days in Last 30 Days) |                   |                 |
+-------------------------------+-------------------+-----------------+
| Very Rural                    | .067              | --.017          |
+-------------------------------+-------------------+-----------------+
| **Overall Model Statistics**  |                   |                 |
+-------------------------------+-------------------+-----------------+
| Df                            | 1                 | 1               |
+-------------------------------+-------------------+-----------------+
| F                             | 17.078            | 32.092          |
+-------------------------------+-------------------+-----------------+
| Sig                           | .000              | .000            |
+-------------------------------+-------------------+-----------------+
| R^2^                          | .271              | .411            |
+-------------------------------+-------------------+-----------------+

^\*^Cronbach's Alpha = .7732.

^†^Items in **bold** are significant at the .001 level.

**Discussion**

Study participants from the *very rural* areas were more likely to be
older and unemployed. This finding supports other studies (Brody et al.,
1994; Conger et al., 1984; Kessler et al., 1994; McLoyd et al., 1994;
Wilson, 1996; Wagenfeld & Wagenfeld, 1981) which refer to the effects of
economic stresses on rural populations. Overall, however, drug users in
this study from *rural* and *very rural* areas are more alike than
different in their socio-demographic background. Their demographic
characteristics are similar to those described by Davidson (1996) as
representing the "new rural ghetto." Davidson maintains that since the
farm crisis in the 1980s, many rural areas have been confronted with
problems similar to those in inner-city areas. Citing the 1971 work of
Bender, Green, and Campbell, he adds that an initial economic crisis,
like the farm crisis of the 1980s, sets in motion a process that is
influenced by some of the same social forces that affect the inner city.
These forces include intergenerational poverty, class-selective
migration---out-migration of more prosperous and younger residents,
leaving behind aging communities characterized by more concentrated
poverty---and an accelerated downward spiral resulting in "ghetto-like"
conditions (Davidson, 1996).

In Kentucky, the effect of the farm crisis was magnified because "it
came on the heels of the mining crisis" (Warner & Leukefeld, 2001, p.
276). As farming and mining are among the main income sources in rural
Kentucky, this study shows some pronounced consequences of these two
economic setbacks among persons admitted to substance abuse treatment in
*very rural* areas. On average, these participants were older and---as
one might expect---their unemployment rate was significantly higher than
among participants in *rural* areas.

In the context of overall drug use, the findings from this study are
similar to an earlier observation by Calahan and colleagues (1969), that
drug abuse in *rural* areas is a relatively new problem compared to
alcohol use, which is both older and growing. We found that any alcohol
use---including use to the point of intoxication---was higher in the
*very rural* areas. This finding could be an artifact of social
norms---alcohol is a legal substance and readily available, whereas
illegal drugs are relatively expensive (Conger, 1997). Illegal drug use
in this study was higher in the rural areas. Current barbiturate and
inhalant use were exceptions. Drug use in rural areas also reflects age
at drug use initiation, with the exception of inhalant use, which was
higher in *very rural* areas.

Participants were significantly troubled or bothered by their current
alcohol and drug abuse problems. Although the data are not significant,
alcohol users were more likely than drug users to view treatment for
their recent alcohol and drug problems as important. Alcohol users had
attended fewer self-help groups than drug users, neither *rural* nor
*very rural* areas were significantly correlated with recent alcohol or
drug use.

An examination of correlates of drug use and related issues, such as
treatment for drug abuse and recent self-help group attendance, revealed
that drug users from *very rural* areas were less likely than those from
rural areas to use any methadone, sedatives, and cocaine/crack and were
less likely to have received any drug abuse treatment. These negative
correlates (see table 2) may be an indication that being from *very
rural* areas is somewhat protective for certain drug use. However, the
negative relationship between *very rural* and treatment for drug abuse
is open and warrants additional research on the availability of
treatment programs in *very rural* areas, their accessibility,
referrals, and drug users' problem recognition. With respect to
substance abuse treatment, users of sedatives, cocaine/crack, marijuana,
and multiple drugs were likely to have a substance abuse history with
repeated treatment episodes. This history evokes the image of a
revolving door and leads to the questions, "How successful are current
substance abuse treatment approaches?" and "How can we change the status
quo?" Specifically, participants who were employed, referred by the
criminal justice system, and came from very rural areas were more likely
to have had fewer treatment episodes. Those with chronic medical
problems were likely to have had more treatment episodes. Older subjects
(32 years or older), those who had a substance abuse treatment history,
and those who took prescription drugs regularly were more likely to have
used multiple drugs. On the other hand, subjects who were in outpatient
treatment were less likely to have used multiple drugs. Male subjects
and those who had a substance abuse treatment history were more likely
to have used marijuana. As with our findings for multiple drug use,
participants who were in outpatient treatment were less likely to have
used marijuana.

We believe that our findings are of value to substance abuse treatment
providers in *rural* and *very rural* areas. Providers can use these
results for assessing specific drug abuse treatment needs in rural
locations. For example, a better understanding of the effects of
"rurality," not only on drug use patterns and on substance abuse problem
recognition, but also on the heterogeneity of rural populations
(Edwards, 1997; Oetting, et al., 1997), will enable providers and
policymakers to improve currently existing substance abuse treatment
programs and/or to develop new programs. Our study shows that further
research is needed to define specific needs so they may be implemented
in new treatment approaches. In particular, "successful treatment" may
need to be redefined. Completion of repeated treatment episodes does not
fit the bill. When funding dollars are to be awarded, policymakers need
to notice, and be willing to act on, the fact that one treatment
approach may be too narrow.

Limitations associated with this study include its size. Because the
sample for this study was not randomly selected, and data were collected
only in one State (Kentucky), generalizability is limited. However, we
wish to point out that firm adherence to the research protocol greatly
reduced---if not eliminated---any chance for bias. We feel confident
that our findings can be applied to other rural places. The data
presented here were self-reported. Subjects consented to the study and
were assured strictest confidentiality; thus we were not able to
validate the self-reported data. As a group, drug users who are admitted
to substance abuse treatment in rural facilities may not be
representative of all substance abuse treatment seekers.

**Table 6. Ordinary Least Squares Regression Stepwise: Beta Values for
Correlates of Substance Abuse in a**

**Sample of Rural and Very Rural Drug Users Admitted to Substance Abuse
Treatment (N = 461)**

+------------+------+-----+-----+-----+-----+----+------+-------+
| **V        | *    |     |     |     |     |    |      | **    |
| ariables** | *Use |     |     |     |     |    |      | Atten |
|            | in   |     |     |     |     |    |      | dance |
|            | Life |     |     |     |     |    |      | at**  |
|            | time |     |     |     |     |    |      |       |
|            | (    |     |     |     |     |    |      | *     |
|            | Beta |     |     |     |     |    |      | *Self |
|            | v    |     |     |     |     |    |      | -Help |
|            | alue |     |     |     |     |    |      | Gro   |
|            | s)** |     |     |     |     |    |      | ups** |
|            |      |     |     |     |     |    |      |       |
|            |      |     |     |     |     |    |      | **in  |
|            |      |     |     |     |     |    |      | Last  |
|            |      |     |     |     |     |    |      | 30    |
|            |      |     |     |     |     |    |      | D     |
|            |      |     |     |     |     |    |      | ays** |
|            |      |     |     |     |     |    |      |       |
|            |      |     |     |     |     |    |      | **    |
|            |      |     |     |     |     |    |      | (Beta |
|            |      |     |     |     |     |    |      | valu  |
|            |      |     |     |     |     |    |      | es)** |
+------------+------+-----+-----+-----+-----+----+------+-------+
|            | *    | *   | **S | **C | *   | ** | **T  |       |
|            | *Met | *Ot | eda | oca | *Ma | Mu | reat |       |
|            | hado | her | tiv | ine | rij | lt | ment |       |
|            | ne** | Op  | e** | /** | uan | ip | f    |       |
|            |      | iat |     |     | a** | le | or** |       |
|            |      | e** |     | **C |     | ** |      |       |
|            |      |     |     | rac |     |    | **   |       |
|            |      |     |     | k** |     | *  | Drug |       |
|            |      |     |     |     |     | *D | Abu  |       |
|            |      |     |     |     |     | ru | se** |       |
|            |      |     |     |     |     | gs |      |       |
|            |      |     |     |     |     | ** |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Outpatient |      |     |     |     | --. | -  |      |       |
|            |      |     |     |     | 133 | -. |      |       |
|            |      |     |     |     | ^†^ | 22 |      |       |
|            |      |     |     |     |     | 0^ |      |       |
|            |      |     |     |     |     | ‡^ |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Age 32 or  |      |     |     |     |     | .1 |      |       |
| Older      |      |     |     |     |     | 09 |      |       |
|            |      |     |     |     |     | ^\ |      |       |
|            |      |     |     |     |     | *^ |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Male       |      |     |     |     | .   |    |      |       |
|            |      |     |     |     | 123 |    |      |       |
|            |      |     |     |     | ^†^ |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Black      |      |     |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Has a      |      |     |     |     |     |    |      | .     |
| Religious  |      |     |     |     |     |    |      | 105\* |
| A          |      |     |     |     |     |    |      |       |
| ffiliation |      |     |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Single     |      |     |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| High       |      |     |     |     |     |    |      |       |
| School or  |      |     |     |     |     |    |      |       |
| Above      |      |     |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Is         |      | -   |     |     |     |    | --   |       |
| Employed   |      | -.0 |     |     |     |    | .106 |       |
| Full or    |      | 94^ |     |     |     |    | ^\*^ |       |
| Part Time  |      | \*^ |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Non        |      |     |     |     |     |    |      |       |
| employment |      |     |     |     |     |    |      |       |
| Income     |      |     |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Admission  | --   | --. |     |     |     |    | -    |       |
| Suggested  | .104 | 143 |     |     |     |    | -.11 |       |
| by         | ^\*^ | ^†^ |     |     |     |    | 5^†^ |       |
| Criminal   |      |     |     |     |     |    |      |       |
| Justice    |      |     |     |     |     |    |      |       |
| System     |      |     |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Had Prior  |      |     | .1  | .   | .   | .  | .30  | .1    |
| Substance  |      |     | 17^ | 186 | 158 | 15 | 0^‡^ | 46^†^ |
| Abuse      |      |     | \*^ | ^‡^ | ^‡^ | 8^ |      |       |
|            |      |     |     |     |     | ‡^ |      |       |
| Treatment  |      |     |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Takes      |      | .   | .   |     |     | .0 |      |       |
| Prescribed |      | 128 | 139 |     |     | 96 |      |       |
| M          |      | ^†^ | ^†^ |     |     | ^\ |      |       |
| edications |      |     |     |     |     | *^ |      |       |
|            |      |     |     |     |     |    |      |       |
| Regularly  |      |     |     |     |     |    |      |       |
| for        |      |     |     |     |     |    |      |       |
| Physical   |      |     |     |     |     |    |      |       |
| and/or     |      |     |     |     |     |    |      |       |
|            |      |     |     |     |     |    |      |       |
| Psy        |      |     |     |     |     |    |      |       |
| chological |      |     |     |     |     |    |      |       |
| Problems   |      |     |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Chronic    |      |     |     |     |     |    | .109 | .1    |
| Medical    |      |     |     |     |     |    | ^\*^ | 18^†^ |
| Problems   |      |     |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Very Rural | --   |     | -   | --. |     |    | -    |       |
|            | .092 |     | -.0 | 119 |     |    | -.11 |       |
|            | ^\*^ |     | 94^ | ^†^ |     |    | 4^†^ |       |
|            |      |     | \*^ |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Overall    |      |     |     |     |     |    |      |       |
| Model      |      |     |     |     |     |    |      |       |
| Statistics |      |     |     |     |     |    |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| df         | 2    | 3   | 3   | 2   | 3   | 4  | 5    | 3     |
+------------+------+-----+-----+-----+-----+----+------+-------+
| F          | 4    | 9.  | 7.  | 12. | 11. | 13 | 17   | 9.074 |
|            | .444 | 047 | 787 | 514 | 153 | .6 | .861 |       |
|            |      |     |     |     |     | 50 |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| Sig        | .012 | .   | .   | .   | .   | .0 | .000 | .000  |
|            |      | 000 | 000 | 000 | 000 | 00 |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+
| R^2^       | .019 | .   | .   | .   | .   | .1 | .164 | .057  |
|            |      | 056 | 049 | 052 | 068 | 08 |      |       |
+------------+------+-----+-----+-----+-----+----+------+-------+

^\*^p\<.05, p^†^\<.01, p^‡^\<.001

In conclusion, our findings indicate that being from very rural areas
may have some sheltering properties, as indicated by lower current drug
use and the generally older age at drug use initiation.

Although no differences were found in alcohol use among subjects from
both *rural* and *very rural* areas, alcohol is the most commonly used
substance both currently and over a lifetime.

Cocaine use, on the other hand, was three times higher in *rural* areas
than in *very rural* areas. While not markedly different in both areas,
illegal drug use remains at unacceptably high levels. More than a decade
ago, Leukefeld and colleagues (1992) reported similar findings.
Subsequently, little has changed. However, participants in this study
recognized they had substance abuse problems and were considerably
bothered by those problems. Interestingly, participants were more
bothered by their drug-related problems than by their alcohol-related
problems. This difference is another indication that, despite the fact
that it is the most used substance in both rural areas, alcohol is
thought to be less problematic. These findings are important because
they contribute to the very limited body of literature on substance
abuse differences among rural populations. With a better understanding
of the effects of "rurality" on different drug use patterns and on
substance abuse problem recognition, providers and policymakers will be
able to use data to improve currently existing substance abuse treatment
programs and/or to develop new programs.

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**Making the Addiction Severity Index User Friendly: An Electronic
Display of Client Outcomes Using Shareware**[^3]

James E. Sorensen, Ph.D., C.P.A.

James Elzey, CMA

Faith Stuart, M.P.A., M.S.W., LICSW

*Contact information:*

James E. Sorensen, Ph.D., C.P.A

School of Accountancy

Daniels College of Business

University of Denver

2101 South University Boulevard

Denver, CO 80208

Phone: (303) 871--2028

Fax: (303) 871--2016

E-mail: jsorense@du.edu

James Elzey, CMA

Bureau for Behavioral Health and Health Facilities, WV Department of
Health and Human Resources

350 Capitol Street

Charleston, WV 25301--3702

Phone: (304) 558--3627

Fax: (304) 558--1008

E-mail: jelzey@wvdhhr.org

Faith Stuart, M.P.A., M.S.W., LICSW

Bureau for Behavioral Health and Health Facilities, WV Department of
Health and Human Resources

350 Capitol Street

Charleston, WV 25301--3702

Phone: (304) 558--5540

Fax: (304) 558--1008

E-mail: faithstuart@wvdhhr.org

*Area of focus:* Addiction Severity Index (ASI) Microsoft® Access
software for calculating and displaying the ASI over multiple time
periods, clients, and settings.

**Abstract**

Rural and frontier alcohol and other drug abuse clinicians need
assistance in calculating and displaying the multimeasure Addiction
Severity Index (ASI) over multiple time periods and for multiple clients
and multiple settings. Clinicians and program managers need to be able
to report:

• Individual client ASI outcomes

• Clinician's clients' ASI outcomes (aggregates all clients of a
clinician for a given time period)

• Reporting unit ASI outcomes (aggregates all clients assigned to a
given organizational unit or area)

• Total program ASI outcomes (aggregates all clients in a designated
program)

In addition, clinicians and program managers need to be able to
summarize ASI program results periodically in terms of the quantities
and percentages of clients who show improvement, maintenance, and
regression. The current version of the ASI Microsoft® Access software
program developed for the Bureau for Behavioral Health and Health
Facilities, West Virginia Department of Health and Human Resources,
meets all of these requirements, provides a user-friendly format, and is
recommended for all ASI users. The program was developed at the Southern
Highlands Community Mental Health Center in Princeton, West Virginia,
and has undergone beta testing at the Appalachian Community Mental
Health Center in Elkins, West Virginia. The ASI Access program is
shareware and is available upon request. The current Access Database
uses only Interview Severity Ratings and, as the addendum reveals, the
ASI Access Database will be modified to include ASI Composite Scores
because these measures offer greater reliability and validity.

**Introduction**

Rural and frontier alcohol and other drug abuse (AODA) programs face
many challenges. Funding methods are shifting as Medicaid expenditures
grow and Federal funds to States and local governments are concurrently
cut. Rural areas suffer from a lack of healthcare resources (existing
resources are often underfunded and understaffed) and an absence of
integrated healthcare systems. New service systems are developing with a
shift from provider-centered to client-centered services. Pressures are
increasing for assessment of client and program outcomes and
effectiveness. Demands are also increasing for more organized and
efficient services, all resulting in a thrust toward managed care
(Broskowski, 1991; Feldman, 1992; Woodward, 1992; Wagenfeld, Murray,
Mohatt, & DeBruyn, 1994; Van Hook & Ford, 1995; Minden & Hassol, 1996;
Manderscheid & Henderson, 1997; "Study Finds Mental Health Spending
Cut," 1998; Heflinger & Northrup, 2000; Dorfman & Smith, 2002). Service
settings grow more complex when a client has a dual diagnosis---mental
health and substance abuse or mental health and developmental
disabilities (Alterman, McLellan, & Shifman, 1993; Solomon, Zimberg, &
Schollar, 1993; Woody, McLellan, Luborsky, & O'Brien, 1995; NASDDDS &
HSRI, n.d.).

Coping with these constraints and opportunities in a rural or frontier
service setting requires a focus on client outcome and program
accountability. Albrecht (1992) stated that in the customer-value
paradigm, "the primary focus of measurement is on outcomes" The basic
question is, "How do we know whether we have succeeded in meeting the
demands for both person-centered outcomes and increased accountability?"
(Schalock, 1999). This paper focuses on how to enable the effective use
of the widely known Addiction Severity Index (ASI) by rural and frontier
AODA clinicians and program managers within a developing managed care
environment.

**Research Description**

This project attacked a root problem in the use of outcome instruments:
the inability to conveniently summarize and display client outcomes
(Sorensen, Brackman, Sayers, Akers, Bell, & Elzey, 2000). The
Microsoft^®^ Access called the "Access Client Outcome Software" suite
was designed to incorporate seven outcome instruments used in the West
Virginia behavioral health system:

• Adult MH/SA Functional Assessment Instrument---Consumer/Staff, Version
5, Office of Behavioral Health Services, 3/97

• Child and Adolescent Functional Assessment Scale (CAFAS) (Subscales)
ages 7--18, Version 5, Office of Behavioral Health Services, 3/97

• Preschool and Early Childhood Functional Assessment Scales (PECFAS)
(Subscales) ages 4--7, Version 5, Office of Behavioral Health Services,
3/97

• Brief Psychiatric Rating Scale--Anchored (BPRS--A), Version 5, Office
of Behavioral Health Services, 3/97

• WV Brief Psychiatric Rating Scale for Children (BPRS--C), Version 5,
Office of Behavioral Health Services, 3/97

• Addiction Severity Index (ASI), Version 5, Office of Behavioral Health
Services, 3/97

• Adaptive Behavior Scale---Residential and Community (ABS--RC:2),
Version 5, Office of Behavioral Health Services, 3/97

In this paper, only the software for reporting ASI outcomes is
illustrated, but the entire suite of programs is available from the
Bureau for Behavioral Health and Health Facilities, West Virginia
Department of Health and Human Resources, State of West Virginia,
Charleston, West Virginia. The software was developed to be in the
public domain and is available upon request.

**Purpose**

The project objective was to develop user-friendly software using
Microsoft^®^ Access programming that will display and print the results
of client outcome instruments used in the West Virginia behavioral
health system. The software was expected to display progression,
regression, or no change status for the domains of an instrument for up
to three time periods (to display three time periods requires four data
points). The input form would employ a table-driven design so that
outcome data could be extracted easily from any of the existing
behavioral health information systems. In addition, clinicians and
program managers needed to be able to summarize ASI program results
periodically in terms of the quantities and percentages of clients who
show improvement, maintenance, and regression or the "Access Client
Outcome Software."

**Barriers/Problems Encountered and Solutions**

The original project was started in 1999, and the software development
was completed in November 2000. As the project approached the beta
testing phase, the State governorship changed parties in the November
2000 election. This event, in turn, led to changes in the West Virginia
Department of Health and Human Resources as well as in the Bureau for
Behavioral Health and Health Facilities. The beta testing phase was not
resumed until fall 2003 and after several changes in the leadership of
the Bureau for Behavioral Health and Health Facilities. The current
leadership now believes that the software could be a valuable resource
for clinicians and program managers and, as a result, has funded the
beta testing that was concluded by March 2004.

**Methods**

**Addiction Severity Index**

The ASI is a semistructured interview designed to assess patient
problems in seven content areas of substance-abusing patients: medical
status, employment and support, drug use, alcohol use, legal status,
family/social status, and psychiatric status (see National Institute of
Alcohol Abuse and Alcoholism,
**www.niaaa.nih.gov/publications/asi.htm**; McLellan, Luborsky, O'Brien,
& Woody, 1980; McLellan et al., 1992). In 1 hour, a skilled interviewer
can gather information from a client on recent (past 30 days) and
lifetime problems in all seven areas. The ASI collects information on
problems in personal and social functioning common among substance
abusers, not just information on problems with drugs and alcohol. It has
been used with psychiatrically ill, homeless, pregnant, and prisoner
populations, but its primary use has been with adults seeking treatment
for substance abuse problems.

The ASI has been used extensively for treatment planning and outcome
evaluation. Reliability studies have been done (namely, test-retest,
split-half, and internal consistency), and measures of validity have
been derived (namely, content, criterion \[predictive, concurrent,
"postdictive"\], and construct). The instrument is in the public domain
because its development was supported by grants from the Veterans
Administration and the National Institute on Drug Abuse. There are no
costs and only minimal charges for photocopying and mailing the ASI, and
it can be acquired from A. Thomas McLellan, Ph.D., Treatment Research
Institute, 600 Public Ledger Building, 150 S. Independence Mall West,
Philadelphia, PA 19106 (phone 215--399--0980, fax 215--399--0987, or
e-mail tmclellan@tresearch.org).

**Dynamic Assessment of Client Progression or Regression**

Accountability for client outcomes is now another responsibility of AODA
service providers. Assessment of client outcomes must be comprehensive,
dynamic, user friendly, and relatively inexpensive. Simple gain scores
(viz., time 1 -- time 2) are subject to extensive criticism. The results
have to be interpreted with caution since those with higher initial
scores can be expected to improve at a higher rate than those with lower
scores. Relating the actual gain to a potential gain is more defensible.
The analysis uses the form

$\frac{\lbrack\text{Older}\text{Score}\rbrack\text{ – }\lbrack\text{Newer}\text{Score}\rbrack}{\lbrack\text{Ideal}\rbrack\text{ – }\lbrack\text{Older}\text{Score}\rbrack}$
x 100 = %

If the ideal is not specified, then the following form relates the
change to the initial base:

$\frac{\lbrack\text{Older}\text{Score}\rbrack\text{ – }\lbrack\text{Newer}\text{Score}\rbrack}{\lbrack\text{Maximum}\text{Score}\text{ + }1\rbrack\text{ – }\lbrack\text{Older}\text{Score}\rbrack}$
x 100

In this analysis, the denominator includes (Maximum Score + 1) and
shifts from the older score (for progression) to the newer score (for
regression) to keep the progression and regression percentages parallel,
to weight more dramatic changes with higher percentages, and to avoid a
potential division by zero.

*The percentage is a dynamic expression of change and is anchored to the
beginning level of performance (which may be shifting over time also).*
For example, if a 5-point scale were used, with 5 = highly dysfunctional
and 1 = highly functional, and a client *progressed* from a score of 3
to a score of 1, then the change of 2 would be:

$\frac{\lbrack\text{Older}\text{Score}\rbrack\text{ – }\lbrack\text{Newer}\text{Score}\rbrack}{(5 + 1)\text{ – }\lbrack\text{Older}\text{Score}\rbrack}$
x 100 =
$\frac{\lbrack 3\rbrack\text{ – }\lbrack 1\rbrack}{\lbrack 6\rbrack\text{ – }\lbrack 3\rbrack}$
x 100 = $\frac{2}{3}$ = 0.67 x 100 = 67%

showing a 67% progression (or improvement).

Likewise, if a 5-point scale were used, with 5 = highly dysfunctional
and 1 = highly functional, and a client *regressed* from a score of 1 to
a score of 3, the change of 2 would be:

$\frac{\lbrack\text{Older}\text{Score}\rbrack\text{– }\lbrack\text{Newer}\text{Score}\rbrack}{(5 + 1)\text{ – }\lbrack\text{Newer}\text{Score}\rbrack}$
x 100 =
$\frac{\lbrack 1\rbrack\text{ – }\lbrack 3\rbrack}{\lbrack 6\rbrack\text{ – }\lbrack 3\rbrack}$
x 100 = $\frac{–2}{3}$ = --0.67 x 100 = --67%

showing a 67% regression. If the client regressed from a score of 1 to a
score of 4, then the computations would be:

$\frac{\lbrack 1\rbrack\text{ – }\lbrack 4\rbrack}{\lbrack 6\text{ – }4\rbrack}$
x 100 = $\frac{–3}{2}$ x 100 = --1.50 x 100 = --150%

revealing a 150% regression. Note that a shift of 3 points (150 percent)
is weighted more heavily than a shift of 2 points (67 percent).

**Report Interpretations**

In general, in all calculations used by this program ("Access Client
Outcome Software"), the *denominator* has the greatest influence on the
equation. The purpose is to represent a scale score change to a more
severe level as more significant than a change to a less severe level.
Consequently, a less dramatic change will result in a less dramatic
score, namely, percentage change. The following analysis will address
each of the client outcome software programs written in Access
specifically and will provide illustrative examples with sample outcomes
and sample computations.

The same principles and descriptions of ASI outcomes apply to all levels
of reporting. Using the Access Client Outcome software, reports may be
generated for

• Individual client ASI outcomes

• Clinician's clients' ASI outcomes (aggregates all clients of a
clinician for a given time period)

• Reporting unit ASI outcomes (aggregates all clients assigned to a
given organizational unit or area)

• Total program ASI outcomes (aggregates all clients in a designated
program)

**Scoring the Addiction Severity Index**

The ASI instrument is separated into seven categories and scored on a
scale of 0--9. Categories are medical problems, employment and support
problems, alcohol problems, drug problems, legal problems, family and
social problems, and psychological problems. For this instrument, a
lower score (severity scores only) means improvement, whereas a higher
score indicates decline. This means that zero is the best possible score
and nine is the worst possible score. For this example, only three
categories of scores are shown in detail; all categories, however,
follow the same pattern.

Regression Formula

$\frac{\lbrack\text{Older}\text{Score}\rbrack\text{– }\lbrack\text{Newer}\text{Score}\rbrack}{\text{10}\text{ – }\lbrack\text{Newer}\text{Score}\rbrack}$
x 100

Progression Formula

$\frac{\lbrack\text{Older}\text{Score}\rbrack –\lbrack\text{Newer}\text{Score}\rbrack}{\text{10}\text{– }\lbrack\text{Older}\text{Score}\rbrack}$
x 100

Table 1 is a set of illustrative scores.

**Clinical Interpretation of Illustrative Scale Scores**

Medical, Alcohol, and Family/Social scales are illustrated. Medical
problems seem to increase during time periods A and B but return to an
improved state in time period C (percent change --12.5%, --14.28%, and
+28.571%). Alcohol consumption appears high initially (level of 8) but
was reduced during time period A (down to a 6), maintained at that level
during time period B, and again was reduced in time period C (down to a
5). *Alcohol is still a major issue.* The Family/Social scale regressed
initially (--33%), improved (+16%) in time period B, but has regressed
in the most recent time period C by moving from a 3 to a 6 (--75%).

**Table 1. Illustrative Addiction Severity Index Scores**

+-------------+-------------+-------------+-------------+-------------+
| *           | **Time      | **Older     | **Newer     | **Percent   |
| *Category** | Period**    | Score**     | Score**     | Change**    |
+-------------+-------------+-------------+-------------+-------------+
| Medical     | A           | 1           | 2           | --12.5%     |
|             |             |             |             |             |
|             | B           | 2           | 3           | --14.285%   |
|             |             |             |             |             |
|             | C           | 3           | 1           | +28.571%    |
+-------------+-------------+-------------+-------------+-------------+
| Alcohol     | A           | 8           | 6           | +100%       |
|             |             |             |             |             |
|             | B           | 6           | 6           | 0%          |
|             |             |             |             |             |
|             | C           | 6           | 5           | +25%        |
+-------------+-------------+-------------+-------------+-------------+
| Fa          | A           | 2           | 4           | -- 33.333%  |
| mily/Social |             |             |             |             |
|             | B           | 4           | 3           | +16.666%    |
|             |             |             |             |             |
|             | C           | 3           | 6           | -- 75%      |
+-------------+-------------+-------------+-------------+-------------+

**Computations**

The regression formula can be illustrated using the Medical category for
time period A, over which the client's condition regressed from 1 to 2.
Specifically:

$\frac{(1\text{ – }2)}{(\text{10}\text{ – }2)}$ = $\frac{\text{–1}}{8}$
= --.125

When the --.125 is multiplied by 100, the percentage change equals
--12.5 percent.

The progression formula can be illustrated using the Medical category
for time period C, over which the client's condition progressed from 3
to 1. Specifically:

$\frac{(3\text{ – }1)}{(\text{10}\text{ – }3)}$ = $\frac{2}{7}$ = .28571

When the .28571 is multiplied by 100, the percentage change equals
+28.571 percent.

**Graphics**

The complete results for a client summary ASI are displayed in figure 1.

**Using Access Client Outcome Software**

**Setting Up Text Documents**

The Access programs that have been designed for the user's organization
interpret data from text documents (\*.txt). The user's organizational
personnel must generate these text documents. If the data are not set up
properly, the Import Text Wizard within Access will generate inaccurate
fields and the programs will not work or will produce inaccurate
information.

In the source data files, all the information pertaining to an
individual client must appear in a single row. The information must
appear in the following order for import to the software's database:

• Case Manager ID

• Case Manager Name (first and last name, preferably with the last name
appearing first)

• Program Reporting Unit

• Client ID

• Client Last Name

• Client First Name

• Oldest Test Date

• Raw Score for Symptom 1 (Oldest Test Date)

• Raw Score for Symptom 2 (Oldest Test Date)

• \[Continue list of scores for other symptoms as needed\]

• Second Oldest Test Date

• Raw Score for Symptom 1 (Second Oldest Test Date)

• Raw Score for Symptom 2 (Second Oldest Test Date)

• \[Continue list of scores for other symptoms as needed\]

• Third Oldest Test Date

• Raw Score for Symptom 1 (Third Oldest Test Date)

• Raw Score for Symptom 2 (Third Oldest Test Date)

• \[Continue list of scores for other symptoms as needed\]

• Most Recent Test Date

• Raw Score for Symptom 1 (Newest Test Date)

• Raw Score for Symptom 2 (Newest Test Date)

• \[Continue list of scores for other symptoms as needed\]

**Figure 1. Client Summary ASI**

![](media/image4.wmf)

**Basic Program Operation**

Once the data have been imported into the custom Access software, the
program is ready to run. First, the user clicks the Run Program control
button on the welcoming screen, which takes the user to the program's
main menu (figure 2). The main menu provides the user access to all of
the program's outputs. The main menu will look similar to figure 2
(details vary depending on the instrument). The screen illustrated in
figure 2 is for functional assessments, but the operations for any of
the various programs, including the ASI, are identical. The callout
boxes on the figure describe various operations. (The Southern Highlands
Community Mental Health Center in Princeton, West Virginia was the
software developmental site for this example.)

**Problems**

**Discharged Clients Report**

The Discharged Clients Report compares the most recent score for each
symptom against the oldest corresponding score, for each client in the
database. Each client is then classified as having improved, regressed,
provided insufficient data, or made no change for each symptom. A client
is classified as having insufficient data if there is only one score
recorded for a symptom (as showing improvement or regression demands a
comparison of two scores). The report function then totals the number of
clients who fit into each category and graphs the data. The user can
print a copy of the report with or without the graph by using the print
buttons on the top, left-hand side of the screen.

A client does not need to have been tested in the most recent time
period to be included in the report. The program automatically sorts
through all the scores and determines which are the oldest and most
recent scores.

The Discharged Clients Report does not distinguish between ongoing
clients and discharged clients. The report function classifies and
counts every client who is entered into the database. Therefore, if
active and discharged clients are entered in the same database, all the
clients will be considered as if they have been discharged. Therefore,
only clients who have truly been discharged should be entered into the
reporting database to produce a report that shows only clients who have
been discharged. The report is titled "Discharged Clients Report"
because reporting the status of discharged patients is the practical
function of the report. A report showing the same results for active
clients may be processed using a database containing only active
clients.

**Findings and Conclusions**

**Developmental Site**

The developmental site, the Southern Highlands Community Mental Health
Center in Princeton, West Virginia, tested the ASI program (along with
others in the developed software suite) with positive results from the
viewpoints of clinicians, program managers, and information systems
staff. Staff responded positively to the visual displays that enabled
clinicians (and clients) to review past results and set new goals in
light of past progress (or maintenance or regression).

**Beta Testing**

The results of the beta test at a site different from the developmental
site, the Appalachian Community Mental Health Center in Elkins, West
Virginia, are now being reviewed, but the initial findings are
promising. Information systems required to meet the new Health Insurance
Portability and Accountability Act legislation have slowed the progress
of the beta testing.

**Figure 2. Client Outcome Software Main Menu**

![](media/image5.wmf)

**Conversion to Access 2002**

The current version of the ASI program is written in Access 97 and can
be run only on Access 97. A contract is under negotiation to update the
ASI program software to Access 2002. Microsoft has made substantial
changes and improvements in recent versions of Access and, as is so
often the case, the newer versions cannot process programs produced
under older versions, unless converted properly.

**Tests of Statistical Significance**

One additional feature to be added to the software suite is a test of
statistical significance. After calculating the changes, the results
will be subjected to a nonparametric statistical test to determine if
the changes are significant.

**Addition of Composite Scores in the Revision of the ASI Database**

While clinicians in the demonstration site indicated a preference for
the Interview Severity Ratings in the qualitative interview phase of the
database design, scores that are better suited for comparison over time
are (1) the ASI Composite Scores and (2) analysis of specific item
variables according to the literature (Carise, 2004; McLellan, Kushner,
Metzger, Peters, Smith, et al., 1992; McLellan et al., 1985). With new
funding to update a suite of client outcome databases, the ASI Composite
Scores will be added so a clinician (or other user) may use the
interview severity ratings, composite scores, or both.

**Recommendations**

**Meeting the Needs of AODA Clinicians and Managers**

Rural and frontier AODA clinicians need assistance in calculating and
displaying the multimeasure Addiction Severity Index over multiple time
periods and for multiple clients and multiple settings. Clinicians and
program managers need to be able to report:

• Individual client ASI outcomes

• Clinician's clients' ASI outcomes (aggregates all clients of a
clinician for a given time period)

• Reporting unit ASI outcomes (aggregates all clients assigned to a
given organizational unit or area)

• Total program ASI outcomes (aggregates all clients in a designated
program)

In addition, clinicians and program managers need to be able to
summarize ASI program results periodically in terms of client
improvement, maintenance, and regression.

The current version of the ASI software program, Access Client Outcome
Software, meets all of these requirements, provides a user-friendly
format, and is recommended for all ASI users. The software is
accompanied by a user manual. It can be operated with a laptop computer
or within a full workstation computer or computer network and can be
easily adapted to a local environment.

**Software Availability**

The ASI Access program developed for the Bureau for Behavioral Health
and Health Facilities, West Virginia Department of Health and Human
Resources, is shareware and is available upon request.

**Additional Resources**

The reader may be interested in the following relevant Web sites:

• The ASI-MV is an interactive, audio/video CD-ROM program that allows
for client self-administration of the widely used Addiction Severity
Index. More information is available at **www.asimv.com.**

• The Treatment Research Institute Web site is a nonprofit research
group founded and directed by A. Thomas McLellan, the lead researcher
and developer of the ASI. The following materials (and many others) are
available at **www.tresearch.org/resources/instruments.htm.**

> -- Addiction Severity Index---5th Edition
>
> -- Addiction Severity Index---5th Edition (Spanish)
>
> -- Addiction Severity Index---5th Edition (for use with Native
> Americans)
>
> -- Addiction Severity Index Lite
>
> -- Addiction Severity Index---5th Edition Clinical Training Version
>
> -- Addiction Severity Index---Lite: Clinical Trials Network
> Version---Part 1
>
> -- Addiction Severity Index---Lite: Clinical Trials Network
> Version---Part 2
>
> -- Treatment Services Review---14 Day
>
> -- Treatment Services Review---30 Day

**References**

Albrecht, K. (1992). *The only thing that matters: Bringing the power of
the customer into the center of your organization*. New York:
HarperBusiness.

Alterman, A. I., McLellan, A. T., & Shifman, R. B. (1993). Do substance
abuse patients with more psychopathology receive more treatment?
*Journal of Nervous and Mental Disease, 181*(9), 576--582.

Broskowski, A. (1991). Current mental health care environments: Why
managed care is necessary. *Professional Psychology: Research &
Practice*, *22*(1), 6--14.

Carise, D. (2004). \[Review of the manuscript *Making the Addiction
Severity Index (ASI) user friendly: An electronic display of client
outcomes using shareware*.\] Rockville, MD: American Institutes for
Research, Performance Management Technical Assistance Coordinating
Center.

Dorfman, S. L., & Smith, S. A. (2002). Preventive mental health and
substance abuse programs and services in managed care. *The Journal of
Behavioral Health Services & Research*, *29*(3), 233--258.

Feldman, S. (Ed.). (1992). *Managed mental health services*.
Springfield, IL: Charles C. Thomas.

Heflinger, C., & Northrup, D. (2000). What happens when capitated
behavioral health comes to town? The transition from the Fort Bragg
demonstration to a capitated managed behavioral health contract. *The
Journal of Behavioral Health Services & Research, 27*(4), 390--405.

Manderscheid, R. W., & Henderson, M. J. (1997). Federal and State
legislative and program directions for managed care. In E. J. Mullen &
J. L. Magnabosco (Eds.), *Outcomes measurement in the human services:
Cross-cutting issues and methods* (pp. 113--123). Washington, DC: NASW
Press.

McLellan, A. T., Carise, D., & Kleber, H. D. (2003) Can the national
addiction treatment infrastructure support the public's demand for
quality care? *Journal of Substance Abuse Treatment 25*, 117--121.

McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I.,
Grissom, G., et al. (1992). The fifth edition of the Addiction Severity
Index. *Journal of Substance Abuse Treatment, 9*(3), 199--213.

McLellan, A. T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F.,
Barr, H. L., et al. (1985). New data from the Addiction Severity Index:
Reliability and validity in three centers. *Journal of Nervous and
Mental Diseases, 173*, 412--423.

McLellan, A. T., Luborsky, L., O'Brien, C. P., & Woody, G. E. (1980). An
improved diagnostic instrument for substance abuse patients: The
Addiction Severity Index. *Journal of Nervous and Mental Diseases, 168*,
26--33.

Minden, S., & Hassol, A. (1996). *Final review of available information
on managed behavioral health care*. Rockville, MD: U.S. Center for
Mental Health Services.

National Association of State Directors of Developmental Disabilities
Services (NASDDDS) & Human Services Research Institute (HSRI). (n.d.).
National Core Indicators project. See **www.hsri.org/nci**.

Schalock, R. L. (1999). A quest for quality: Achieving organizational
outputs and personal outcomes. In J. F. Gardner & S. Nudler (Eds.),
*Quality performance in human services: Leadership, values, and vision*
(pp. 55--80). Baltimore, MD: Paul H. Brookes Publishing Co.

Solomon, J., Zimberg, S., & Schollar, E. (1993). *Dual diagnosis:
Evaluation, treatment, training, and program development*. New York:
Plenum Publishing Corp.

Sorensen, J. E., Brackman, K., Sayers, P., Akers, J., Bell, S., & Elzey,
J. (2000). *Client outcome instruments user's manual*. Charleston, WV:
Bureau for Behavioral Health and Health Facilities, West Virginia
Department of Health and Human Resources.

Study finds mental health spending cut in half over last decade (1998,
May 7). *The Wall Street Journal*, p. B1.

Van Hook, M. P., & Ford, M. (1995). Linking mental and primary health
care in rural areas. *Administration and Policy in Mental Health,
22*(6), 633--641.

Wagenfeld, M. O., Murray, J. D., Mohatt, D. F., & DeBruyn, J. C. (1994).
*Mental health and rural America: 1980--1993; An overview and annotated
bibliography*. NIH Publication No. 94--3500. Washington, DC: Office of
Rural Health, Health Resources and Services Administration and Office of
Rural Mental Health Research, National Institute of Mental Health.

Woodward, A. (1992). Managed care and case management of substance abuse
treatment. In R. S. Ashery (Ed.), *Progress and issues in case
management* (pp. 34--53). NIDA Research Monograph No. 127. Rockville,
MD: National Institute on Drug Abuse, U.S. Department of Health and
Human Services.

Woody, G. E., McLellan, A. T., Luborsky, L., & O'Brien, C. P. (1995).
Psychotherapy in community methadone programs: A validation study.
*American Journal of Psychiatry, 152*(9), 1302--1308.

**Addendum**

With a useful review by and suggestions from Deni Carise, Ph.D.,
Treatment Research Institute (**dcarise@tresearch.org**), the authors
intend to update the ASI Database to include ASI Composite Scores.
Improved reliability and validity are available for the ASI Composite
Scores. The recent financing by the Bureau of Behavioral Health and
Health Facilities, West Virginia Department of Health and Human
Resources, Charleston, West Virginia of an update of several outcome
databases (including this ASI Database) will enable the software to be
updated to Access 2002--2003 versions and to add ASI Composite Scores.
An early review of the client database submissions by West Virginia
treatment providers has identified pre-existing data elements for ASI
Composite Scores. It is not clear without further research if the scores
are computed or if the scores need to be computed. In any event, the
revised ASI Database could include an option for the computation of the
scores if not computed. This additional feature, as an aside, may widen
the application of the software to users who do not have a ready
capability to calculate ASI Composite Scores. The computation of ASI
Composite Scores can be accomplished without any user (or license) fees
(Carise, 2004). When the ASI Database is updated, a new manuscript
describing all of its features will be created.

**Resources on Rural Substance Abuse Issues**

**National Rural Alcohol & Drug Abuse Network, Inc. (NRADAN)**

*Contact information:*

P.O. Box 40

Tony, WI 54563-0040

Phone: (715) 532--9030

Fax: (715) 532--9030

Web Site: **www.uwstout.edu/solutions/conf/nri/nri_nradan.htm**

*Description:*

NRADAN is a private, nonprofit foundation that promotes networking
between rural programs, and professionals along with providing liaisons
to key Federal and State government agencies and private resources.

**The National Rural Health Association (NRHA)**

*Contact information:*

521 East 63rd Street

Kansas City, MI 64410-3329

Phone: (816) 756--3140

Fax: (816) 756--3144

Web Site: **www.nrharural.org**

*Description:*

NRHA is a national nonprofit membership organization with more than
10,000 members that provides leadership on rural health issues. The
association's mission is to improve the health and well-being of rural
Americans and to provide leadership on rural health issues through
advocacy, communications, education, research, and leadership.

**Rural Assistance Center (RAC)**

*Contact information:*

P.O. Box 9037

Grand Forks, ND 58202

Phone: (800) 270--1898

Fax: (800) 270--1913

E-mail: info@raconline.org

Web Site: **www.raconline.org**

*Description:*

RAC helps rural communities and other rural stakeholders access the full
range of available programs, funding, and research that can enable them
to provide quality health and human services to rural residents.

**Substance Abuse Facility Locator**

*Contact information:*

Web Site: **dasis3.samhsa.gov**

*Description:*

A searchable database that provides assistance with locating drug and
alcohol abuse treatment programs (including in rural areas).

**2-1-1 Resource Line**

*Contact information:*

Web Site: **211.org/status.html**

*Description:*

2-1-1 is an easy to remember telephone number that, where available,
connects people with important community services and referral agencies
in their areas. This is a nationwide program with services varying
State-by-State.

**National Hotline Call Center for Alcohol and Drug Abuse**

*Contact information:*

Phone: (800) 784--6776

Web Site: **www.addictioncareoptions.com**

*Description:*

The National Hotline Call Center for Alcohol and Drug Abuse provides
accurate information about alcohol and drug abuse and offers
alternatives and suggestions to anyone looking for answers and
assistance. Staff is on duty 24 hours a day, 7 days a week. They provide
in-depth information about court orders, family interventions,
detoxification, treatment, rehab programs, insurance, and anything that
is related to alcohol and drug abuse. Services are free of charge.

**Selected Publications on Rural Substance Abuse Issues**

Center for Substance Abuse Treatment. (1997). *Bringing Excellence to
Substance Abuse Services in Rural & Frontier America: 1996 Award for
Excellence Papers*. Technical Assistance Publication (TAP) number 20.
Rockville, MD: Substance Abuse and Mental Health Services
Administration. Available from the National Clearinghouse for Alcohol
and Drug Information at **www.ncadi.samhsa.gov**.

Center for Substance Abuse Treatment. (1998). *Rural Issues in Alcohol
and Other Drug Abuse Treatment*. Technical Assistance Publication (TAP)
number 10. Rockville, MD: Substance Abuse and Mental Health Services
Administration. Available from the National Clearinghouse for Alcohol
and Drug Information at **www.ncadi.samhsa.gov**.

Robertson, E. B., Sloboda, Z., Boyd, G. M., Beatty, L., and Kozel, N. J.
(Eds.). (1997). *Rural Substance Abuse: State of Knowledge and Issues*.
NIDA Research Monograph 168. NIH Publication No. 97-4177. Rockville, MD:
National Institute on Drug Abuse.

**Other Technical Assistance Publications (TAPs) include:**

TAP 1 *Approaches in the Treatment of Adolescents with Emotional and
Substance Abuse Problems* **PHD580**

TAP 2 *Medicaid Financing for Mental Health and Substance Abuse Services
for Children and Adolescents* **PHD581**

TAP 3 *Need, Demand, and Problem Assessment for Substance Abuse
Services* **PHD582**

TAP 4 *Coordination of Alcohol, Drug Abuse, and Mental Health Services*
**PHD583**

TAP 5 *Self-Run, Self-Supported Houses for More Effective Recovery from
Alcohol and Drug Addiction* **PHD584**

TAP 6 *Empowering Families, Helping Adolescents: Family-Centered
Treatment of Adolescents with Alcohol, Drug Abuse, and Mental Health
Problems* **BKD81**

TAP 7 *Treatment of Opiate Addiction With Methadone: A Counselor Manual*
**BKD151**

TAP 8 *Relapse Prevention and the Substance-Abusing Criminal Offender*
**BKD121**

TAP 9 *Funding Resource Guide for Substance Abuse Programs* **BKD152**

TAP 10 *Rural Issues in Alcohol and Other Drug Abuse Treatment*
**PHD662**

TAP 11 *Treatment for Alcohol and Other Drug Abuse: Opportunities for
Coordination* **PHD663**

TAP 12 *Approval and Monitoring of Narcotic Treatment Programs: A Guide
on the Roles of Federal and State Agencies* **PHD666**

TAP 13 *Confidentiality of Patient Records for Alcohol and Other Drug
Treatment* **BKD156**

TAP 14 *Siting Drug and Alcohol Treatment Programs: Legal Challenges to
the NIMBY Syndrome* **BKD175**

TAP 15 *Forecasting the Cost of Chemical Dependency Treatment Under
Managed Care: The Washington State Study* **BKD176**

TAP 16 *Purchasing Managed Care Services for Alcohol and Other Drug
Abuse Treatment: Essential Elements and Policy Issues* **BKD167**

TAP 17 *Treating Alcohol and Other Drug Abusers in Rural and Frontier
Area*s **BKD174**

TAP 18 *Checklist for Monitoring Alcohol and Other Drug Confidentiality
Compliance* **PHD722**

TAP 19 *Counselor's Manual for Relapse Prevention With Chemically
Dependent Criminal Offenders* **PHD723**

TAP 20 *Bringing Excellence to Substance Abuse Services in Rural and
Frontier America* **BKD220**

TAP 21 *Addiction Counseling Competencies: The Knowledge, Skills, and
Attitudes of Professional Practice* **BKD246**

TAP 22 *Contracting for Managed Substance Abuse and Mental Health
Services: A Guide for Public Purchasers* **BKD252**

TAP 23 *Substance Abuse Treatment for Women Offenders: Guide to
Promising Practices* **BKD310**

TAP 24 *Welfare Reform and Substance Abuse Treatment Confidentiality:
General Guidance for Reconciling Need to Know and Privacy* **BKD336**

TAP 25 *The Impact of Substance Abuse Treatment on Employment Outcomes
Among AFDC Clients in Washington State* **BKD367**

TAP 26 *Identifying Substance Abuse Among TANF-Eligible Families*
**BKD410**

TAP 27 *Navigating the Pathways: Lessons and Promising Practices in
Linking Alcohol and Drug Services with Child Welfare* **BKD436**

TAP 28 *The National Rural Alcohol and Drug Abuse Network Awards for
Excellence 2004, Submitted and Award-Winning Papers* **BKD552**

Other TAPs may be ordered by contacting the National Clearinghouse for
Alcohol and Drug

Information (NCADI), (800) 729-6686 or (240) 221-4017, TDD (for hearing
impaired), (800) 487-4889.

DHHS Publication No. (SMA) 06-4183

NCADI Publication No. BKD552

Printed 2006

[^1]: This paper is written from Judge Roper's perspective, and much of
    the information presented is not in research or record but
    represents the judge's opinion based on personal experience.
    Statements that are not supported in the research literature, or
    otherwise documented, are referred to as conclusions or actions of
    "the Court," which refers to the Honorable Judge Roper and his
    Tulare County Adult Drug Court.

[^2]: This project was supported by the Center for Substance Abuse
    Treatment and Substance Abuse and Mental Health Services
    Administration Cooperative Agreement, Grant number: 6 UR1
    TI11613-01-1

[^3]: Funding for this project was provided by the Substance Abuse and
    Mental Health Services Administration through a data information
    grant to the West Virginia Department of Health and Human Resources.