Women in Substance Abuse Treatment:

Results from the Alcohol and Drug Services Study

(ADSS)

Thomas M. Brady

Olivia Silber Ashley

Editors

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Office of Applied Studies
ii

Acknowledgments

This report was prepared by the Office of Applied Studies (OAS), Substance Abuse and Mental Health Services

Administration (SAMHSA), RTI International (a trade name of Research Triangle Institute) of Research Triangle

Park, North Carolina, and Synectics for Management Decisions, Inc., of Arlington, Virginia, under Contract No.

283-99-9018. At SAMHSA, Thomas M. Brady co-edited the report, and Theodora Fine, Sharon Amatetti, Peter

Delany, and Al Woodward provided review comments. At RTI, Olivia Silber Ashley was co-editor, and Mary Ellen

Marsden was senior advisor. B. Kathleen Jordan, Kara Riehman, and Wendee M. Wechsberg provided review

comments. Also at RTI, Molly Aldridge, Catherine Aspden, Kyung-Hee Bae, Michael Bradshaw, Jessica Cance,

Larry Crum, Jennie L. Harris, Mindy Herman-Stahl, Amy Hernandez, Jennifer J. Kasten, Kellie M. Loomis, Alex

Orr, Barry Weaver, Nathan West, and Megan Williams provided research or writing assistance; Diane G. Caudill

produced the graphics; Catherine A. Boykin and Loraine G. Monroe assisted with the tables; Joyce Clay-Brooks,

Linda Fonville, and Judith Cannada provided document preparation support; Teresa F. Gurley and Pamela Couch

Prevatt readied files for the SAMHSA printer and Web site; and D.J. Bost, Richard S. Straw, K. Scott Chestnut,

Jason Guder, and Jeff Novey copyedited and proofread the report. At Synectics, Sameena Salvucci, Leigh A.

Henderson, Alisa Male, Albert Parker, and Lev S. Sverdlov provided statistical, research, and writing support. Final

report production was provided by Beatrice Rouse, Coleen Sanderson, and Jane Feldmann at SAMHSA.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied without permission

from SAMHSA. However, this publication may not be reproduced or distributed for a fee without the specific,

written authorization of the Office of Communications, SAMHSA, U.S. Department of Health and Human Services

(DHHS). Citation of the source is appreciated. Suggested citation:

Brady, T. M., & Ashley, O. S. (Eds.). (2005). Women in substance abuse treatment: Results from

the Alcohol and Drug Services Study (ADSS) (DHHS Publication No. SMA 04-3968, Analytic

Series A-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office

of Applied Studies.

Disclaimer

The statements contained in this report are solely those of the authors and do not necessarily reflect the views,

policies, or position of OAS, SAMHSA, or any other part of the DHHS, and no official endorsement of the authors’

views is intended or should be inferred.

Obtaining Additional Copies of Publication

Copies may be obtained, free of charge, from the National Clearinghouse for Alcohol and Drug Information

(NCADI), a service of SAMHSA:

National Clearinghouse for Alcohol and Drug Information

P.O. Box 2345, Rockville, MD 20847-2345

(301) 468-2600, 1-800-729-6686, TDD 1-800-487-4889

Electronic Access to Publication

http://www.samhsa.gov

http://www.oas.samhsa.gov

Originating Office

SAMHSA, OAS

1 Choke Cherry Road, Room 7-1044

Rockville, MD 20857

September 2005
iii

Table of Contents

Chapter Page

List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1. Introduction ............................................................5

Gender Differences Among Substance Abuse Treatment Clients . . . . . . . . . . . . . . . . . . . 5

Substance Use and Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Economic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Gender Differences in Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Psychological Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Family and Partner Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Social Stigma and Discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Implications for Retention in Substance Abuse Treatment . . . . . . . . . . . . . . . . . 12

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Alcohol and Drug Services Study (ADSS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Overview of Chapters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

2. Substance Abuse Treatment Programming for Women: A Literature Review . . . . . . . . 29

Comprehensive Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Historical Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Availability of Substance Abuse Treatment Programming for Women . . . . . . . . . . . . . 32

Effectiveness of Substance Abuse Treatment Programming for Women . . . . . . . . . . . . 33

Child Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Prenatal Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Women-Only Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Use of Supplemental Education Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

3. Data and Methods Used in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Data Source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

ADSS Phase I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

ADSS Phase II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

ADSS Phase III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Analysis Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Measures and Definitions of Terms Used in This Report . . . . . . . . . . . . . . . . . . . . . . . . 48

Client Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Components of Substance Abuse Treatment Programming for Women . . . . . . . 48
iv

Table of Contents (continued)

Chapter Page

Other Facility Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Statistical Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Analysis of Client Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Analysis of Facility Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Descriptive Analyses of Treatment Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Logistic Regression Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Survival Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Limitations of the Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

ADSS Phase I Data Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

ADSS Phase II Data Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Limitations of the Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

4. Characteristics of Substance Abuse Treatment Clients . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

5. Characteristics of Substance Abuse Treatment Facilities Providing Treatment

Programming for Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Female Clients in Substance Abuse Treatment Facilities . . . . . . . . . . . . . . . . . . . . . . . . 67

Availability of Substance Abuse Treatment Programming for Women . . . . . . . . . . . . . 67

Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Special Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Comparisons between Women-Only and Mixed-Gender Facilities . . . . . . . . . . . . . . . . 69

Comparisons between Facilities with and without Child Care Services . . . . . . . . . . . . . 70

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

6. Retention in Substance Abuse Treatment: Gender and Substance Abuse Treatment

Programming for Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Descriptive Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Logistic Regression Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Survival Analysis Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

7. Conclusion and Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Availability and Effectiveness of Substance Abuse Treatment Programming for 

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Implications for Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Implications for Treatment Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Implications for Treatment Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
v

Table of Contents (continued)

Chapter Page

Gender Differences in Substance Abuse Treatment Client Characteristics . . . . . . . . . . . 92

Implications for Treatment of Specific Populations . . . . . . . . . . . . . . . . . . . . . . 92

Treatment Retention among Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Implications for Treatment Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Issues in Women's Substance Abuse Treatment Research . . . . . . . . . . . . . . . . . . . . . . . 93

Implications for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Appendix

Statistical Methods and Limitations of the Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
vi

List of Figures

Figure Page

1.1 Numbers of Substance Abuse Treatment Admissions, by Gender and Year: TEDS,

1992–2002 .............................................................6

2.1 Percentages of Facilities Offering Special Programs for Women or Pregnant

Women, by Type of Care: N-SSATS, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

4.1 Percentages of Substance Abuse Treatment Clients Having a Child/Children at

Admission, by Gender and Service Type: 1997–1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

4.2 Percentages of Employment at Admission among Substance Abuse Treatment

Clients Discharged from Outpatient Nonmethadone Treatment, by Gender:

1997–1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

4.3 Percentages of Primary Source of Payment for Treatment among Substance Abuse

Treatment Clients Discharged from Outpatient Nonmethadone Treatment, by

Gender: 1997–1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

5.1 Percentages of Female Clients in Substance Abuse Treatment Facilities, by

Facility Type of Care: 1996–1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

6.1 Percentages of Reasons for Discharge among Substance Abuse Treatment Clients

Aged 18 or Older, by Gender: 1997–1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

6.2 Average Length of Stay (LOS), in Days, of Substance Abuse Treatment Clients

Aged 18 or Older, by Facility Type of Care: 1997–1999 . . . . . . . . . . . . . . . . . . . . . . . . . 79
List of Tables

Table Page

vii

1.1 Alcohol Use in Past Month among Persons Aged 12 or Older, by Gender:

Percentages, NSDUH, 2003 ................................................7

1.2 Substance Dependence among Persons Aged 12 or Older, by Gender: Percentages,

NSDUH, 2003 ..........................................................7

2.1 Percentages of Substance Abuse Treatment Facilities Offering Child Care or

Prenatal Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

2.2 Randomized Studies of the Effectiveness of Substance Abuse Treatment

Programming for Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

3.1 ADSS Phase I Facility Sample Sizes, by Facility Characteristics and Availability

of Substance Abuse Treatment Programming for Women: 1996–1997 . . . . . . . . . . . . . 47

3.2 ADSS Phase II Client Sample Sizes for All Substance Abuse Treatment Clients

Aged 13 or Older, by Gender and Service Type of Care: 1997–1999 . . . . . . . . . . . . . . . 49

4.1 Percentages of Clients with Different Characteristics Discharged from Substance

Abuse Treatment, by Treatment Service Type and Gender: 1997–1999 . . . . . . . . . . . . . 62

5.1 Percentages of Substance Abuse Treatment Facilities Offering Substance Abuse

Treatment Programming for Women, Overall and by Facility Type of Care:

1996–1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

5.2 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse

Treatment Facility Characteristics, by Facility Clientele Composition: 1996–1997 . . . . 71

5.3 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse

Treatment Facility Characteristics, by Availability of Child Care Services: 

1996–1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

6.1 Completion of Planned Treatment among Substance Abuse Treatment Clients

Aged 18 or Older at Admission, by Gender and Facility Type of Care . . . . . . . . . . . . . . 79

6.2 Length of Stay (LOS), in Days, among Substance Abuse Treatment Clients Aged

18 or Older at Admission, by Gender and Facility Type of Care . . . . . . . . . . . . . . . . . . . 80
viii

List of Tables (continued)

Table Page

6.3 Completion of Planned Treatment among Female Substance Abuse Treatment

Clients Aged 18 or Older at Admission, by Facility Clientele Composition and

Facility Type of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

6.4 Length of Stay (LOS), in Days, among Female Substance Abuse Treatment

Clients Aged 18 or Older at Admission, by Facility Clientele Composition and

Facility Type of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

6.5 Completion of Planned Treatment among Female Substance Abuse Treatment

Clients Aged 18 or Older at Admission, by Availability of Child Care Services

and Facility Type of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

6.6 Length of Stay (LOS), in Days, among Female Substance Abuse Treatment

Clients Aged 18 or Older at Admission, by Availability of Child Care Services

and Facility Type of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

6.7 Adjusted Odds Ratios (ORs) of Completion of Planned Treatment among

Substance Abuse Treatment Clients Aged 18 or Older at Admission

Discharged from Nonhospital Residential Facilities, Outpatient

Nonmethadone Facilities, or Combination Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . 83

6.8 Adjusted Odds Ratios (ORs) of Completion of Planned Treatment among

Female Substance Abuse Treatment Clients Aged 18 or Older at Admission

Discharged from Nonhospital Residential Facilities, Outpatient

Nonmethadone Facilities, or Combination Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . 84

6.9 Adjusted Hazard Ratios (HRs) of Length of Stay (LOS) among Substance

Abuse Treatment Clients Aged 18 or Older at Admission Discharged from

Nonhospital Residential Facilities, Outpatient Nonmethadone Facilities, or

Combination Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

6.10 Adjusted Hazard Ratios (HRs) of Length of Stay (LOS) among Female

Substance Abuse Treatment Clients Aged 18 or Older at Admission

Discharged from Nonhospital Residential Facilities, Outpatient

Nonmethadone Facilities, or Combination Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . 86
1

Highlights

Gender is an important variable to consider in substance abuse treatment research. The

proportion of females among substance abuse treatment clients has increased over the past

decade, and female clients currently constitute about one third of the treatment population.

Reports have shown that female substance abusers experience a number of barriers to receiving

treatment, including child care responsibilities, stigmatization, and inability to pay for treatment.

Female substance abusers are more vulnerable than male substance abusers to some of the

physiological effects of substance use, and substance abuse among females is rooted more often

in psychosocial problems and traumatic life events. These important gender differences suggest

the need for specialized treatment programming for women.

Women in Substance Abuse Treatment: Results from the Alcohol and Drug Services

Study (ADSS) presents an in-depth analysis of substance abuse treatment clients and facilities,

with a special focus on women. First, an introduction provides a brief history of how gender has

been addressed in previous substance abuse treatment studies, along with an overview of current

data about gender differences. Next, a literature review summarizes current information about

substance abuse treatment programming for women. Then, results from analyses of data from a

nationally representative sample of substance abuse treatment facilities and treatment clients

from ADSS provide new insights into gender differences among substance abuse treatment

clients, the availability of substance abuse treatment programming for women, and the extent to

which women-focused services are associated with treatment retention. Finally, a discussion of

the findings suggests implications and future research. 

The in-depth review of current data and research findings on substance abuse treatment

programming for women (Chapter 2) places special emphasis on evaluations of effectiveness of

such programming. Substance abuse treatment programming for women includes diverse

services provided by treatment facilities that aim to reduce the barriers women face to entering

and staying in treatment and to address the specific substance abuse–related problems of women.

Such treatment may include the following:

! ancillary services, such as child care or transportation services, intended to

increase female clients' access to substance abuse treatment;

! services intended to address the specific needs of women, such as prenatal care

and well-baby care; and

! admissions for women only, creating a unique treatment environment that is more

focused on women's issues than is mixed-gender treatment.

Substance abuse treatment programming for women, which is not available at all substance abuse

treatment facilities, may substantially improve how long female clients remain in treatment. Key

highlights from Chapter 2 include the following:
2

! The substance abuse treatment system has increasingly recognized the need for

programming for women during the last 35 years.

! Services offered may be available only to a limited number of clients. 

! Substance abuse treatment programming specifically designed for women, such as

provision of child care services, prenatal care services, women-only treatment,

mental health services, and supplemental services and workshops addressing

women-focused topics, can be beneficial in improving treatment outcomes.

Improved outcomes include changes in substance use, mental health symptoms,

perinatal/birth outcomes, employment, self-reported health status, and HIV risk

reduction.

Subsequent chapters in this volume provide insight into the gender differences in

demographic characteristics of substance abuse treatment clients, the organizational

characteristics of facilities that offer women’s substance abuse treatment programming, and the

treatment facility and client correlates of treatment retention as measured by completion of

planned treatment and length of stay (LOS) in treatment. Data for these analyses are from 2,395

substance abuse treatment facilities and 5,005 treatment clients in ADSS, which was conducted

for the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the

U.S. Department of Health and Human Services (DHHS). Key highlights of the analyses results

are provided below:

Characteristics of Substance Abuse Treatment Clients

! Females and males in substance abuse treatment were similar on a number of

demographic characteristics. However, at admission to treatment, female clients

were more likely than male clients to have children (Chapter 4). 

! Among clients in outpatient nonmethadone treatment,

– female clients were less likely than male clients to be employed full-time

and more likely to be unemployed;

– Medicaid was more likely to be the primary source of payment for

treatment among female clients than among male clients; and 

– female clients were more likely than male clients to be admitted for drug

abuse instead of alcohol abuse (Chapter 4).

! Nationally, about 32 percent of clients in substance abuse treatment were female,

although this percentage varied by type of care: 30 percent of clients in outpatient

nonmethadone facilities (the most common type of care), 39 percent of clients in

outpatient methadone, 36 percent in nonhospital residential facilities, and 28

percent in hospital inpatient facilities were female (Chapter 5).
3

Facilities That Offer Substance Abuse Treatment Programming for Women

! An estimated 13 percent of substance abuse treatment facilities offered child care

services, and 12 percent offered prenatal services. Of all substance abuse

treatment facilities, 6 percent served women only, 37 percent offered special

programs for women, and 19 percent offered special programs for pregnant

women (Chapter 5).

! The availability of substance abuse treatment programming for women varied by

type of care. A larger proportion of nonhospital residential facilities served

women only than did other types of facilities, and outpatient methadone facilities

were less likely than other types of facilities to offer child care services. Special

programs for women overall were more likely to be offered in nonhospital

residential or outpatient methadone facilities than in other types of care. Special

programs for pregnant women were more likely to be offered in outpatient

methadone facilities than in other types of facilities (Chapter 5).

! Compared with mixed-gender facilities, women-only facilities served higher

proportions of blacks and clients whose primary source of payment was public

payment other than Medicaid and Medicare. Women-only facilities also were

more likely to offer child care services, prenatal care services, transportation

services, and special programs for women than were mixed-gender facilities

(Chapter 5).

! Compared with facilities that did not offer child care services, a larger proportion

of female clients were served by facilities that offered child care services.

Facilities offering child care services also were more likely to offer prenatal care

services, transportation services, and special programs for women than were

facilities without child care (Chapter 5).

Treatment Retention

! The rate of treatment completion was lower for women than for men in

nonhospital residential or outpatient nonmethadone facilities. However, after

controlling for client and facility characteristics, gender was not associated with

completion of planned treatment (Chapter 6).

! Women averaged shorter stays in nonhospital residential treatment than men, but

the LOS was similar among women and men in other types of care. After

controlling for client and facility characteristics, gender was not associated with

LOS (Chapter 6).

! Among women, receiving treatment at women-only facilities or at facilities

offering child care services was not associated with completion of planned

treatment, after controlling for client and facility characteristics. However, women

who received treatment at women-only facilities or facilities offering child care
4

services stayed in treatment longer than women who received treatment in

mixed-gender facilities or facilities not offering child care services, after

controlling for client and facility characteristics (Chapter 6).
5

Chapter 1. Introduction

Gender is an important variable to consider when designing and analyzing studies in all

areas and at all levels of biomedical and health-related research (Wizemann & Pardue, 2001).

Consideration of gender and dissemination of data regarding gender differences, or lack thereof,

has been recommended by the Institute of Medicine (IOM). Gender is especially important in

substance abuse treatment services research because the background characteristics, substance

abuse patterns, and personal histories of female substance users may differ from those of males.

As such, treatment programming designed specifically for women is needed to address not only

women’s substance abuse-related problems but also their special needs and barriers to treatment.

Although many service providers acknowledge and address gender differences among substance

abuse treatment clients, these differences and the programming that addresses them have not

been adequately studied. At the national, State, and local levels, policymakers and service

providers need new knowledge to understand how male and female substance abuse treatment

clients differ in terms of sociodemographic and substance use characteristics and retention in

treatment. Information about the availability and effectiveness of substance abuse treatment

programming for women can help guide public policy about how the treatment system should be

structured. 

This report discusses the need for substance abuse treatment programming for women

and summarizes evidence about the effectiveness of such programming. The report compares

characteristics of male and female clients discharged from substance abuse treatment and

estimates the availability of substance abuse treatment programming targeting women's needs.

Finally, the report provides new information about the relationship between gender, substance

abuse treatment programming for women, and retention in treatment. 

This chapter includes a brief history of how gender has been addressed or ignored in

sentinel substance abuse treatment research studies. The chapter examines current data about

gender differences in substance abuse treatment utilization, substance use epidemiology, social

context and etiology of substance use, barriers to receiving treatment, physiological

consequences of substance use, and retention in substance abuse treatment. In addition, a brief

introduction to the Alcohol and Drug Services Study (ADSS) is presented, followed by an

overview of the remaining chapters in this report. 

Gender Differences Among Substance Abuse Treatment Clients

Early substance abuse treatment studies—including the Drug Abuse Reporting Program

(DARP) and the Treatment Outcome Prospective Study (TOPS)—did not fully analyze

male-female differences in substance abuse treatment data (Kandall, 1996; Sells, Demaree,

Simpson, & Joe, 1978; Simpson & Sells, 1982). Analyses of important outcome measures were

not reported by gender, and in some instances, female research subjects were excluded from

analyses. The National Treatment Improvement Evaluation Study (NTIES), conducted from 1993

to 1995, and the California Drug and Alcohol Treatment Assessment (CALDATA), conducted

from 1992 to 1994, analyzed treatment outcomes by gender and reported many similarities
6

Year

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

2000000

Males Females

among females and males (Gerstein & Johnson, 2000; Gerstein et al., 1994). Gender differences

among treatment clients also have been analyzed using data from the Drug Abuse Treatment

Outcome Study (DATOS) (Grella & Joshi, 1999; Wechsberg, Craddock, & Hubbard, 1998).

The proportion of substance abuse treatment clients who are female has increased

moderately over the past decade (Figure 1.1). In 2002, according to the Treatment Episode Data

Set (TEDS), about 30 percent (565,000) of admissions to substance abuse treatment facilities

were females, up from 28 percent in 1992 (Substance Abuse and Mental Health Services

Administration [SAMHSA], 2004).

Figure 1.1 Numbers of Substance Abuse Treatment Admissions, by Gender and Year:

TEDS, 1992–2002.

Source: SAMHSA, Office of Applied Studies, Treatment Episode Data Set (TEDS, 1992–2002)

It is important to consider the proportion of female substance abuse treatment clients in

the context of gender differences in the epidemiology of substance use and dependence (e.g.,

Walter et al., 2003; Weiss, Kung, & Pearson, 2003). According to the National Survey on Drug

Use and Health (NSDUH, formerly the National Household Survey on Drug Abuse [NHSDA]),

the proportion of females to males engaging in binge alcohol use (having five or more drinks on

the same occasion on 5 or more days during the past 30 days) in 2003 was similar to the above

proportion of females to males in substance abuse treatment (Table 1.1; Office of Applied

Studies [OAS], 2004a). However, the proportion of females (7 percent) to males (10 percent)

engaging in past month illicit drug use was higher than the proportion of females to males in

substance abuse treatment. The rate of substance dependence on an illicit drug was even more

similar between females (1.5 percent) and males (2.2 percent) (Table 1.2; OAS, 2004a).

Furthermore, research has shown that women who used psychotropic drugs, such as sedatives or

tranquilizers, were significantly more likely than men to develop dependence on those drugs

(Kandel, Warner, & Kessler, 1998).
7

Table 1.1 Alcohol Use in Past Month among Persons Aged 12 or Older, by Gender:

Percentages, NSDUH, 2003

Gender Binge Alcohol Use 1 Heavy Alcohol Use 2 Any Illicit Drug Use 3

Male 30.9 10.4 10.0

Female 14.8 3.4 6.5

1 Binge Alcohol Use is defined as drinking five or more drinks on the same occasion (i.e., at the same time or

within a couple of hours of each other) on at least 1 day in the past 30 days. 2 Heavy Alcohol Use is defined as drinking five or more drinks on the same occasion on each of 5 or more days in

the past 30 days; all Heavy Alcohol Users are also Binge Alcohol Users. 3 Any Illicit Drug includes marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or any

prescription-type psychotherapeutic used nonmedically.

Source: SAMHSA Office of Applied Studies, National Survey on Drug Use and Health, 2003.

Table 1.2 Substance Dependence among Persons Aged 12 or Older, by Gender:

Percentages, NSDUH, 2003

Gender Alcohol Any Illicit Drug 1

Male 4.3 2.2

Female 2.2 1.5

Note: Dependence is based on the definition found in the 4th edition of the Diagnostic and Statistical Manual of

Mental Disorders (DSM-IV). 1 Any Illicit Drug includes marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or any

prescription-type psychotherapeutic used nonmedically.

Source: SAMHSA Office of Applied Studies, National Survey on Drug Use and Health, 2003.

Rates of substance use among adolescents show fewer gender differences. For example,

in the 2003 NSDUH, among adolescents aged 12 to 17, an estimated 11.4 percent of boys and

11.1 percent of girls had used an illicit drug during the past month (OAS, 2004a). According to

the 2003 Monitoring the Future national survey, the rate of past year use of any illicit drug other

than marijuana was slightly higher for girls than for boys (Johnston, O'Malley, Bachman, &

Schulenberg, 2003). There was little male-female difference in 8th and 10th grades in rates of

past year use of LSD, cocaine, crack, heroin, Ritalin, Rohypnol, and GHB. Furthermore, rates of

past year inhalant, amphetamine, and tranquilizer use were slightly higher among females than

among males in 8th and 10th grades. While these rates of substance use among adolescent

females raise concerns about risks for substance abuse and addiction in adulthood, additional

complexities have been identified for women in relation to substance use, including substance

use during pregnancy, economic considerations, physiological differences from men, cooccurring psychological problems, traumatic experiences, family and partner influences, social

stigma and discrimination, and barriers to retention in substance abuse treatment. 
8

Substance Use and Pregnancy

Among females, rates of substance use and treatment among pregnant women are of

special concern (Ebrahim & Gfroerer, 2003). The 2002 TEDS estimated that 4 percent of females

admitted to treatment were known to be pregnant when admitted (SAMHSA, 2004). Compared

with nonpregnant female admissions aged 15 to 44, pregnant admissions of similar age entering

treatment were more likely to report cocaine/crack (22 percent vs. 17 percent),

amphetamine/methamphetamine (21 percent vs. 13 percent), or marijuana (17 percent vs. 13

percent) as their primary substance of abuse (OAS, 2004b). Among pregnant women responding

to the 2002 and 2003 NSDUHs, 10 percent reported alcohol use, 4 percent reported binge alcohol

use, and almost 1 percent reported heavy alcohol use in the month prior to the survey (OAS,

2004b). The 2000–2001 Pregnancy Risk Assessment Monitoring System (PRAMS) estimated

that the prevalence of alcohol use during pregnancy ranged from 3 percent to 10 percent (Phares

et al., 2004). Women aged 35 or older, non-Hispanic women, women with more than a high

school education, and women with higher incomes reported the highest prevalence of alcohol use

during pregnancy. The 1992 National Pregnancy and Health Survey found that 19 percent of

females used alcohol during pregnancy, and 5 percent of females used an illicit drug at least once

during pregnancy, including marijuana (3 percent), psychotherapeutic medication without a

prescription (2 percent), and cocaine (1 percent) (National Institute on Drug Abuse [NIDA],

1996). More recent data from the Maternal Life Study, which oversampled very low birthweight

infants, found that 35 percent of pregnant females at four study sites reported alcohol use and 8

percent reported marijuana use during pregnancy (Lester et al., 2001). Meconium toxicology

screens were positive for cocaine or opioids in 11 percent of infants screened. 

In studies of substance abuse treatment among women, pregnancy and childbearing are

important events because they may represent barriers to seeking, receiving, or completing

treatment. Women with substance use disorders may avoid seeking treatment for fear of losing

custody of their children (Ayyagari, Boles, Johnson, & Kleber, 1999; DeAngelis, 1993;

Finkelstein, 1994; Grella, 1997), due to well-publicized cases of drug use during pregnancy

resulting in prosecutions for child abuse, delivery of drugs to a minor, and other charges

(Associated Press, 2003; Chavkin, Breitbart, Elman, & Wise, 1998; Paltrow, 1992, 1998). For

example, 14 states consider substance use during pregnancy to be child abuse under civil childwelfare statutes, and 9 states require health care professionals to report suspected prenatal

substance abuse (Figdor & Kaeser, 2005).

Women in treatment are more likely to be responsible for the care of children, to have

more children living in their homes, and to be more concerned about issues related to children

than men (Brady, Grice, Dustan, & Randall, 1993; Wechsberg et al., 1998; Wong, Badger,

Sigmon, & Higgins, 2002). Responsibility for children, coupled with little access to child care

services, is one of the most significant and most frequently cited barriers among females who

seek treatment (Allen, 1995; Copeland, 1997; Grella, 1997; Kaltenbach & Finnegan, 1998; van

Olphen & Freudenberg, 2004), and women with substance use disorders often perceive that many

substance abuse treatment programs fail to provide such services (Nelson-Zlupko, Dore,

Kauffman, & Kaltenbach., 1996). Referrals for substance abuse treatment programs in the past

often have neglected to accommodate the needs of low-income women with children, such as by

providing child care and transportation (Johnson & Meckstroth, 1998). 
9

Economic Considerations

In addition to legal consequences and logistical difficulties, pregnant and parenting

women may experience economic consequences from treatment seeking. Recent studies have

estimated that between 5 and 35 percent of women receiving Temporary Aid to Needy Families

(TANF) have a substance abuse problem that can impede their ability to work (Klein & Zahnd,

1997). The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)

required TANF recipients to work 20 hours per week or to be engaged in job training or job

readiness activities. If appropriate substance abuse treatment is not received, substance abusing

women are unlikely to find or maintain employment, and their ability to provide care for their

children is diminished. Substance abuse treatment participation could be considered an activity

counted toward work requirements, although not all States allow this. In February 2003, the

House of Representatives and a Senate committee passed bills to reauthorize TANF through

2008. The House legislation increased the work requirements to 40 hours per week (24 hours of

direct work activities and 16 hours of approved indirect work activities to be determined by the

individual States). In this legislation, substance abuse treatment is considered to be an allowable

direct work activity for up to 3 months in any 24-month period. The Senate committee expanded

on the House legislation and proposed allowing substance abuse treatment to count toward work

requirements for 6 months within a 2-year period, provided that during the second 3 months

treatment is combined with work or job-readiness activities. The full Senate has not yet ruled on

this legislation. 

However, women identified as substance abusers may also have difficulty maintaining

eligibility for entitlement programs. Many States either currently screen or plan to implement

alcohol and other drug screening of TANF recipients, and some require urine drug testing

(Montoya & Atkinson, 2002). The use of urine drug testing within TANF programs is still

controversial and has been implemented as a means of sanctioning TANF recipients (Hammett,

Gaiter, & Crawford, 1998). In addition, follow-up on referral to treatment often is limited, with

many women identified as needing treatment never presenting to receive it (Klein & Zahnd,

1997). Thus, access to treatment may be limited for substance-using females receiving TANF.

Further contributing to economic difficulties is the fact that female substance abuse

treatment clients have lower educational attainment and rates of employment than their male

counterparts (Wong et al., 2002). In a study of DATOS data, a national study of more than

10,000 substance abuse treatment clients, women were found to be younger, less educated, and

less likely to be employed than men (Wechsberg et al., 1998). In a study of Los Angeles

substance abuse treatment clients, the average age for females was lower than that for males, and

39 percent of females had less than a high school education compared with 19 percent of males

(Hser, Huang, Teruya, & Anglin, 2003). In an Oregon and State of Washington study of health

maintenance organization (HMO) clients, women were younger than men entering treatment, had

lower incomes, were less well educated, and were less likely to be employed (Green, Polen,

Dickinson, Lynch, & Bennett, 2002). Furthermore, although a greater proportion of males than

females entering treatment have no health insurance, when insured, females are more likely to

have public insurance than private insurance (Wechsberg et al., 1998). 
10

Gender Differences in Physiology

Compared with male substance abusers, female substance abusers may have more

physical problems, and females appear to be more vulnerable than males to the physiological

effects of substance use. For example, in a study of alcohol problems among trauma center

patients, women were significantly more likely than men to have liver disease (Gentilello et al.,

2000). Differences in the way women absorb, distribute, eliminate, and metabolize alcohol may

increase their vulnerability to alcohol-related problems (Mumenthaler, Taylor, O'Hara, &

Yesavage, 1999; Wasilow-Mueller & Erickson, 2001). The female liver appears to be more

sensitive to the toxic effect of chronic alcohol intake than the male liver (Colantoni et al., 2003;

Mandayam, Jamal & Morgan, 2004; Mann, Smart, & Govoni, 2003). Females develop alcoholic

liver disease (i.e., cirrhosis and hepatitis) after comparatively shorter periods and less intense

drinking than do males. Although males have higher rates of cirrhosis mortality than women,

proportionately, more alcohol-dependent females die from cirrhosis than do alcohol-dependent

males (Fuchs et al., 1995; Lieber, 1993; Mann et al., 2003; NIAAA, 1999). One of the reasons

for gender differences in alcoholic liver disease is that females achieve higher concentrations of

alcohol in the blood than males after drinking equivalent amounts of alcohol (Bradley, Badrinath,

Bush, Boyd-Wickizer, & Anawalt, 1998; Frezza et al., 1990; Redgrave, Swartz, & Romanoski,

2003). In a cohort study of over 13,000 men and women in Europe, for example, the relative risk

of developing alcohol-related liver disease was significantly higher among women than men for

any given level of alcohol intake (Becker et al., 1996). An additional reason for gender

differences in alcoholic liver disease is that the level of alcohol dehydrogenase, an enzyme

associated with alcohol metabolism, may be lower in females than in males (Baraona et al., 2001;

Thomasson, 1995). Estrogen has also been associated with alcohol-related liver disease

(Moshage, 2001; Yin et al., 2000).

Although one review reports that evidence of gender differences in alcohol-induced brain

damage remains inconclusive (Hommer, 2003), most studies suggest that females are more

susceptible than males to the adverse neurologic consequences of alcohol (NIAAA, 1999;

Prendergast, 2004; Wuethrich, 2001). In a study of alcoholic and nonalcoholic men and women's

brain volumes, for example, the significance of differences in gray and white matter volumes

between alcoholic and nonalcoholic men was of a smaller magnitude than the significance of the

differences between alcoholic and nonalcoholic women (Hommer, Momenan, Kaiser, &

Rawlings, 2001). Females may also be more susceptible than males to alcohol-related cardiac

problems (Blum, Nielsen, & Riggs, 1998; Piano, 2002), and women have shown different

mechanisms leading to a higher sensitivity to alcohol-induced heart damage (Fernandez-Sola &

Nicolas-Arfelis, 2002; Urbano-Marquez et al., 1995). In a study of alcoholic cardiomyopathy, the

prevalence of heart disease was similar in alcohol-dependent males and females, yet alcoholic

women reported a significantly lower daily dose of alcohol, a shorter duration of alcoholism, and

a lower total lifetime dose of alcohol consumption than did alcoholic men (Fernandez-Sola et al.,

1997).

These biological differences may be associated with the physical functioning and overall

health status of women. In a study that reviewed medical records and interviewed research

subjects over a 2-year period, females who abused or were dependent on alcohol reported poorer

physical functioning, poorer physical and mental health, and disproportionately more impairment
11

compared with their male counterparts (Grazier, 2001). One report has shown death rates among

female alcoholics to be much higher than those of male alcoholics (Walter et al., 2003).

Psychological Problems

In addition to various medical problems, women substance abusers are at increased risk

for psychological problems (Alvarez, Olson, Jason, Davis, & Ferrari, 2004; Brady & Randall,

1999; Chander & McCaul, 2003; Chatham, Hiller, Rowan-Szal, Joe, & Simpson, 1999;

Gentilello et al., 2000; Mann, Hintz, & Jung, 2004; OAS, 2004c; Phillips, Carpenter, & Nunes,

2004; Wechsberg et al., 1998; Zimmermann et al., 2004). Psychosocial antecedents more likely

to be associated with substance use by females than with that of males include comorbid

psychiatric disorders, such as depression, anxiety, bipolar affective disorder, phobias,

psychosexual disorders, eating disorders, or posttraumatic stress disorder (PTSD) (Boyd, 1993;

Brady, Dansky, Sonne, & Saladin, 1998; Denier, Thevos, Latham, & Randall, 1991; Fornari,

Kent, Kabo, & Goodman, 1994; Institute of Medicine [IOM], 1990; Mendelson et al., 1991;

Merikangas & Stevens, 1998; Najavits, Weiss, & Shaw, 1997; Nelson-Zlupko, Kauffman, &

Dore, 1995; Saxe & Wolfe, 1999). For example, an analysis of the relationship of age at first

substance use relative to the onset of affective and anxiety disorders found that the onset of

psychiatric disorders preceded the onset of substance use disorders more often in females than in

males (Kessler et al., 1997). In addition, substance-dependent females have been found to be

more likely to need help for emotional problems at a younger age and to have attempted suicide

than substance-dependent males (Haseltine, 2000). Unfortunately, females with co-occurring

substance abuse and psychiatric disorders face unique barriers to substance abuse treatment, such

as difficulty in obtaining a dual disorder assessment and diagnosis, social stigma attached to both

conditions, and insufficient knowledge and training among providers of health, mental health, or

substance abuse treatment services to manage coexisting disorders (Grella, 1996, 1997).

Trauma

Substance use by females is linked to traumatic events or stressors, including sexual and

physical assault or abuse, sudden physical illness, an accident, or disruption in family life (Grella,

1997; IOM, 1990; Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Kilpatrick, Resnick,

Saunders, & Best, 1998; Martin, Beaumont & Kupper, 2003; Najavits et al., 1997). Females

often use alcohol or other drugs to self-medicate in an effort to cope with these traumatic events

(Miranda, Meyerson, Long, Marx, & Simpson, 2002; Teusch, 2001; Young, Boyd, & Hubbell,

2002). Women with substance use problems have been found to be significantly more likely than

men to exhibit recent physical, emotional, or sexual abuse (Gentilello et al., 2000), and female

substance abuse treatment clients report more problems related to physical and sexual abuse and

domestic violence victimization than males (Green et al., 2002; Wechsberg et al., 1998).

However, some therapeutic approaches, such as confrontational models often used in traditional

therapeutic communities, present a special barrier for female substance abusers (Copeland, 1997)

because they often “reenact” traumatic experiences and may engender feelings of distress and

powerlessness associated with such experiences.
12

Family and Partner Influences

Female substance abusers are more likely than their male counterparts to report greater

dysfunction in the family of origin (Chatham et al., 1999) and lack adequate role models for

parenting (Davis, 1990; Sheridan, 1995). Females often are referred to substance abuse treatment

through child protective services as a requirement for retaining or regaining custody of children

(Clark, 2001). Poor interactions with children can also be a significant source of stress that

interferes with female's treatment efforts (Davis, 1990; Greif & Drechsler, 1993). In addition,

female substance abusers are more likely than male substance abusers to enter into dependent

relationships dominated by their partner (Woodhouse, 1992), hindering their ability to perform

basic life skills, such as managing money and planning for the future. Substance-dependent

females are more likely than substance-dependent males to have substance-dependent spouses or

partners (Amaro & Hardy-Fanta, 1995; Blum et al., 1998; Henderson, Boyd, & Mieczkowski,

1994; Riehman, Iguchi, Zeller, & Morral, 2003; Tuten & Jones, 2003), who may not be

supportive of their seeking treatment. Thus, seeking treatment may create a serious problem for

the relationship (McCollum & Trepper, 1995). The partner often not only discourages the woman

from entering treatment but also may threaten violence or leave the relationship if the woman

seeks treatment (Amaro & Hardy-Fanta, 1995), and partner substance use and treatment behavior

have been found to be more strongly associated with treatment motivation for females than for

males (Riehman, Hser, & Zeller, 2000). In contrast, common reasons for males' entering

treatment are family pressure and spousal opposition to substance abuse (Grella & Joshi, 1999).

Social Stigma and Discrimination

Substance use among females is more highly stigmatized than among males (Grella &

Joshi, 1999), and social stigma, labeling, and guilt are significant barriers for females to

receiving treatment (Ayyagari et al., 1999; Copeland, 1997; Dvorchak, Grams, Tate, & Jason,

1995; Finkelstein, 1994; IOM, 1990; Nelson-Zlupko et al., 1995). Stigma and guilt may foster

denial of problems by females, creating a further barrier to treatment (Blume, 1997). In addition,

females in a variety of treatment settings have been found to be more likely than males to belong

to minority racial/ethnic groups (e.g., Hser et al., 2003). As such, women in substance abuse

treatment may have experienced racism and may harbor mistrust of the medical and substance

abuse treatment systems, which may compromise provider-patient relationships and hinder

treatment and recovery. 

Implications for Retention in Substance Abuse Treatment

A number of studies have shown that males remain in substance abuse treatment longer

than females (Hser, Evans, Huang & Anglin, 2004; Mammo & Weinbaum, 1993; Petry & Bickel,

2000; Sayre et al., 2002; Simpson et al., 1997a; Simpson, Joe, & Brown, 1997b; Simpson, Joe, &

Rowan-Szal, 1997c), even after controlling for other factors (Arfken, Klein, di Menza, &

Schuster, 2001; McCaul, Svikis, & Moore, 2001) and regardless of type of care (Arfken et al.,

2001). However, relatively few data are available about retention among female substance abuse

treatment clients, and findings are not consistent. The Treatment Outcome Prospective Study

(TOPS) of clients in treatment during the early 1980s showed that gender differences in length of

stay varied by type of care; longer stays in treatment were found for females compared with
13

males in outpatient methadone treatment and outpatient drug-free treatment, but no differences

were found among females and males in residential treatment (Hubbard et al., 1989). Some

recent studies have reported no gender differences in retention after controlling for other factors

(Wickizer et al., 1994), including analyses of DATOS data among residential and outpatient

methadone types of care (Broome, Flynn, & Simpson, 1999; Joe, Simpson, & Broome, 1999),

and higher rates of retention have been found among females than males in nonmethadone

treatment, after controlling for other factors (Broome et al., 1999; Joe et al., 1999).

Other factors associated with retention include age, race/ethnicity, education, marital

status, partner’s drug use, presenting substance abuse problem at admission, severity of substance

abuse, age at first use, psychiatric symptom severity, referral source, type of care, and intensity or

level of service (Ashley, Sverdlov, & Brady, 2004; Broome et al., 1999; Green et al., 2002;

Grella, Anglin, Wugalter, Rawson, & Hasson, 1994; Grella, Joshi, & Hser, 2000; Haller, Miles,

& Dawson, 2002; Hser, Joshi, Maglione, Chou, & Anglin, 2001; Joe et al., 1999; Kelly,

Blacksin, & Mason, 2001; Knight, Logan, & Simpson, 2001; Lang & Belenko, 2000); Maglione,

Chao, & Anglin, 2000; McCaul et al., 2001; Mertens & Weisner, 2000; Nishimoto & Roberts,

2001; Rowan-Szal, Joe, & Simpson, 2000; Smith, North, & Fox, 1995; Strantz & Welch, 1995;

Tuten & Jones, 2003; Veach, Remley, Kippers, & Sorg, 2000; Wickizer et al., 1994; Williams &

Roberts, 1991). However, large, nationally representative studies are lacking and knowledge gaps

still exist about factors influencing retention in substance abuse treatment, particularly among

females.

This report includes analyses of retention among a nationally representative sample of

substance abuse treatment facilities serving male and female clients. Treatment retention is

measured in two ways in this study: (1) as the percentage of clients who successfully completed

treatment and (2) as mean length of stay (LOS) in treatment. Both measures are important

because they are associated with improved treatment outcomes, such as reduced drug use,

criminality, or unemployment (French, Zarkin, Hubbard, & Rachal,1993; Green, Polen, Lynch,

Dickinson, & Bennett, 2004; Hser et al., 2004; Hubbard, Craddock, Anderson, 2003; Hubbard,

Craddock, Flynn, Anderson, & Etheridge, 1997; Metsch, McCoy, Miller, McAnany, & Pereyra,

1999; Satre, Mertens, & Weisner, 2004; TOPPS-II Interstate Cooperative Study Group, 2004;

Wallace & Weeks, 2004; Zarkin, Dunlap, Bray, & Wechsberg, 2002). Longer stays in treatment

among pregnant substance abusers have been associated with improved pregnancy and neonatal

outcomes (Kissin, Svikis, Moylan, Haug, & Stitzer, 2004). In a drug treatment program for

pregnant and postpartum women in New York City, for example, LOS was associated with less

maternal drug use and greater mean birth weight and less intrauterine growth retardation among

infants (McMurtrie, Rosenberg, Kerker, Kan, & Graham, 1999).

Summary

Women and men with substance use disorders are different. Among clients who present

for substance abuse treatment services, women have more children living in their homes, are

often younger, have lower incomes, and are less likely to be employed than men. Factors such as

the heightened scrutiny of substance use during pregnancy, the lack of affordable child care, and

social stigma impact women more than men. There also appear to be different reasons for

initiating careers in substance use among men and women. Important differences also appear to
14

exist among adults in the adverse consequences of substance use, although most of the findings

of gender differences deal with alcohol use and alcoholism. 

Gender differences in social and psychological characteristics have important

implications for substance abuse treatment retention for females, although some important

studies show conflicting findings about the association between gender and retention. Females

have unique treatment needs in contrast to males, and gender-specific approaches to substance

abuse treatment have been developed to address these needs.

Alcohol and Drug Services Study (ADSS)

This report utilizes data from the Alcohol and Drug Services Study (ADSS). ADSS was

conducted between 1996 and 1999 for the OAS and was designed to collect detailed information

on the characteristics of substance abuse treatment facilities and their clients and to study the

relationships among facility characteristics, treatment services, and clients in treatment (OAS,

2003). The ADSS sample was selected using a multistaged, stratified design, with selection of

2,395 facilities in Phase I, selection of a subset of Phase I responding facilities, selection of client

discharge records in Phase II, and client follow-up in Phase III. Facilities in the sampling frame

were stratified by treatment type of care: hospital inpatient, nonhospital residential, outpatient

primarily alcohol, outpatient primarily methadone, other outpatient, and combined treatment

types (OAS, 2003).

Overview of Chapters

The chapters in this report review existing research and analyze ADSS data to provide

important new knowledge:

! Chapter 2, “Substance Abuse Treatment Programming for Women: A Literature

Review,” examines previous research on the availability and effectiveness of

substance abuse treatment programming for women.

! Chapter 3, “Data and Methods Used in This Report,” describes the ADSS data

source, measures of key study variables, and statistical methods.

! Chapter 4, “Characteristics of Substance Abuse Treatment Clients,” summarizes

the sociodemographic characteristics of female and male substance abuse

treatment clients.

! Chapter 5, “Characteristics of Substance Abuse Treatment Facilities Providing

Treatment Programming for Women,” estimates the prevalence of substance

abuse treatment programming for women.

! Chapter 6, “Retention in Substance Abuse Treatment: Gender and Substance

Abuse Treatment Programming for Women,” addresses the relationship between

gender and retention in treatment and between types of substance abuse treatment

programming for women and treatment retention among women.
15

! Chapter 7, “Conclusions and Implications,” summarizes the chief findings of this

report and discusses the implications of these findings with suggestions for future

research.

! The appendix, “Statistical Methods and Limitations of the Data,” discusses

generalizability of the study findings, suppression criteria for reporting results,

response rates, missing data, validity of data, and analytic methodology.
16

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29

Chapter 2. Substance Abuse Treatment 

Programming for Women: A Literature Review

This chapter summarizes the current literature about substance abuse treatment

programming for women. A definition of substance abuse treatment programming for women is

presented, and the history and origins of this type of programming are briefly described. Current

data are presented about the availability of this type of programming, and selected empirical

research is reviewed on the relationship between gender-specific substance abuse treatment

programming and treatment outcomes among women.

Comprehensive Definition

There is no universally accepted definition of substance abuse treatment programming for

women. In general, this term refers to the delivery of services and treatment that reduce females’

barriers to entering substance abuse treatment and/or address their specific substance abuse

treatment needs. Such programming includes the following core components, which may be

combined:

1. ancillary services intended to increase female clients’ access to substance abuse

treatment, such as child care or transportation services;

2. services intended to address the specific needs of females, such as prenatal and

well-baby care, psychosocial education focusing on issues relevant to women or

parenting, human immunodeficiency virus (HIV) prevention and risk reduction that

targets women, and mental health services that address a woman’s history of abuse

and trauma; and

3. programs and services provided for women only, creating a unique treatment

environment that is more focused on women’s issues than are mixed-gender services.

Although treatment programs addressing females’ barriers to treatment or their specific

needs differ, they often incorporate one or more of the above components. Substance abuse

treatment programming for women may also emphasize a comprehensive service approach to

address psychosocial problems, pregnancy education, parenting, employment, housing, and

trauma services. Such programming may reflect unique treatment philosophies that serve to

empower women and to provide a supportive, nonconfrontational approach to treatment.

Historical Context

Although the substance abuse treatment system has increasingly recognized the need for

programming that addresses women’s specific substance abuse–related problems and barriers to

treatment, women’s treatment needs were obscured for many years. Little research can be

identified before the 1980s describing substance abuse treatment programming for women, but

two seminal studies in this area are highlighted here. 
30

First, an early study of a comprehensive program for substance-dependent women

described the Family Center program initiated in Philadelphia in 1969 (Connaughton, Finnegan,

Schut, & Emich, 1975). Family Center provided outpatient medical (primarily methadone)

treatment and psychosocial services addressing education and treatment to substance-dependent

women. Obstetricians and pediatricians provided perinatal medical services, and personnel

trained in mother-child interaction and early childhood development subsequently joined the

staff. Other services included a clothing bank and a small food bank for registrants, and staff

organized women-only and parent education groups.

Second, in 1975, using pregnancy as the focus, the National Institute on Drug Abuse

(NIDA) initiated funding for a series of comprehensive drug treatment demonstration grants for

women in Detroit; Houston; New York; Philadelphia; Washington, DC; and San Rafael,

California (Beschner & Brotman, 1977). The New York City program—the Pregnant Addicts

and Addicted Mothers Program (PAAM)—was inaugurated in 1975, emphasizing

comprehensive care and providing onsite addiction treatment, medical services, individual and

group counseling, child development services, parent education classes, child care, and

developmental assessments of infants (Suffet & Brotman, 1984). All services were housed on the

same floor of one building, which facilitated communication between providers and patient

access to services. PAAM concentrated on helping women addicted to opiates or methadone

have a normal pregnancy and deliver a healthy newborn, as well as helping the newborn develop

normal cognitive and motor abilities. The comprehensive approach to treatment embedded in the

PAAM treatment model demonstrated positive outcomes, such as treatment compliance and

favorable newborn outcomes (Suffet & Brotman, 1984). PAAM was initiated at the Center for

Comprehensive Health Practice of New York Medical College in 1969 as a pilot project offering

obstetrical, pediatric, and psychological services to East Harlem mothers and their children. The

program eventually received two successive 3-year NIDA grants (1975–1981) and began

operating under contract to the New York State Division of Substance Abuse Services.

The crack cocaine epidemic of the 1980s focused attention on female crack abusers and,

in particular, on pregnant women and their children. The media focused on drug-exposed infants,

resulting in heightened concern for the devastating and costly effects of prenatal cocaine

exposure on newborns (Hartman & Golub, 1999; Lyons & Rittner, 1998). This attention resulted

in increased funding for treatment programs serving females. Block grant legislation was

amended by the Federal Government in 1984 to require that each State set aside 5 percent of its

block grant allocation to provide new or expanded substance abuse treatment services for

women. By 1988, this set-aside for women’s services had increased to 10 percent, and in 1990

the General Accounting Office (GAO) called for an urgent national response to the growing issue

of drug-exposed infants in the United States (Grella & Greenwell, 2004). Within the U.S. Public

Health Service (PHS), branches of the Alcohol, Drug Abuse, and Mental Health Administration

(ADAMHA), the National Institute on Child Health and Human Development (NICHD), and the

Health Resources and Services Administration (HRSA) all implemented special programs for

females with substance use disorders.

During the 1980s and 1990s, an increasing number of Federal programs were geared

specifically to substance-abusing mothers. The NIDA “Perinatal-20” funded 20 demonstration

grant projects in 1989 and 1990 that focused on the treatment of drug-abusing pregnant women
31

and their offspring. The intent of the Perinatal-20 was to conduct treatment research and create

new treatment slots for women and their children (Kandall, 1996). Each of the 20 projects was

designed to evaluate either a comprehensive treatment program composed of an integrated

system of services or a specific targeted therapeutic intervention embedded in a comprehensive

continuum of care. Each study targeted in its evaluation drug-abusing women in treatment either

with or without their children (Rahdert, 1996). Through these funding and policy initiatives,

availability of treatment services for women increased, and this increase enabled researchers and

evaluators to study gender-specific treatment processes and outcomes.

The Substance Abuse and Mental Health Services Administration (SAMHSA) and its

predecessor, the Alcohol, Drug Abuse, and Mental Health Administration, initiated important

programs for women with substance use disorders. One program managed under both agencies,

the Pregnant and Postpartum Women and their Infants (PPWI) Demonstration Grant Program,

awarded 147 grants in 37 States between 1989 and 1993. These projects provided comprehensive

prevention, intervention, and treatment services to substance-abusing pregnant and postpartum

women (Carter & Larson, 1997). These programs also provided health care services to the infants

of women in treatment. An evaluation of 90 of the 147 demonstration grant projects found them

to be highly successful in improving the coordination, availability, and accessibility of health

care and alcohol and drug treatment for pregnant and postpartum women, with at least one third

of the women treated by these programs reporting a reduction in drug use (Carter & Larson,

1997).

In addition to the PPWI Demonstration Grant Program, SAMHSA’s Residential Women

and Children (RWC) and the Pregnant and Postpartum Women (PPW) Demonstration Program

awarded 5-year grants to 70 projects between 1993 and 1995 (Clark, 2001). Both of these

initiatives were designed to support comprehensive residential treatment services, including

primary health care, mental health assessments and counseling, and other social services for

substance-abusing women and their children. The Center for Substance Abuse Treatment

(CSAT) conducted a cross-site evaluation of 50 of these programs. One of the key findings from

that evaluation was that between 1993 and 1996, the number of women who reported the use of

illicit drugs decreased by between 73 and 80 percent from intake to postdischarge (Carter &

Larson, 1997). Other benefits of these programs included reduction of adverse pregnancy

outcomes, reduction of criminal involvement, and improvement in retaining custody of children

(Substance Abuse and Mental Health Services Administration [SAMHSA], 2001). In addition,

47 of the 50 RWC/PPW projects obtained funding for the continuation of services beyond the

original CSAT funding.

Today, SAMHSA, through CSAT and the Center for Mental Health Services (CMHS),

continues to fund programs providing comprehensive residential substance abuse treatment

services for pregnant, postpartum, and/or parenting women and their minor children. A variety of

funding vehicles supports these programs, including Targeted Capacity Expansion, Addiction

Treatment for the Homeless, HIV Outreach, and Drug Court grants. An example of one of these

programs is the Women, Co-Occurring Disorders and Violence Study, a 5-year initiative jointly

supported by the three centers of SAMHSA to study women with substance abuse and mental

health disorders who have histories of violence. Knowledge gained from this study is expected to

be useful in advancing national, State, and local policy that affects how the various service
32

systems respond to women with co-occurring disorders and histories of violence. As of June 

2004, CSAT had funded over 100 grantees targeting women. In addition to SAMHSA’s efforts,

some states have created or funded treatment programs or provided priority access to treatment

for pregnant substance abusers (Dailard & Nash, 2000).

Availability of Substance Abuse Treatment Programming for Women

Limited information is available about the prevalence of components of substance abuse

treatment programming for women. Services are not clearly defined, and the services offered

may be available to only a limited number of clients because of restricted resources.

Nevertheless, the data provide important insight about the types and scope of treatment options

for females.

Table 2.1 presents data about the prevalence of child care or prenatal care services offered

by substance abuse treatment facilities. Nationally across studies, as shown in the table, 8 percent

of substance abuse treatment facilities offer child care services, and 7 percent offer prenatal care

services, although the rate in urban settings may be higher.

Table 2.1 Percentages of Substance Abuse Treatment Facilities Offering Child Care or

Prenatal Care Services

Data Source

Facilities Offering

Child Care Services

Facilities Offering

Prenatal Care Services

2003 N-SSATS (SAMHSA, 2004) 7.9 Not available

1998 UFDS (OAS, 2000) 8.6 6.5

Opioid Treatment Program Study

(CSAT, 2003)

7.5 Not available

1994 Los Angeles Study (Grella,

Polinsky, Hser, & Perry, 1999)

Not available 30.4

The 2003 National Survey of Substance Abuse Treatment Services (N-SSATS) found that

14 percent of substance abuse treatment facilities offered special programs for pregnant or

postpartum women. Although this figure cannot be compared to percentages from previous years

due to a change in the N-SSATS survey instrument, the percentage of facilities offering special

programs for pregnant or postpartum women remained relatively stable between 1997 and 2002.

The 2003 N-SSATS also found that 35 percent of substance abuse treatment facilities offered

special programs for women, a figure that has remained relatively stable ever since an increase

from 1998 to 1999 (SAMHSA, 2004). Among the major types of care, special programs for

women most often were offered at combined residential and outpatient facilities (Figure 2.1).

More than one third of all facilities offered transportation assistance to treatment.

In a survey of 172 opioid treatment programs in 15 states, CSAT (2003) found that 49

percent offered special services for women, and 59 percent offered special services for pregnant

women. Among a subset of 108 of these programs in 14 states, Wechsberg and colleagues (2001)
33

found that 83 percent provided priority admission for pregnant women, 58 percent offered

counseling to families, and 9 percent reported matching female clients with female counselors.

Figure 2.1 Percentages of Facilities Offering Special Programs for Women or Pregnant

Women, by Type of Care: N-SSATS, 2003

Source: SAMHSA, Office of Applied Studies, National Survey of Substance Abuse Treatment Services (N-SSATS,

2003)

Using Los Angeles County data, a 1994 study of 161 drug treatment programs for adults

found that 42 percent provided activities for children, 39 percent targeted pregnant women, and

19 percent served women only (Grella et al., 1999). Compared with mixed-gender programs,

women-only programs were more likely to provide priority admission for pregnant women,

charge no fees, and plan for longer treatment duration. Women-only programs also were more

likely than mixed-gender programs to offer pediatric/well-baby care, children’s activities, and

housing assistance. In addition, women-only programs were more likely to serve Latinos and

Native Americans and to accept Medicaid payment than were mixed-gender programs. The

authors stated that the high percentage of women-only programs receiving public funding

generally reflected the lower economic status of females.

Effectiveness of Substance Abuse Treatment Programming for Women

Although studies evaluating substance abuse treatment programming for women in the

past often lacked control groups or analyzed small samples that limited their conclusions about

effectiveness (McCrady & Raytek, 1993), recent research has shown promising results. Studies

have demonstrated higher rates of retention when women in residential treatment are allowed to

live with their children (Szuster, Rich, Chung, & Bisconer, 1996). Additionally, several studies

have demonstrated better outcomes for women in outpatient treatment with comprehensive
1

However, studies that start out as randomized controlled trials may not be able to sustain the original study

design because subjects may drop out to enter a treatment program of choice that offers special child care services,

has a more convenient location, or offers outpatient (vs. inpatient) treatment, for example.

34

support services, including pregnancy-related services, parenting/training classes, child care, and

family services (Grella & Greenwell, 2004). 

This section provides a review of the literature evaluating the effectiveness of substance

abuse treatment programming for women. Studies published between 1980 and 2000 of

substance abuse treatment programming for women were identified through a systematic

literature search. To be included in this review, studies must have explicitly defined the

population at risk, described the intervention, and presented outcome measures to evaluate the

impact of substance abuse treatment programming. The outcome measures included retention in

treatment and changes in substance use, mental health symptoms, perinatal/birth outcomes,

employment, self-reported health status, and HIV risk. A total of 37 studies were identified; 7

were randomized controlled trials, and 30 were nonrandomized studies. Detailed methods for this

review have been published elsewhere (Ashley, Marsden, & Brady, 2003). 

Optimally, health interventions are evaluated through a rigorous randomized controlled

trial (or series of trials), the standard for establishing efficacy (Sackett, Haynes, Guyatt, &

Tugwell, 1991).1

 The 7 randomized trials differed in interventions and methodologies, while the

30 nonrandomized studies employed a variety of descriptive, cohort, preexperimental, and

quasi-experimental study designs. Of the seven randomized, controlled trials reviewed here,

Dahlgren and Willander’s (1989) study came closest to the optimal study design: females were

randomly assigned to treatment in either a regular ward/alcoholism treatment center or a

women-only outpatient or residential setting, and results were compared after 2 years.

Across the 37 populations analyzed, 36 studies reported improved treatment outcomes for

female clients. All 7 randomized controlled trials showed positive results (Table 2.2), and 29 of

the 30 nonrandomized studies showed positive results. The one study that did not report

improved treatment outcomes was conducted in Australia. This study found no differences in

treatment outcomes among females in a women-only program and in two mixed-gender

treatment programs (Copeland, Hall, Didcott, & Biggs, 1993). However, more lesbian women,

women with dependent children, and women with a history of childhood sexual abuse or

maternal substance abuse participated in the women-only program than in the mixed-gender

programs.

This review focuses primarily on three components of gender-specific treatment: child

care services, prenatal care services, and women-only treatment. In addition, the effects of two

additional components of substance abuse treatment programming for women were examined:

mental health programming and supplemental education sessions that address women-focused

topics. Transportation was provided infrequently within the studies reviewed and was not

evaluated by any study as a primary intervention; therefore, it is not discussed independently

from other components.
35

Table 2.2 Randomized Studies of the Effectiveness of Substance Abuse Treatment

Programming for Women

Study Citation N Population Interventions

Control

Condition Outcomes

Carroll, Chang,

Behr, Clinton,

& Kosten

(1995)

14 Pregnant,

outpatient

methadone

clinic

patients

Prenatal care,

therapeutic child

care during

treatment visits,

monetary rewards

for abstinence,

relapse prevention

Standard

methadone

treatment

At delivery:

Increased

gestational length,

birthweight, and

number of

prenatal care

visits; no change

in maternal drug

use

Dahlgren &

Willander

(1989)

200 Women

entering

alcohol

treatment

Women-only

outpatient and

residential treatment

Treatment in

regular wards

and alcoholism

treatment center

At 2-year followup: 

Decreased alcohol

use, decreased job

loss

Elk, Mangus,

Rhodes,

Andres, &

Grabowski

(1998)

12 Pregnant

cocainedependent

women who

had used the

drug during

this

pregnancy

but had

ceased use

Contingent

reinforcement for

cocaine abstinence

and attending

prenatal visits,

transportation, child

care, behaviorally

based drug

counseling, weekly

prenatal visits

Behaviorally

based drug

counseling,

weekly prenatal

visits

At delivery: 

Improved

perinatal

outcomes and

increased prenatal

care but no

significant

difference in

abstinence from

cocaine

Hiller, RowanSzal,

Bartholomew,

& Simpson

(1996)

17 Women in

residential

treatment

Weekly sessions on

women’s health,

HIV/AIDS

prevention, and

assertiveness/

communication

skills

No specialized

treatment

intervention

On intervention

completion: 

Increased selfesteem, more

positive attitudes

toward practicing

safer sex

Hughes et al.

(1995)

53 Female

cocaine

abusers with

children

Children allowed to

live with mothers in

a therapeutic

community

Standard (no

child)

community

treatment

By discharge:

Improved

retention

(continued)
Table 2.2 Randomized Studies of the Effectiveness of Substance Abuse Treatment

Programming for Women (continued)

Study Citation N Population Interventions

Control

Condition Outcomes

36

O’Neill et al.

(1996)

73 Pregnant

women

enrolled in

methadone

maintenance

programs for

pregnant

women

Six-session

cognitive-behavioral

intervention focused

on the acquisition of

skills aimed at

helping prevent

relapse to needle

sharing and to

unsafe sex,

methadone

maintenance

treatment,

counseling and

advice about HIV

risk-taking

behaviors

Methadone

maintenance

treatment,

counseling, and

advice about

HIV risk-taking

behaviors

At 9-month

follow-up:

Reduction of

injecting risk

behaviors

associated with

“typical” drug use

and binge use, no

change in sexual

risk behaviors, no

change in drug

use per se

Volpicelli,

Markman,

Monterosso,

Filing, &

O’Brien (2000)

84 Cocainedependent

mothers

Parenting skills

class, access to a

psychiatrist,

individual therapy

sessions, GED

classes

Case

management–

oriented

outpatient

treatment

program

At 12-month

follow-up:

Decreased drug

use, increased

program retention,

no change in

psychosocial

functioning

(including

employment

status)

Although in clinical trials, all subjects assigned to a particular condition (e.g., child care

services) will normally receive the service, in studies of substance abuse treatment programs,

clients in programs offering services may not actually receive them. Thus, there is the potential in

such studies for Type II error—that is, differences in outcomes between programs with women’s

services and those without such services may be identified as small or nonexistent because not all

of the female clients at programs offering services received them. Findings are discussed below.

Child Care Services

It is difficult to analyze the unique impact of child care services on treatment outcomes

for females because in some studies, the service was bundled with other intervention services. In

other studies, child care was provided to study participants, but its impact was not evaluated

(Carroll, et al., 1995; Elk et al., 1997). Most studies that evaluated the effectiveness of providing
37

child care services to female clients in substance abuse treatment examined services for children

living with their mothers in a residential treatment program. In one clinical trial, females who

lived with their children in therapeutic community treatment programs remained in treatment

significantly longer (mean length of stay [LOS] = 300 days) than females whose children were

placed with caretakers (mean LOS = 102 days) (Hughes et al., 1995). Less rigorous studies also

found that program changes enabling women to bring their children into residential treatment

were associated with increased LOS (e.g., Stevens, Arbiter, & Glider, 1989; Wobie, Eyler,

Conlon, Clarke, & Behnke, 1997). One study found that measures of depression were lower and

measures of self-esteem were higher for females whose infants accompanied them to the

treatment facility compared with females who did not have their infants in the treatment facility

(Wobie et al., 1997). This study suggested that the earlier a mother’s infant resides with her in

the treatment setting, the longer the mother will stay in treatment.

Prenatal Care Services

One small-scale randomized trial compared standard methadone maintenance to an

enhanced treatment program that offered prenatal care services, relapse-prevention groups,

positive contingency awards for abstinence, and therapeutic child care services (Carroll et al.,

1995). A second nonrandomized study evaluated a similar intervention (Chang, Carroll, Behr, &

Kosten, 1992). Both studies found that females in the enhanced methadone program made 3

times as many prenatal visits and experienced better birth outcomes than females in the standard

program; however, both studies analyzed small sample sizes. Another randomized study

combined contingency reinforcement for abstinence with weekly prenatal visits, transportation,

child care, and behaviorally based drug counseling and found improved perinatal outcomes and

increased prenatal care but no change in substance use at delivery (Elk et al., 1998).

Other studies examined the effectiveness of mental health interventions coupled with

prenatal care, child care, human immunodeficiency virus (HIV) counseling, parenting and

nutrition classes, and transportation (Elk et al., 1997; Kukko & Halmesmaki, 1999). These

studies reported high rates of abstention from drug use or reduced drug use, retention in

treatment, compliance with prenatal care, and good perinatal outcomes.

Women-Only Treatment

Although the literature contains many reports of women-only treatment programs, only

one randomized study in Sweden compared females in a women-only treatment unit consisting of

an outpatient clinic and a residential ward with females placed in the care of traditional

mixed-gender alcoholism treatment centers (Dahlgren & Willander, 1989). A 2-year follow-up

showed a more successful rehabilitation in terms of alcohol consumption and social adjustment

(including employment status) for the females treated in the specialized women-only unit. 

Using a nonrandomized design, Grella and colleagues (1999) found that females treated

in publicly funded women-only residential treatment programs in Los Angeles reported they had

more problems, such as mental health issues and substance severity, than females at mixedgender programs. However, the clients in women-only programs actually spent more time in

treatment and were more than twice as likely to complete treatment than females in mixed-gender
38

programs. In contrast, programs that treat male and female clients together are less able to attract

and retain especially vulnerable females, such as lesbian women, women with a history of

physical or sexual violence, women who have worked as prostitutes, and single parents

(Copeland & Hall, 1992; Fullilove, Lown, & Fullilove, 1992; Grella, 1997; Pottieger, Inciardi, &

Tressell, 1996).

Copeland and colleagues (1993) compared the results achieved by subjects in a

women-only treatment program with those for subjects in two traditional mixed-gender treatment

programs in Australia. Their study found no statistically significant differences at 6 months

following treatment on any treatment outcome measure between the females in the two types of

programs, including self-reports of alcohol or drug use, a detoxification episode, a drug-related

conviction, and Alcoholics Anonymous/Narcotics Anonymous (AA/NA) attendance. However,

at entry into treatment, the women-only program served more lesbian women, women with

dependent children, women sexually abused in childhood, and women with a maternal history of

substance dependence than did the mixed-gender programs.

Mental Health Services

A number of studies evaluated the effectiveness of mental health programming for

females in substance abuse treatment. Volpicelli and colleagues (2000) randomly assigned

cocaine-dependent mothers to either a case management outpatient treatment program or to a

psychosocially enhanced treatment (PET) program that offered access to a psychiatrist, individual

therapy sessions, parenting classes, and high school equivalency education. Overall, PET patients

averaged 15.4 weeks in treatment compared with 13.9 weeks for the case management group.

Although cocaine use decreased from baseline levels in both groups, the PET group had used

cocaine on significantly fewer days at 12-month follow-up than the case management group. The

investigators suggested that individual therapy may have been the primary cause of the PET

group’s marginally better outcomes because individual therapy was the most extensively utilized

service in the PET group.

Another study randomly assigned pregnant injecting drug users either to (1) a six-session

cognitive-behavioral intervention addressing relapse prevention, needle sharing, and unsafe sex

in addition to their usual methadone maintenance treatment or (2) their usual methadone

maintenance treatment only. Results indicated that the intervention group had significantly

reduced some HIV risk-taking behaviors at a 9-month follow-up (O’Neill et al., 1996).

Nonrandomized studies have evaluated the effectiveness of outpatient individual

counseling and/or group therapy in combination with vocational and recreational activities,

medical care, parenting classes, relaxation therapy, child care, and prenatal care services (Bander,

Stilwell, Fein, & Bishop, 1983; Field et al., 1998; Kukko & Halmesmaki, 1999). Results

included abstinence or lower incidence of substance use, an increase in education and

employment, improved mother-child interactions, lowered incidence of preterm birth, increased

gestational age and birthweight, improved child physical and psychosocial functioning, and

lowered repeat pregnancy. In another study, researchers examined the effectiveness of a therapy

group addressing grief and loss among females enrolled in a gender-specific residential substance

abuse treatment program (McComish et al., 1999). Females who participated in the grief group
39

remained in treatment longer and had higher self-esteem at follow-up than those enrolled in the

same residential substance abuse treatment program but who did not participate in the grief

group.

Use of Supplemental Education Sessions

Research has shown the effectiveness of supplemental education sessions for females in

substance abuse treatment. One randomized study evaluated a treatment program that

supplemented standard substance abuse treatment with weekly psychosocial workshops on topics

covering breast health and breast self-examination; sexual and reproductive anatomy; sexually

transmitted diseases (STDs), including HIV and acquired immune deficiency syndrome (AIDS)

prevention; plus assertiveness and communication skills (Hiller et al., 1996). This approach

improved attitudes toward practicing safer sex and increased self-esteem. Several nonrandomized

studies also assessed supplemental psychoeducational sessions and workshops. These studies

evaluated standard substance abuse treatment supplemented with workshops as the primary focus

of an intervention (Bartholomew, Rowan-Szal, Chatham, & Simpson, 1994) and in combination

with other intervention components, including child care and prenatal or health care (Field et al.,

1998; Knight, Hood, Logan, & Chatham, 1999; Saunders, 1993; Wobie et al., 1997), the

provision of educational materials and behavioral strategies (Walitzer & Connors, 1997), and

comprehensive program restructuring to address the special needs of women (Stevens & Arbiter,

1995; Stevens et al., 1989; Zankowski, 1987).

Summary

This review of the current knowledge about substance abuse treatment programming for

women suggests that for substance-abusing females, treatment programming that includes

auxiliary and/or wraparound services, such as child care services, prenatal care services,

women-only treatment, mental health services, and supplemental services and workshops

addressing women-focused topics, can be beneficial. Positive treatment outcomes included

decreased substance use, increased treatment retention, improved perinatal/birth outcomes and

prenatal care, improvements in self-esteem and depression, and HIV risk reduction. Programs

that narrowly define the problems that females face solely as alcohol or other drug abuse may not

improve outcomes substantially.
40

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44
45

Chapter 3. Data and Methods Used in This Report

Analyses in this report are based on data from a nationally representative sample of

substance abuse treatment facilities and clients in the Alcohol and Drug Services Study (ADSS).

This chapter provides information about ADSS and an overview of the analytic methods used in

this report.

Data Source

ADSS provides detailed information on the characteristics of substance abuse treatment

facilities and their clients. Conducted in three phases between 1996 and 1999, ADSS collected

data by administering questionnaires to substance abuse treatment facility directors through

telephone interviews, abstracting client record data, and conducting postdischarge personal

interviews with clients. ADSS was sponsored by the Substance Abuse and Mental Health

Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services

(DHHS). Data collection was carried out by Brandeis University and Westat, Inc., under a

contract with SAMHSA’s Office of Applied Studies (OAS). In-depth information about ADSS

methods is described in another SAMHSA report (OAS, 2003a) and on the OAS website at

http://www.oas.samhsa.gov/adss.htm. Data collection instruments for ADSS’s three phases can

be found at http://www.oas.samhsa.gov/adss.htm#Qn. Data used in this report were drawn from

the first two phases of the study. 

ADSS Phase I

The Phase I target population comprised active public and private substance abuse

treatment facilities. Facilities excluded from the survey included halfway houses without paid

counselors, solo practitioners, correctional facilities, military/Department of Defense (DoD)

facilities, Indian Health Service (IHS) facilities, and facilities that perform intake and referral

only. Phase I of the survey was conducted from December 1996 to June 1997 among a nationally

representative sample of substance abuse treatment facilities.

The ADSS Phase I questionnaire was administered in about 50 minutes and used

telephone-administered structured interview methods with substance abuse treatment facility

directors. The questionnaire was mailed 2 weeks in advance and required approximately 3 hours

for respondents to obtain answers to questions prior to the telephone data collection.

Respondents were assured that information collected during both Phases I and II would be

handled in the strictest confidence. Furthermore, information collected was protected from civil

and criminal subpoena by a Certificate of Confidentiality issued by the DHHS.

ADSS employed a national sampling design including all 50 states and the District of

Columbia. Substance abuse treatment facilities were assigned to one of seven strata based on the

type of care delivered to clients: (1) hospital inpatient, (2) other residential, (3) outpatient—

predominantly methadone, (4) outpatient—almost exclusively alcohol, (5) outpatient—all other,

(6) combined, or (7) unknown. The design oversampled hospital inpatient, residential, outpatient
2

Active clients were defined as individuals who (1) had been admitted to the treatment facility and for

whom a substance abuse treatment plan had been developed, (2) had been seen on a scheduled appointment basis for

substance abuse treatment at least once during the preceding month or were inpatients/residential patients on October

1, 1996, and (3) had not been discharged from treatment as of October 1, 1996.

3

These clients included those who were formally discharged on completion of treatment; dropped out of

treatment or otherwise failed to return; were terminated by the facility (for noncompliance with rules, lack of

payment, termination of type of care, etc.); were incarcerated and ended treatment; died; were transferred to another

facility, thereby ending their treatment at the sampled facility; or in any other way ended treatment at the sampled

facility during the 6-month reference period.

46

methadone, and combined facilities. The Phase I questionnaire collected information on each

facility’s organizational characteristics; facility counts of active clients in treatment2

 and special

programs offered to specific types of clients, using a reference date of October 1, 1996; and

12-month facility data on specific services offered (OAS, 2002). 

ADSS Phase II

The ADSS Phase II target population comprised clients discharged from nonhospital

residential or outpatient substance abuse treatment facilities. Discharged clients were those who

ended treatment in some way during the 6-month period preceding the data collection visit,

regardless of when they were admitted.3

 Clients excluded from this phase were those discharged

from hospital inpatient facilities, facilities in which all clients were treated for alcohol abuse

only, and facilities outside a nationally representative subset of 62 primary sampling units

(PSUs). Phase II was conducted from August 1997 to April 1999. A client record abstraction

form was used to collect information from the client treatment records during site visits to the

facilities.

The Phase II client sample was drawn from client discharges from the 280 Phase II

respondent facilities. Substance abuse treatment discharges during the most recent 6 months were

listed for those Phase II facilities that participated in all steps of the Phase II study protocol, and a

sample of client discharge records was randomly selected from the client lists. To be included on

the list, clients must have been an active treatment client, had at least 1 day in treatment or at

least one outpatient visit, and ended treatment during the 6-month period. The Phase II record

abstraction form collected demographic and background, medical, substance abuse history,

mental disorder, and discharge information.

ADSS Phase III

ADSS Phase III included personal follow-up interviews with selected subgroups of Phase

II discharged clients and the collection of postdischarge urine samples. Phase III data were not

included in this analysis.

Analysis Samples

Facility directors from a total of 2,395 substance abuse treatment facilities completed the

Phase I survey (Table 3.1), and 280 of those facilities participated in the Phase II data collection. 
47

Table 3.1 ADSS Phase I Facility Sample Sizes, by Facility Characteristics and Availability

of Substance Abuse Treatment Programming for Women: 1996–1997

Facility Characteristic

Number of Facilities Overall

(n = 2,395 Facilities)

Number of Facilities with

Child Care Services Data

(n = 2,390 Facilities)

Total 

WomenOnlyMixedGender

Offered

Child Care

Services

Did Not Offer

Child Care

Services

Facility Type of Care

Outpatient nonmethadone only 1,083 20 1,063 161 918

Nonhospital residential only 428 64 364 51 377

Outpatient methadone only 324 2 322 30 294

Hospital inpatient only 203 — 203 2 201

Combination 357 10 347 76 280

Number of Clients

175 or more 619 1 618 117 501

75 to 174 542 7 535 81 460

25 to 74 597 18 579 55 540

24 or fewer 637 70 567 67 569

Ownership

Private, nonprofit 1,478 81 1,397 233 1,241

Private, for-profit 498 3 495 22 475

City or county government 249 7 242 47 202

State government 95 3 92 12 83

Federal government 64 1 63 2 62

Tribal government 11 1 10 4 7

Services Offered 1,2

Child care 320 54 266 320 2,070

Prenatal care 385 34 351 98 287

Transportation 1,183 87 1,096 236 945

Family counseling 1,958 77 1,881 279 1,675

Combined substance abuse treatment and

mental health services 1,252 38 1,214 177 1,071

Special Programs Offered 1,2

Women 973 88 885 250 720

Pregnant women 562 50 512 190 371

Dual-diagnosis clients 973 34 939 168 802

AIDS/HIV-positive clients 691 33 658 137 554

1 Sampled facilities for which no answer was recorded for the item about provision of a service or program are

counted as not offering the service or program. 2 Categories are not mutually exclusive.

AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus.

Source: Alcohol and Drug Services Study (ADSS), Phase I data, 1996–1997. Substance Abuse and Mental Health

Services Administration, Office of Applied Studies.
48

The Phase II data contain abstracted information for 5,005 discharged substance abuse treatment

clients aged 13 or older (Table 3.2). The sample of client records was used to examine

characteristics of substance abuse treatment clients (Chapter 4). The sample of Phase I facilities

was used to examine characteristics of facilities offering substance abuse treatment programming

for women (Chapter 5). The sample for the analysis of the relationship between the gender of

clients and retention (Chapter 6) was restricted to records for clients aged 18 or older (n = 4,689

clients). This sample excludes youths younger than 18 because differences between adult and

juvenile treatment systems are significant, and the findings were intended to be generalized only

to the adult treatment system. Furthermore, differences, such as child care needs, between adults

and youths regarding treatment programming were expected. The analysis of the relationship

between substance abuse treatment programming for women and retention among women

(Chapter 6) was based on records for female clients aged 18 or older for whom retention

information was available (n = 1,239 clients).

Measures and Definitions of Terms Used in This Report

This section describes ADSS measures and provides definitions of key study variables.

Client Characteristics

A range of client demographic and background variables was included in ADSS Phase I and

Phase II data. Age of the client was defined as “age at admission.” Phase I client race/ethnicity

was reported by facilities, and Phase II client race information was abstracted from client records.

Missing data for client ethnicity precluded including this information in Phase II analyses. Phase

II data included client education at admission, primary source of referral to treatment, primary

source of payment for treatment, marital status at admission, clients’ having a child or children at

admission, employment at admission, and living arrangement at admission. Phase II gleaned data

about clients’ presenting substance abuse problem at admission and the substance of choice

specified at admission. Treatment service type (Chapter 4) was measured using ADSS Phase II

client abstract data and refers to the specific service received by each client, regardless of

whether the facility providing treatment offered more than one type of care. The three service

types are (1) outpatient nonmethadone, (2) nonhospital residential, and (3) outpatient methadone

treatment. Categories for some client demographic, background, and substance use

characteristics were collapsed for some analyses.

Components of Substance Abuse Treatment Programming for Women

Prevalence and retention estimates associated with substance abuse treatment programming for

women were based on the following facility characteristics: women-only facilities, facilities

offering child care services, facilities offering prenatal care services, facilities offering special

programs for women, and facilities offering special programs for pregnant women. Women-only

facilities referred to those with active clients on October 1, 1996, and that served only female

clients on that date. Facilities offering child care services referred to facilities offering child care

services during the most recent 12-month period for which data were available, defined as

“services that provide care for minor children of active clients, including supervised activities.”

Similarly, facilities offering prenatal care services referred to facilities offering prenatal care
49

Table 3.2 ADSS Phase II Client Sample Sizes for All Substance Abuse Treatment Clients

Aged 13 or Older, by Gender and Service Type of Care: 1997–1999

Characteristic

Service Type of Care

Outpatient

Nonmethadone Nonhospital Residential Outpatient Methadone 

Total Female Male Total Female Male Total Female Male

Total 3,642 939 2,703 878 198 680 463 197 266

Age at Admission (Years)

13 to 17 239 67 172 54 9 45 1 -- 1

18 to 24 562 115 447 99 19 80 24 12 12

25 to 34 1,215 347 868 290 80 210 165 79 86

35 to 44 1,069 294 775 299 63 236 183 80 103

45 to 54 372 80 292 99 15 84 73 21 52

55 or older 135 24 111 23 6 17 12 4 8

Unknown/not mentioned 50 12 38 14 6 8 5 1 4

Race

White 2,263 574 1,689 411 100 311 186 82 104

Black 763 260 503 364 75 289 126 63 63

Other 214 34 180 30 10 20 65 24 41

Unknown/not mentioned 402 71 331 73 13 60 86 28 58

Marital Status at Admission 1

Not married 2,663 724 1,939 690 149 541

Married/common law 859 183 676 152 38 114

Unknown/not mentioned 120 32 88 36 11 25

Have Child/Children at

Admission 1

Yes 1,961 648 1,313 509 149 360

No 1,117 204 913 269 38 231

Unknown/not mentioned 564 87 477 100 11 89

Living Arrangement at

Admission 1

With spouse/partner 999 251 748 124 35 89

With parent(s) 817 173 644 143 28 115

Alone 432 101 331 73 21 52

With other family 348 116 232 58 12 46

With no other adult(s)/children

only 113 85 28 10 8 2

No stable arrangement at

admission (includes

homeless, shelters) 163 46 117 185 38 147

With friends 212 46 166 35 7 28

Correctional facility 20 4 16 102 6 96

Other institution/closed facility 76 21 55 56 9 47

Unknown/not mentioned 462 96 366 92 34 58

(continued)
Table 3.2 ADSS Phase II Client Sample Sizes for All Substance Abuse Treatment Clients

Aged 13 or Older, by Gender and Service Type of Care: 1997–1999 (continued)

Characteristic

Service Type of Care

Outpatient

Nonmethadone Nonhospital Residential Outpatient Methadone 

Total Female Male Total Female Male Total Female Male

50

Education at Admission 1

Less than high school graduate 1,277 361 916 316 73 243

High school graduate/GED 1,301 301 1,000 299 65 234

Some college, college

graduate, or postgraduate 806 223 583 212 48 164

Unknown/not mentioned 258 54 204 51 12 39

Employment at Admission

Unemployed 1,357 471 886 596 150 446 270 113 157

Employed full time (35

hours/week or more) 1,151 166 985 104 11 93 67 19 48

Employed part time (fewer

than 35 hours/week) 279 90 189 30 6 24 30 17 13

Keeping house, not otherwise

employed 63 59 4 6 6 — 11 10 1

Employed, not otherwise

specified 326 39 287 15 2 13 24 12 12

Disabled 156 35 121 34 7 27 28 11 17

Other 116 28 88 54 6 48 3 — 3

Unknown/not mentioned 194 51 143 39 10 29 30 15 15

Primary Source of Referral for

Treatment

Criminal justice system 1,925 322 1,603 298 42 256 18 4 14

Self-referred/voluntary 553 195 358 247 70 177 264 117 147

Other treatment facility 268 81 187 114 24 90 59 30 29

Welfare office or other social

service agencies 271 124 147 57 15 42 9 4 5

Health care, mental health, or

insurance providers 230 107 123 73 25 48 25 8 17

Family/friend 163 52 111 52 13 39 37 15 22

Other 123 18 105 4 — 4 2 2 —

Unknown/not mentioned 109 40 69 33 9 24 49 17 32

Primary Expected Source of

Payment for Treatment

Client self-payment 1,367 225 1,142 214 41 173 113 43 70

Medicaid 444 216 228 58 30 28 214 88 126

Medicare or other public

funding 455 117 338 236 55 181 53 21 32

(continued)
Table 3.2 ADSS Phase II Client Sample Sizes for All Substance Abuse Treatment Clients

Aged 13 or Older, by Gender and Service Type of Care: 1997–1999 (continued)

Characteristic

Service Type of Care

Outpatient

Nonmethadone Nonhospital Residential Outpatient Methadone 

Total Female Male Total Female Male Total Female Male

51

Private health insurance,

fee-for-service 234 54 180 30 8 22 4 3 1

Private health insurance,

HMO/PPO/managed care 275 85 190 29 5 24 12 7 5

Criminal justice system 253 49 204 123 7 116 — — —

No payment 171 59 112 68 25 43 11 5 6

Other 57 22 35 21 5 16 12 6 6

Unknown/not mentioned 386 112 274 371 93 278 44 24 20

Presenting Substance Abuse

Problem at Admission 1

Alcohol and drug abuse 1,904 532 1,372 575 132 443

Alcohol abuse only 1,206 211 995 125 25 100

Drug abuse only (excluding

alcohol) 459 181 278 169 41 128

Unknown/not mentioned 73 15 58 9 — 9

Substance of Choice at

Admission 1

Alcohol 1,799 367 1,432 295 67 228

Cocaine 513 223 290 262 70 192

Marijuana, hashish, THC 434 88 346 71 7 64

Amphetamines 68 25 43 32 15 17

Heroin 134 35 99 84 16 68

Nontreatment methadone or

other opiates 26 17 9 11 5 6

Barbiturates, benzodiazepines,

or other sedatives or

hypnotics 13 9 4 5 2 3

Any other drug, multiple, or no

substance of choice 119 39 80 36 5 31

Unknown/not mentioned 536 136 400 82 11 71

1 Not collected for outpatient methadone clients.

GED = general equivalency diploma; HMO = health maintenance organization; PPO = preferred provider

organization; THC = tetrahydrocannabinol.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client record

abstract data, 1997–1999.
4

In 2002, according to the National Survey of Substance Abuse Treatment Services (N-SSATS), 81 percent

of all facilities offered outpatient care (including 7 percent that offered methadone treatment), 28 percent offered

residential care, and 8 percent offered hospital inpatient care. In addition, an estimated 90 percent of clients received

outpatient treatment (including 19 percent receiving outpatient care), 8 percent received residential care, and less

than 1 percent received hospital inpatient care (OAS, 2003b). In 1996, an estimated 76 percent of clients received

outpatient nonmethadone treatment, 14 percent received outpatient methadone care, 9 percent were in nonhospital

residential care, and 1 percent were in hospital inpatient care (OAS, 2003c). Outpatient nonmethadone facilities do

not provide methadone for treatment of dependence on heroin or other opioids and provide care in outpatient

settings; nonhospital residential facilities provide detoxification or rehabilitation in 24-hour nonhospital settings;

outpatient methadone facilities dispense methadone to treat dependence on heroin or other opioids on an outpatient

basis; and hospital inpatient facilities provide detoxification or rehabilitation services in hospital inpatient settings.

These facilities vary in the clients they serve and the approaches they use, as well as in the average LOS. In ADSS,

the average LOS for all clients discharged from treatment in the facilities studied was 133 days, or about 4.4 months

(Lee, Reif, Ritter, Levine, & Horgan, 2004). On average, outpatient methadone clients stayed in treatment longest

(mean = 520 days), followed by outpatient nonmethadone clients (mean = 144 days) and nonhospital residential

clients (mean = 45 days). Methadone treatment is typically provided over a long-term period of maintenance.

However, substantial variation exists across facilities and across studies (McLellan & McKay, 1998).

52

services during the most recent 12-month period for which data were available. Facilities offering

special programs for women or special programs for pregnant women referred to those that

offered such programs on October 1, 1996.

Other Facility Characteristics

Analyses discussed in Chapters 5 and 6 grouped substance abuse treatment facilities into

categories representing five facility types of care from Phase I data: (1) outpatient nonmethadone

only, (2) nonhospital residential only, (3) outpatient methadone only, (4) hospital inpatient only,

or (5) combination facilities (i.e., those that offered more than one type of care, such as a single

treatment facility that offered residential and outpatient care).4

 Analyses in Chapter 5 also

grouped facilities into categories based on the total number of active clients.

Retention

Two important constructs are used in the substance abuse treatment literature: treatment

completion and length of stay (LOS). A program or facility that has good retention is one that

generally is able to keep clients in treatment for longer periods of time. Treatment completion

means that an individual has successfully completed a treatment plan that is either generic to the

program or facility or is tailored to the client’s needs. LOS represents how long a person stays in

treatment. In Chapter 6, completion of planned treatment was 1 of 11 response options for reason

for discharge among clients in nonmethadone facilities; LOS was indicated by the number of

days between the client’s date of admission and the date of discharge in both methadone and

nonmethadone facilities.

Statistical Methods

WesVar® software (Westat, Inc., 2000) was used for descriptive analyses, incorporating

sample weights and jackknife variance estimation (Rust & Rao, 1996). In this report, a p value

less than 0.05 is considered statistically significant, except in Chapter 5 analyses of client
5

The Bonferroni procedure (Dunn, 1961) is designed to avoid Type I error (identifying differences that do

not really exist) by applying a more stringent criterion to determine differences between clients and facilities.

53

characteristics, special programs, and services reported by facilities. These analyses used a

Bonferroni adjustment for multiple comparisons, such that a p value less than 0.05 divided by the

number of comparisons is considered statistically significant.5

 The following sections describe

the statistical methods used in this report. 

Analysis of Client Characteristics

Chi-square tests were used to compare the distribution of client characteristics among

females and males (Chapter 4). Statistically significant differences were then examined using

two-sided Student’s t tests. Because the client populations of service types differed substantially,

analyses were stratified by service type of care.

Analysis of Facility Characteristics

In Chapter 5, the prevalence of substance abuse treatment programming for women was

calculated for facilities overall and for each facility type of care. For analyses in Chapter 5 of

selected client characteristics reported by facilities, an individual facility rate was calculated by

dividing the number of active clients with each characteristic (i.e., gender, race/ethnicity, age,

and payment source) by the total number of active clients for each facility based on aggregate

counts reported by facility directors in ADSS Phase I. Next, a national facility rate for each

characteristic was calculated by summing individual facility percentages and dividing by the

number of facilities with active clients reporting the characteristic. Two-sided Student’s t tests

with Bonferroni adjustment for multiple comparisons were used to examine differences in rates

for facility client variables between women-only and mixed-gender facilities and between

facilities offering child care services and those not offering such services.

Percentages of facilities with selected facility characteristics were calculated among the

numbers of women-only or mixed-gender facilities and among the numbers of facilities offering

child care services and not offering such services. Chi-square tests were used to examine

differences in facility size and ownership. Two-sided Student’s t tests were conducted to identify

the contribution of different proportions to significant chi-squares. Two-sided Student’s t tests

with Bonferroni adjustment for multiple comparisons were used to examine differences in

percentages of facilities offering services or special programs among women-only and

mixed-gender facilities and among facilities offering child care services and those not offering

such services. 

Descriptive Analysis of Treatment Retention

Descriptive analyses of treatment retention in Chapter 6 used F tests to compare rates of

treatment completion or LOS among adult female and male clients and among adult female

clients at facilities with and without substance abuse treatment programming for women.
6

Hospital inpatient facilities typically have the shortest planned LOS. Outpatient nonmethadone and

residential facilities have longer stays, and methadone treatment is typically meant to be long term. Among clients in

treatment during the early 1980s, the Treatment Outcome Prospective Study (TOPS) found the average LOS in

treatment to vary by type of care (Hubbard et al., 1989). The average number of weeks in outpatient methadone

treatment was 38.4 compared with 21.3 weeks in residential treatment and 14.6 weeks in outpatient drug-free

treatment. These averages were noted as similar to those found in the Drug Abuse Reporting Program (DARP) study

a decade earlier. Thus, when examining LOS, it is important to control for facility type; that is, LOS must be

examined only within individual facility types and not compared across facility types.

54

Different types of facilities have different treatment completion rates and different planned LOS.6

Thus, all analyses of treatment completion and LOS were stratified by facility type of care.

Two-sided Student’s t tests were conducted to identify the different proportions’ contribution to

significant F statistics.

Logistic Regression Analysis

In Chapter 6, WesVar® software (Westat, Inc., 2000) was used for the logistic regression

analysis, incorporating sample weights and jackknife variance estimation. Logistic regression

procedures were used to model completion of planned treatment as a function of clients’ gender

and, among women, treatment at women-only facilities or facilities offering child care services.

Odds ratio (OR) estimates derived from logistic regression procedures denote the estimated

magnitude of an association between a binary outcome (e.g., treatment completion) and a

covariate (e.g., client gender). An OR estimate greater than 1.00 indicates a positive association

between the outcome of interest and the covariate; an OR estimate less than 1.00 indicates an

inverse association. A 95 percent confidence interval (CI) of the OR also is presented.

Survival Analysis

SUDAAN® software (Shah, Barnwell, & Bieler, 1995) with Taylor series variance

estimation was used for the survival analyses in Chapter 6 to take into account the complex

survey design of ADSS. Survival analysis, specifically Cox’s proportional hazard regression

(Hosmer & Lemeshow, 1999; Parmar & Machin, 1995), was used to model LOS as a function of

adult clients’ gender and, among women, treatment at women-only facilities or facilities offering

child care services. Hazard ratio (HR) estimates derived from survival analysis procedures denote

the estimated magnitude of an association between a covariate (e.g., client gender) and an

outcome (e.g., discharge from treatment) over time for a defined population. An HR estimate

greater than 1.00 indicates a greater likelihood of leaving treatment earlier; a value of less than

1.00 reflects a lower likelihood of leaving treatment earlier. The HR also is presented with a CI.

Limitations of the Data

This section discusses limitations of the data source that should be considered when

interpreting analysis results.
55

ADSS Phase I Data Limitations

ADSS Phase I data are based on retrospective reports by facility directors made up to 6

months after the survey point-prevalence date. Thus, these data may be subject to recall and

reporting biases. Some sources of potential bias are related to the Phase I questionnaire and

retrospective self-reports.

First, some degree of overreporting or underreporting by facility directors on the types

and numbers of clients and services may have occurred because of a lack of updated knowledge

of activities at the client or service level (TecMRKT Works, 2004), selective perception,

nonstandardized definitions of services, or a desire to represent the facility as providing more

services than it actually does. Self-report data also may be influenced by memory and recall

errors if not verified through client or service records, including recall delay (tendency to forget

events occurring long ago) or forward telescoping (tendency to report that activities occurred

more recently than they actually did). These memory errors would tend to result in estimates for

less recent data (i.e., at the beginning of the 12-month reference period) that are downwardly

biased (because of recall delay) and estimates for more recent data that are upwardly biased

(because of telescoping). However, efforts were made to minimize these sorts of biases by

requesting that facility directors check external sources of data for their responses, and attempts

were made to standardize data collection efforts across facilities through extensive training

sessions and materials for interviewers. Efforts were made to validate data through site visits and

listing/sampling of client records.

Second, in some instances, the Phase I questionnaire lacked clear definitions to describe

programs and services. For example, the Phase I questionnaire did not define “special programs”

for specific populations. It did not specify whether offering such services as child care,

transportation, or prenatal care included arrangements with other agencies to provide these

services. Thus, the validity and reliability of the responses may be limited in providing a true

estimate of service availability.

Third, there is a potential bias associated with Phase I client characteristics data

referencing a single day (October 1, 1996) if that point estimate was unrepresentative in some

way (e.g., due to seasonal variation). However, analyses of ADSS Phase I data have shown that

there is little seasonal variation.

ADSS Phase II Data Limitations

The ADSS Phase II data are based on abstraction of clinical documents by ADSS staff,

and they may be subject to additional biases. Some sources of bias are related to the abstraction

process and missing data.

First, some degree of error may have occurred because of the abstraction process. Prior

studies have shown that numerous factors may compromise data quality in record abstraction,

such as vague specification of variables or inappropriate interpretation by abstractors (Allison et

al., 2000; Peabody, Luck, Glassman, Dresselhaus, & Lee, 2000), which may be especially

challenging for mental health and substance abuse research because of the subjective nature of
7

Student’s t tests were used to examine study variables for significantly different amounts of missing data,

and records with missing data for a variable were excluded from analysis of that variable if there was no statistically

significant difference in the amount of missing data between groups. Where the amounts of missing data differed

significantly between the analytic groups, the missing data were included as a category and were presented in the

analysis. For example, in multivariate analyses in Chapter 6, records with missing data for a specific variable were

categorized as “not ascertained” and included in the analyses.

8

For example, information about having a child/children at admission, living arrangement at admission,

education at admission, presenting substance abuse problem at admission, and reason for discharge was not

abstracted from client records in outpatient methadone facilities.

56

the abstraction process (Katz, Chang, Sangha, Fossel, & Bates, 1996). Abstraction errors would

result in misclassification bias by categorizing records incorrectly and could yield an

underestimation of differences in the characteristics of clients from different groups or of

associations between substance abuse treatment programming and retention in treatment among

clients. Attempts were made to minimize this type of bias through a detailed trainer’s guide and

abstraction manual for ADSS Phase II interviewers.

Second, the Phase II client record data include fields with missing data, which may result

from poor or missing recording of information in the original chart (Allison et al., 2000; Luck,

Peabody, Dresselhaus, Lee, & Glassman, 2000). Thus, the ability to analyze some data fields is

limited.7

 For example, ethnicity, pregnancy status, and information about history of psychological

disorders were more likely than other data not to be recorded in the original client chart. Missing

data are not uncommon to the medical record and record abstraction process because clinic staff

often rush through or abbreviate their paperwork duties to meet the direct needs of their clients.

In addition, the Phase II study design called for the collection of only limited information about

clients discharged from methadone treatment.8

 The Appendix presents more detailed information

about missing data.

Limitations of the Analyses

The analyses presented here have important limitations, including their ability to detect

true differences between analytic groups and the lack of control for level of service utilization.

The lack of control for service intensity across facilities is probably the most important

limitation. The literature suggests that clients treated in programs that provide more services tend

to have better outcomes than clients in programs with fewer services (Broome, Simpson, & Joe,

1999; Gerstein et al., 1997; McLellan et al., 1998; Pringle et al., 2002; Smith & Marsh, 2002). As

described in Chapter 5, facilities that offered woman-focused programming were more likely to

offer more services overall than facilities not offering such programming. Therefore, when

comparisons are made between females at facilities with and without woman-focused

programming, any differences found may be the result of comparing females who received a high

level of services bundled with women-focused programming with other female treatment clients

who may have received fewer services overall. Thus, receiving treatment at facilities offering

woman-focused programming may be associated with longer stays in treatment and improved

treatment outcomes because of the high level of service intensity in such facilities. 
57

In addition, true differences may not be found or the magnitude of the differences may be

underestimated because of the low threshold of exposure to treatment required for inclusion in

ADSS. Phase II data were included in these analyses for all clients who had received at least one

treatment session, and analysis was not limited to those with a particular LOS. Thus, some

individuals coded as having received treatment may actually have received very little exposure to

programming offered by the treatment facility, and thus no effect of this programming would be

expected for these individuals. Therefore, the findings for comparisons between clients at

facilities offering substance abuse treatment programming for women and those at facilities not

offering such programming may be misleading. The findings may show no differences or

underestimate the magnitude of the difference between clients because too many individuals at

facilities offering specialized programming received an insufficient level of exposure to the

programming.
58

References

Allison, J. J., Wall, T. C., Spettell, C. M., Calhoun, J., Fargason, C. A. Jr, Kobylinski, R. W.,

Farmer, R., & Kiefe, C. (2000). The art and science of chart review. Joint Commission Journal

on Quality Improvement, 26, 115-136.

Broome, K. M., Simpson, D. D., & Joe, G. W. (1999). Patient and program attributes related to

treatment process indicators in DATOS. Drug and Alcohol Dependence, 57, 127-135.

Dunn, O. J. (1961). Multiple comparisons among means. Journal of the American Statistical

Association, 56, 52-64.

Gerstein, D. R., Datta, A. R., Ingels, J. S., Johnson, R. A., Rasinski, K. A., Schildhaus, S., Talley,

K., Jordan, K., Phillips, D. B., Anderson, D. W., Condelli, W. G., & Collins, J. S. (1997, March).

NTIES: The National Treatment Improvement Evaluation Study final report. Retrieved August 6,

2004, from http://www.icpsr.umich.edu/SAMHDA/NTIES/NTIES-PDF/ntiesfnl.pdf

Hosmer, D. Jr., & Lemeshow, S. (1999). Applied survival analysis: Regression modeling of time

to event data. New York: Wiley.

Hubbard, R. L., Marsden, M. E., Rachal, J. V., Harwood, H. J., Cavanaugh, E. R., & Ginzburg,

H. M. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill, NC:

University of North Carolina Press.

Katz, J. N., Chang, L. C., Sangha, O., Fossel, A. H., & Bates, D. W. (1996). Can comorbidity be

measured by questionnaire rather than medical record review? Medical Care, 34, 73-84.

Lee, M. T., Reif, S., Ritter, G. A., Levine, H. J., & Horgan, C. M. (2004). Alcohol and Drug

Services Study (ADSS) Phase II: Client record abstract report (DHHS Publication No. SMA

04-3974, Analytic Series No. A-27). Rockville, MD: Substance Abuse and Mental Health

Services Administration. [Available as a PDF at http://www.oas.samhsa.gov/analytic.htm and

http://www.oas.samhsa.gov/adss.htm]

Luck, J., Peabody, J. W., Dresselhaus, T. R., Lee, M., & Glassman, P. (2000). How well does

chart abstraction measure quality? A prospective comparison of standardized patients with the

medical record. American Journal of Medicine, 108, 642-649.

McLellan, A. T., Hagan, T. A., Levine, M., Gould, F., Meyers, K., Bencivengo, M., & Durell, J.

(1998). Supplemental social services improve outcomes in public addiction treatment. Addiction,

93, 1489-1499.

McLellan, A. T., McKay, J. R. (1998). The treatment of addiction: What can research offer

practice? In S. Lamb, M. R. Greenlick, & D. McCarthy (eds.), Bridging the gap between practice

and research: Forging partnerships with community-based drug and alcohol treatment (pp. 147-

185). Washington, DC: National Academy Press.
59

Office of Applied Studies. (2002, June). Alcohol and Drug Services Study, 1996-1999 [United

States]: Phase I facility questionnaire (Part 1) [Computer file] (ICPSR 3088, conducted by

Brandeis University, 2nd ICPSR ed.). Ann Arbor, MI: Inter-university Consortium for Political

and Social Research [producer and distributor]. [Available as a PDF at

http://www.oas.samhsa.gov/adss.htm and

http://www.oas.samhsa.gov/ADSS/ADSS1FacilityQN.pdf]

Office of Applied Studies. (2003a). Alcohol and Drug Services Study (ADSS): Methodology

report: Phases I, II, and III. Rockville, MD: Substance Abuse and Mental Health Services

Administration. [Available as a PDF at http://www.oas.samhsa.gov/adss.htm]

Office of Applied Studies. (2003b). Alcohol and Drug Services Study (ADSS): The national

substance abuse treatment system: Facilities, clients, services, and staffing. Rockville, MD:

Substance Abuse and Mental Health Services Administration. [Available as a PDF at

http://www.oas.samhsa.gov/adss.htm]

Office of Applied Studies. (2003c). National Survey of Substance Abuse Treatment Services

(N-SSATS): 2002. Data on substance abuse treatment facilities (DHHS Publication No. SMA

03-3777, Drug and Alcohol Services Information System Series S-19). Rockville, MD:

Substance Abuse and Mental Health Services Administration. [Available at

http://www.oas.samhsa.gov/dasis.htm#nssats2]

Parmar, M., & Machin, D. (1995). Survival analysis: A practical approach. New York: Wiley.

Peabody, J. W., Luck, J., Glassman, P., Dresselhaus, T. R., & Lee, M. (2000). Comparison of

vignettes, standardized patients, and chart abstraction: A prospective validation study of 3

methods for measuring quality. Journal of the American Medical Association, 283, 1715-1722. 

Pringle, J. L., Edmondston, L. A., Holland, C. L., Kirisci, L., Emptage, N. P., Balavage, V. K.,

Ford, W. E., Etheridge, R. M., Hubbard, R. L., Jungblut, E., & Herrell, J. M. (2002). The role of

wrap around services in retention and outcome in substance abuse treatment: Findings from the

Wrap Around Services Impact Study. Addictive Disorders & Their Treatment, 1(4), 109–118.

Rust, K. F., & Rao, J. N. (1996). Variance estimation for complex surveys using replication

techniques. Statistical Methods in Medical Research, 5, 283-310.

Shah, B. V., Barnwell, B. G., & Bieler, G. S. (1995). SUDAAN®: Software for the analysis of

correlated data, Release 6.4 [Computer software and manual]. Research Triangle Park, NC:

Research Triangle Institute.

Smith, B. D., & Marsh, J. C. (2002). Client-service matching in substance abuse treatment for

women with children. Journal of Substance Abuse Treatment, 22, 161-168.

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from http://www.tecmrkt.com/paps_data_collection_tech_frameset.htm
60

Westat, Inc. (2000). WesVar® 4.0 [Computer software and manual]. Rockville, MD: Author.

[Also see http://www.westat.com/wesvar/]
61

Chapter 4. Characteristics of Substance 

Abuse Treatment Clients

Using ADSS Phase II data, this chapter compares sociodemographic characteristics of

female and male clients discharged from substance abuse treatment facilities (i.e., completed

treatment, dropped out, or were asked to leave) during a 6-month period in 1996. These

characteristics include age, race, marital status, having a child/children, living arrangement,

education, and employment at admission, as well as primary source of referral for this treatment,

primary expected source of payment for this treatment, presenting substance abuse problem at

admission, and substance of choice at admission. Because client populations receiving individual

service types differ substantially in their characteristics (e.g., age and severity of problems),

analyses were stratified by service type of care (outpatient nonmethadone, nonhospital

residential, and outpatient methadone). All results are weighted estimates based on data from

clients discharged from treatment. Although estimates are based on a 6-month data collection

period, estimated annual numbers of discharges are presented for comparisons.

Among clients discharged from outpatient nonmethadone, nonhospital residential, and

outpatient methadone treatment, females and males were similar on age at admission and race

(Table 4.1). However, female clients were generally more likely than male clients to have a

child/children at admission (Figure 4.1). 

Clients discharged from outpatient nonmethadone treatment exhibited additional gender

differences:

! Females were more likely than males to live with no other adult(s)/children only

and were less likely to live with friends.

! At admission, females were more likely than males to be unemployed and were

less likely to be employed full-time (Figure 4.2).

! The primary source of referral for treatment was less likely to be the criminal

justice system, and more likely to be a welfare office or other social services

agencies, among females than males.

! The primary expected source of payment for treatment was more likely to be

Medicaid among females than males (Figure 4.3).

! The presenting substance abuse problem was less likely to be alcohol abuse only,

and more likely to have been drug abuse only, among females than males.

! Alcohol was less likely to be the substance of choice at admission among females

than males.
62

Table 4.1 Percentages of Clients with Different Characteristics Discharged from Substance Abuse Treatment, by Treatment

Service Type and Gender: 1997–1999

Service Type of Care

Estimated Annual Number of Discharges

Outpatient Nonmethadone Nonhospital Residential Outpatient Methadone 

Female Male Female Male Female Male

352,922 1,049,099 160,253 537,572 51,420 66,672 

Characteristic Percent Percent PercentAge at Admission (Years)13 to 17 1 7.8 6.2 7.3 6.3 — * 18 to 24 13.6 16.4 10.2 11.2 6.6 3.6 25 to 34 36.5 31.4 34.0 33.2 42.9 31.1 35 to 44 26.8 29.7 33.1 33.6 40.3 40.6 45 to 54 12.0 11.0 11.7 12.1 10.0 21.4 55 or older 3.4 5.3 3.7 3.5 * 2.7 RaceWhite 74.1 78.1 62.8 60.4 51.8 54.8 Black 22.6 16.0 32.0 35.8 36.7 30.3 American Indian, Alaska Native, Asian or Pacific Islander 3.3 5.9 5.3 3.8 11.5 14.9 Marital Status at Admission 2

Never married, widowed, separated/divorced, single,

unknown/not mentioned, or other 73.9 70.3 73.5 80.1 

Married/common law 26.1 29.7 26.5 19.9 Have Child/Children at Admission 2,3,4

Yes 67.6 51.1 72.6 55.2 No 22.9 31.5 24.7 32.6 Unknown/not mentioned 9.5 17.4 2.7 12.2 Living Arrangement at Admission 2,3With spouse/partner 35.3 34.6 29.4 20.8 With parent(s) 20.9 22.8 23.0 22.0 Alone 11.9 15.4 14.6 14.1 With other family 12.2 8.9 8.2 8.8 With no other adult(s)/children only 10.4 1.3 5.8 * No stable arrangement (includes homeless and shelters) 3.2 6.4 11.2 16.6 With friends 3.5 7.9 4.3 3.7 Correctional facility * 0.9 2.8 9.0 Other institution/closed facility 2.4 1.8 0.8 4.5 

(continued) 
63

Table 4.1 Percentages of Clients with Different Characteristics Discharged from Substance Abuse Treatment, by Treatment

Service Type and Gender: 1997–1999 (continued)

Service Type of Care

Estimated Annual Number of Discharges

Outpatient Nonmethadone Nonhospital Residential Outpatient Methadone 

Female Male Female Male Female Male

352,922 1,049,099 160,253 537,572 51,420 66,672 

Characteristic Percent Percent PercentEducation at Admission 2

Less than high school graduate (not otherwise specified),

8–11 years, or fewer than 8 years 39.2 33.8 40.0 35.8 

High school graduate/GED 34.3 40.8 33.1 41.7 Some college, college graduate, or postgraduate 26.5 25.4 26.9 22.5 Employment at Admission 5Unemployed 47.6 32.7 69.6 55.4 58.2 60.2 Employed full time (35 hours/week or more) 25.9 40.3 10.1 22.1 9.4 18.9 Employed part time (fewer than 35 hours/week) 8.2 6.7 5.0 4.2 9.3 5.1 Keeping house, not otherwise employed 7.5 * 3.7 — 3.7 * Employed, not otherwise specified 4.9 12.0 * 2.3 12.3 5.3 Disabled 2.0 4.2 5.7 7.6 7.1 7.2 Retired, inmate, or unknown/not mentioned 3.9 4.0 4.7 8.4 — * Primary Source of Referral for Treatment 3Criminal justice system 39.4 57.0 24.1 35.2 * 9.1 Self-referred/voluntary 22.1 15.4 36.5 32.9 71.1 62.0 Other treatment facility 10.7 7.3 11.5 11.1 12.1 12.4 Welfare office or other social service agencies 11.3 4.2 6.4 4.6 * 1.4 Health care, mental health, or insurance providers 8.5 4.9 10.7 9.6 1.9 4.4 Family/friend 6.2 5.4 10.9 5.6 8.7 10.7 Employer or unknown/not mentioned 1.7 5.9 — * * — Primary Expected Source of Payment for Treatment 3Client self-payment 34.7 44.1 30.6 40.1 28.9 35.7 Medicaid 20.1 5.8 23.9 8.6 39.2 37.2 Medicare or other public funding 8.6 10.0 45.4 44.4 16.9 16.9 Private health insurance, fee-for-service 9.4 10.4 15.5 12.5 * * Private health insurance, HMO/PPO/managed care 8.5 7.6 14.9 10.5 2.9 2.0 Criminal justice system 9.8 12.7 11.8 23.4 — — No payment 6.7 7.5 5.7 4.3 1.6 3.0 Not permitted to abstract or unknown 2.2 1.9 6.7 4.8 8.0 5.0 

(continued)
64

Table 4.1 Percentages of Clients with Different Characteristics Discharged from Substance Abuse Treatment, by Treatment

Service Type and Gender: 1997–1999 (continued)

Service Type of Care

Estimated Annual Number of Discharges

Outpatient Nonmethadone Nonhospital Residential Outpatient Methadone 

Female Male Female Male Female Male

352,922 1,049,099 160,253 537,572 51,420 66,672 

Characteristic Percent Percent PercentPresenting Substance Abuse Problem at Admission 2,3

Alcohol and drug abuse 53.7 53.3 60.1 63.3 Alcohol abuse only 27.2 38.5 19.4 21.3 Drug abuse only (excluding alcohol) 19.1 8.2 20.5 15.4 Substance of Choice at Admission 2,3Alcohol 49.4 63.4 40.5 45.8 Cocaine 19.2 11.3 32.3 23.6 Marijuana, hashish, THC 14.2 16.2 4.7 10.9 Amphetamines 4.5 2.5 4.8 4.6 Heroin 2.3 2.9 7.9 9.5 Nontreatment methadone or other opiates 4.9 0.2 5.3 0.6 Barbiturates, benzodiazepines, or other sedatives or hypnotics 0.9 * * * Any other drug, multiple, or no substance of choice 4.7 3.4 3.5 4.9 

* Low precision; no estimate reported.– Not available.

1 Persons under age 18 are generally not eligible for methadone treatment.2 Not collected for outpatient methadone clients.3 Difference between female and male estimates is statistically significant at the 0.05 level among clients discharged from outpatient nonmethadone treatment. 4 Difference between female and male estimates is statistically significant at the 0.05 level among clients discharged from residential nonmethadone treatment. 5 Difference between female and male estimates is statistically significant at the 0.001 level among clients discharged from outpatient nonmethadone treatment. 

GED = general equivalency diploma; HMO = health maintenance organization; PPO = preferred provider organization; THC = tetrahydrocannabinol.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data, 1997–1999.
65

67.6

51.1

72.6

55.2

22.9

31.5

24.7

32.6

9.5 17.4

2.7 12.2

Outpatient Nonmethadone Treatment 

Female Male Female Male

0

20

40

60

80

100

Residential Nonmethadone Treatment

Have a Child/Children at Admission

Do Not Have a Child/Children at Admission

Unknown/Not Mentioned

Figure 4.1 Percentages of Substance Abuse Treatment Clients Having a Child/Children at

Admission, by Gender and Service Type: 1997–1999

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data,

1997–1999.

Figure 4.2 Percentages of Employment at Admission among Substance Abuse Treatment

Clients Discharged from Outpatient Nonmethadone Treatment, by Gender:

1997–1999

Note: Small sample sizes prevented analyses of outpatient nonmethadone clients keeping house, not otherwise

employed.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data,

1997–1999.
66

34.7

20.1

8.6

18.3

9.8

6.7

2.2

44.1

5.8

10.0

20.3

12.7

7.5

1.9

Medicaid Private Insurance No Payment

0

10

20

30

40

50

Female Male

Criminal Justice

System

Not Permitted to Abstract,

Unknown, or Other

Medicare/Other

Public

Client 

Self-Pay

Figure 4.3 Percentages of Primary Source of Payment for Treatment among Substance

Abuse Treatment Clients Discharged from Outpatient Nonmethadone

Treatment, by Gender: 1997–1999

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data,

1997–1999.

Summary

Although female and male clients generally were similar on race and age at admission to

treatment, females were more likely to have a child/children at admission than males. There were

important gender differences in economic status among clients discharged from outpatient

nonmethadone treatment, including lower levels of employment and higher rates of Medicaid

payment for treatment among females than males. Compared with males, females discharged

from outpatient methadone treatment were also more likely to be admitted for drug abuse instead

of alcohol abuse. 
67

Chapter 5. Characteristics of Substance Abuse Treatment

Facilities Providing Treatment Programming for Women

This chapter presents estimates of the percentages of female clients in substance abuse

treatment facilities, the availability of substance abuse treatment programming for women, and

comparisons between facilities treating women only and those that treat both women and men.

These estimates are based on Alcohol and Drug Services Study (ADSS) Phase I data, which are

from facility directors’ or administrators’ reports on facility characteristics. Phase I data also

include facility directors’ or administrators’ reports of the number and type of active clients on a

reference date of October 1, 1996. After calculating each facility’s percentage of female clients,

national female-client rates were determined by summing facility percentages and dividing by the

number of facilities with active clients, across all facilities and by type of care. 

The prevalence of substance abuse treatment programming designed specifically for women

also was examined, focusing on the following components: women-only treatment, child care

services, prenatal care services, and special programs offered to women or pregnant women.

Respondents were asked whether facilities offered services to any substance abuse clients during

the most recent 12-month period for which client data were available and whether any special

programs were offered to specific types of clients. Differences in the characteristics of facilities

treating women only and facilities treating both women and men also were examined, based on

ADSS Phase I questions on the number of active female clients. Facilities were classified as

women-only if 100 percent of their active clients were female on the reference date. Finally,

characteristics of facilities offering child care services were compared with those of facilities not

offering child care services.

Female Clients in Substance Abuse Treatment Facilities

According to facility administrators’ reports, 32 percent of clients were female in substance

abuse treatment facilities across the nation (Figure 5.1). The percentage of female clients varied

across types of care. Almost 30 percent of clients were female in outpatient nonmethadone

facilities, the most common type of care; in comparison, 39 percent of outpatient methadone

clients were female. 

Availability of Substance Abuse Treatment Programming for Women

Table 5.1 presents estimates of availability of substance abuse treatment programming for

women. Almost 6 percent of all facilities served only female clients:

! Women-only treatment availability ranged from about 2 percent of outpatient

nonmethadone facilities to 21 percent of nonhospital residential facilities.

! No hospital inpatient facilities in the ADSS Phase I sample served only females.
68

31.9

29.8

36.1

39.4

26.6

34.3

Facility Type of Care

Facilities Overall

Outpatient Nonmethadone Only

Nonhospital Residential Only

Outpatient Methadone Only

Hospital Inpatient Only

Combination

0

10

20

30

40

50

Figure 5.1 Percentages of Female Clients in Substance Abuse Treatment Facilities, by

Facility Type of Care: 1996–1997

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data,

1996–1997.

Services

Overall, 13 percent of facilities offered child care services, including 15 percent of

nonhospital residential facilities, 13 percent of outpatient nonmethadone facilities, and 8 percent

of outpatient methadone facilities. Almost 12 percent of facilities overall offered prenatal care

services: 6 percent of outpatient nonmethadone facilities, 19 percent of nonhospital residential or

outpatient methadone facilities, and 33 percent of hospital inpatient facilities.

Special Programs

Overall, a little more than one third of facilities nationwide offered special programs for

women, and 19 percent offered special programs for pregnant women:

! Nonhospital residential facilities and outpatient methadone facilities were most

likely to provide special programs for women (43 percent each).

! Hospital inpatient facilities were least likely to offer special programs for women

(19 percent). 

! Outpatient methadone facilities were most likely to offer special programs for

pregnant women (39 percent).

! Hospital inpatient facilities were least likely to offer special programs for pregnant

women (13 percent).
69

Table 5.1 Percentages of Substance Abuse Treatment Facilities Offering Substance

Abuse Treatment Programming for Women, Overall and by Facility Type of

Care: 1996–1997

Facility Type of Care

Facility

Characteristic

Facilities

Overall

N = 12,387

n = 2,395

Outpatient

Nonmethadone

N = 7,524

n = 1, 083

Nonhospital

Residential

N = 2,135

n = 428

Outpatient

Methadone

N = 464

n = 324

Hospital

Inpatient

N = 378

n = 203

Combination

Types of Care

N = 1,886

n = 357

Women-Only

Facilities 1 5.9 2.2 21.0 * * 6.2

Child Care

Services 2 13.3 12.7 15.4 7.8 * 17.0

Prenatal Care

Services 2 11.9 5.7 19.1 19.0 32.6 22.8

Special Programs

for Women 2 37.4 36.3 42.8 42.7 19.0 38.0

Special Programs

for Pregnant

Women 2 19.3 17.0 21.4 39.4 12.6 22.7

* Low precision; no estimate reported.

N = Estimated number of facilities with active clients in the United States; N excludes facilities with no clients in

treatment for substance abuse on October 1, 1996.

n = Number of facilities sampled with active clients; n excludes facilities with no clients in treatment for

substance abuse on October 1, 1996. 1 Facilities with no active clients on October 1, 1996, were not counted as women-only facilities. 

2 Sampled facilities that did not report whether they offered a service or special program were not counted as

offering the service or special program.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data,

1996–1997.

Comparisons between Women-Only and Mixed-Gender Facilities

Women-only and mixed-gender facilities exhibited many differences (Table 5.2):

! Compared with mixed-gender facilities, women-only facilities served higher

proportions of black clients.

! The proportion of clients aged 35 or older was lower at women-only facilities

compared with mixed-gender facilities.

! Rates for client self-payment, private health insurance, or Medicare were lower

among women-only facilities compared with mixed-gender facilities.

! The rate for public payment other than Medicaid or Medicare was higher among

women-only than mixed-gender facilities. 
9

Note that p < 0.01 (0.05 divided by 5 comparisons for Bonferroni adjustment) is statistically significant.

70

! Women-only facilities were more likely to serve a smaller number of active

clients compared with mixed-gender facilities.

In addition, women-only facilities were more likely than mixed-gender facilities to offer

women’s programming, such as child care services, prenatal care services, transportation

services, special programs for women, and special programs for pregnant women.

Comparisons between Facilities with and without Child Care Services

Table 5.3 presents estimates of facilities offering child care services and those not

offering child care services. Compared with facilities that did not offer child care services, those

that offered these services treated higher proportions of female clients and clients for whom

Medicaid was the primary source of payment. The distribution of client race/ethnicity was similar

among facilities with and without child care services.9

 The rate for HMO/PPO/managed care

private health insurance was lower among facilities with child care services than among facilities

without these services.

Facilities offering child care services were more likely to be larger facilities, and were

more likely to offer other women’s programming (such as prenatal care services, transportation

services, special programs for women, and special programs for pregnant women) than facilities

that did not offer child care services. In addition, facilities with child care services were more

likely to offer special programs for dual-diagnosis clients or AIDS/HIV-positive clients than

facilities without child care services.

Facilities offering child care services were more likely to be larger facilities, and were

more likely to offer other women’s programming (such as prenatal care services, transportation

services, special programs for women, and special programs for pregnant women), than facilities

that did not offer child care services. In addition, facilities with child care services were more

likely to offer special programs for dual-diagnosis clients or AIDS/HIV-positive clients than

facilities without child care services.
71

Table 5.2 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse

Treatment Facility Characteristics, by Facility Clientele Composition:

1996–1997

Facility Clientele Composition

Characteristic

Women-Only Facilities

N = 733

n = 96

Mixed-Gender Facilities

N = 11,562

n = 2,281

NFR NFR

Race/Ethnicity

White, not Hispanic 1 43.1 62.1

Black, not Hispanic 1 36.4 22.2

Hispanic 13.8 9.5

Asian or Pacific Islander 1.3 0.8

American Indian or Alaska Native 4.3 2.4

Unknown 1.1 2.9

Age at Admission (Years)

Younger than 18 9.4 11.5

18 to 24 2 25.7 13.4

25 to 34 1 41.9 31.5

35 to 44 2 19.2 26.9

45 or older 1 2.8 12.2

Unknown 2 1.1 4.5

Primary Expected Source of Payment

No payment 7.1 7.5

Client self-payment 2 13.3 23.7

Private health insurance, fee-for-service 1 0.4 9.9

Private health insurance, HMO/PPO/managed care 1 1.4 10.7

Medicaid 20.2 14.6

Medicare 1 0.1 3.8

Other public payment 1 55.0 26.9

Unknown 2.3 3.0

Percent Percent

Number of Clients 1

175 or more * 14.2

75 to 174 6.3 20.6

25 to 74 11.5 32.5

24 or fewer 81.4 32.7

(continued) 
72

Table 5.2 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse

Treatment Facility Characteristics, by Facility Clientele Composition:

1996–1997 (continued)

Facility Clientele Composition

Characteristic

Women-Only Facilities

N = 733

n = 96

Mixed-Gender Facilities

N = 11,562

n = 2,281

Percent Percent

Services Offered 4

Child care 1 55.5 10.6

Prenatal care 1 39.9 10.1

Transportation 1 92.8 46.6

Family counseling 76.8 86.1

Combined substance abuse treatment and mental

health services 3 41.1 55.2

Special Programs Offered 4

Women 1 91.0 34.0

Pregnant women 1 54.6 17.1

Dual-diagnosis clients 37.0 40.5

AIDS/HIV-positive clients 30.1 21.2

Note: NFRs were calculated by summing individual facility percentages and dividing by the number of facilities

with active clients reporting each client characteristic.

* Low precision; no estimated reported.

Degrees of freedom = 200.

N = Estimated number of facilities with active clients in the United States; N excludes facilities with no clients in

treatment for substance abuse on October 1, 1996.

n = Number of facilities sampled with active clients; n excludes facilities with no clients in treatment for substance

abuse on October 1, 1996. 1 Difference between women-only and mixed-gender facility estimates is statistically significant at the 0.001 level.

2 Difference between women-only and mixed-gender facility estimates is statistically significant at the 0.01 level. 3 Difference between women-only and mixed-gender facility estimates is statistically significant at the 0.05 level. 4 Sampled facilities for which no answer was recorded for the item about provision of a service or program are

counted as not offering the service or program. Estimates are affected accordingly. Categories are not mutually

exclusive.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data, 1996–1997.
73

Table 5.3 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse

Treatment Facility Characteristics, by Availability of Child Care Services:

1996–1997

Characteristic

Facilities Offering 

Child Care Services

N = 1,621

n = 318

Facilities Not Offering

Child Care Services

N = 10,605

n = 2,054

NFR NFR

Gender

Female 1 51.3 29.0

Male 1 47.6 69.9

Unknown 1.1 1.1

Race/Ethnicity

White, not Hispanic 56.9 61.6

Black, not Hispanic 2 28.3 22.3

Hispanic 9.1 9.9

Asian or Pacific Islander 0.5 0.9

American Indian or Alaska Native 3.3 2.4

Unknown 1.8 3.0

Age at Admission (Years)

Younger than 18 8.2 11.9

18 to 24 3 18.4 13.5

25 to 34 1 37.7 31.4

35 to 44 23.7 26.7

45 or older 1 8.9 12.1

Unknown 3.0 4.4

Primary Expected Source of Payment

No payment 8.3 7.3

Client self-payment 21.0 23.5

Private health insurance, fee-for-service 2 6.4 9.8

Private health insurance, HMO/PPO/managed care 1 5.1 10.5

Medicaid 3 22.8 13.8

Medicare 2.2 3.8

Other public payment 31.7 28.3

Unknown 2.5 3.0

Percent Percent

Number of Clients 1

175 or more 23.2 11.9

75 to 174 24.8 19.1

25 to 74 22.5 32.8

24 or fewer 29.6 36.2

(continued) 
74

Table 5.3 National Facility Rates (NFRs) and Percentages for Selected Substance Abuse

Treatment Facility Characteristics, by Availability of Child Care Services:

1996–1997 (continued)

Characteristic

Facilities Offering Child

Care Services

N = 1,643

n = 320

Facilities Offering Child

Care Services

 N = 10,676

n = 2,070

Percent Percent

Services Offered 4

Prenatal care 1 30.8 9.1

Transportation 1 78.1 45.2

Family counseling 83.1 85.9

Combined substance abuse treatment and mental

health services 55.5 53.9

Special Programs Offered 4

Women 1 78.6 31.1

Pregnant women 3 57.2 13.5

Dual-diagnosis clients 3 50.9 38.8

AIDS/HIV-positive clients 3 35.3 19.8

Note: National facility rates (NFRs) were calculated by summing individual facility percentages and dividing by the

number of facilities with active clients reporting each client characteristic.

* Low precision; no estimate reported.

Degrees of freedom = 200.

N = Estimated number of facilities with active clients in the United States; N excludes facilities with no clients in

treatment for substance abuse on October 1, 1996.

n = Number of facilities sampled with active clients; n excludes facilities with no clients in treatment for substance

abuse on October 1, 1996. 1 Difference between estimates for facilities offering child care services and those not offering such services is

statistically significant at the 0.001 level.

2 Difference between estimates for facilities offering child care services and those not offering such services is

statistically significant at the 0.05 level.

3 Difference between estimates for facilities offering child care services and those not offering such services is

statistically significant at the 0.01 level.

4 Sampled facilities for which no answer was recorded for the item about provision of a service or program are

counted as not offering the service or program. Estimates are affected accordingly. Categories are not mutually

exclusive.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data, 1996–1997.
75

Summary

The availability of substance abuse treatment programming for women varied by type of

facility:

! Outpatient nonmethadone facilities were less likely than facilities overall to treat

women only or offer prenatal services and were equally as likely as other facility

types to offer child care services, special programs for women, or special

programs for pregnant women.

! Nonhospital residential facilities were most likely to serve women only and were

more likely than other types of care to offer child care services, prenatal care

services, or special programs for women or for pregnant women.

! Outpatient methadone facilities were most likely to offer special programs for

women or pregnant women, but few offered child care services.

! Hospital inpatient facilities did not serve women only, were the most likely of all

types of care to offer prenatal care services, and were least likely to offer special

programs for women or pregnant women. 

Comparisons of types of facilities revealed the following findings: 

! Compared with mixed-gender facilities, women-only facilities were smaller; were

less likely to serve clients with private health insurance or whose primary source

of payment was self-pay; and were more likely to offer child care, prenatal care, or

transportation services. 

! Compared with facilities not offering child care services, facilities offering these

services were larger; were more likely to serve female clients; and were more

likely to offer other women-oriented programming, such as prenatal care services,

transportation services, special programs for women, or special programs for

pregnant women.
76
77

Chapter 6. Retention in Substance Abuse Treatment:

Gender and Substance Abuse Treatment Programming 

for Women

This chapter presents findings on (1) gender differences in LOS and completion of

planned substance abuse treatment and (2) differences in LOS and treatment completion among

females at facilities with and without substance abuse treatment programming specifically for

women. Data in this chapter about client and organizational factors associated with retention can

potentially inform approaches to treatment efforts and also may improve understanding of the

underlying factors affecting treatment retention. First, percentages of clients’ reasons for

discharge from substance abuse treatment (including treatment completion) were calculated.

Mean LOS by facility type of care was also estimated. Next, gender differences in completion of

planned treatment and LOS were examined using Alcohol and Drug Services Study (ADSS)

Phase I and II data. Analyses of LOS included Phase II data for female and male clients aged 18

or older discharged from outpatient nonmethadone, nonhospital residential, or combination

facilities. Phase I data were used to identify facility type of care. Because data about reason for

discharge were not abstracted from Phase II client records at outpatient methadone facilities,

analyses of treatment completion did not include clients discharged from outpatient methadone

facilities. Analyses also focus on two components of substance abuse treatment programming for

women: women-only treatment and child care services. Differences in treatment retention were

examined among (1) clients at women-only facilities and women at mixed-gender facilities and

(2) women at facilities offering child care services and at facilities not offering child care

services. Phase I data were used to identify facility characteristics.

Descriptive analyses are presented first, followed by multivariate analyses. Logistic

regression procedures were used to determine the relationship between gender or substance abuse

treatment programming for women and completion of planned treatment. Survival analysis

procedures were used to determine the relationship between gender or substance abuse treatment

programming for women and LOS. Multivariate analyses controlled for additional client and

organizational characteristics associated with retention.

Descriptive Analyses

Among adult clients discharged from outpatient nonmethadone, nonhospital residential,

or combination facilities, 54 percent completed planned treatment (Figure 6.1). Mean LOS varied

by facility type of care (Figure 6.2).

At outpatient nonmethadone or nonhospital residential facilities, women were less likely

to complete planned treatment than were men (Table 6.1). Among adult clients at facilities

providing a combination of types of care, women were more likely to complete planned treatment

than were males. At facilities providing nonhospital residential treatment, women averaged

shorter stays in treatment than did men (Table 6.2). Women averaged longer stays in treatment

than did men at facilities providing other types of care, although these differences were not

statistically significant. 
10Differences in treatment completion among women-only and mixed-gender outpatient nonmethadone or

combination facilities could not be analyzed because of small sample sizes or because one of the strata contained

only one primary sampling unit.

78

2

1.3

0.4

0.1

0.5

1.2

6.1

8.4

25.2

54.3

Percent

0 10 20 30 40 50 60

Completed Planned Treatment

Did Not Complete Treatment, Referred/

Transferred to Another Program

Unknown/Not Mentioned

Other

Did Not Complete Treatment,

Not Otherwise Specified

Did Not Complete

Treatment, Incarcerated

Did Not Complete Treatment

by Client Choice

Did Not Complete Treatment by

Administration Choice

Did Not Complete Treatment,

No Payment Source

Did Not Complete Treatment,

Insurance Benefits Expired

.2

Figure 6.1 Percentages of Reasons for Discharge among Substance Abuse Treatment

Clients Aged 18 or Older: 1997–1999

Note: Analysis of client deceased as reason for discharge could not be conducted because of small sample size.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data,

1997–1999.

Rates of treatment completion were similar among clients at women-only facilities and

among women at mixed-gender nonhospital residential facilities (Table 6.3).10 At facilities

providing nonhospital residential treatment, clients at women-only facilities stayed in treatment

longer than women at mixed-gender facilities (Table 6.4). However, at facilities providing a

combination of types of care, clients at women-only facilities remained in treatment for shorter

stays than women at mixed-gender facilities. Rates of treatment completion were lower among

women at facilities offering child care services than among women at facilities not offering these

services, although these differences were not statistically significant (Table 6.5). At nonhospital

residential facilities, women stayed in treatment longer at facilities offering child care services

than did women at facilities without child care services (Table 6.6).
79

147.4

54.6

481.7

93.5

Facility Type of Care

Outpatient Nonmethadone

Nonhospital Residential

Outpatient Methadone

Combination

0

100

200

300

400

500

Figure 6.2 Average Length of Stay (LOS), in Days, of Substance Abuse Treatment

Clients Aged 18 or Older, by Facility Type of Care: 1997–1999

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase II client data,

1997–1999.

Table 6.1 Completion of Planned Treatment among Substance Abuse Treatment Clients

Aged 18 or Older at Admission, by Gender and Facility Type of Care

Gender

Facility Type of Care

Women Men

Number Completing

Planned Treatment Percent

Number Completing

Planned Treatment Percent

Outpatient nonmethadone 110,678 46.0 1 393,364 53.1

Nonhospital residential 42,803 60.4 2 176,250 68.2

Combination 80,201 62.3 2 236,851 54.6

1 Difference between estimate for women and estimate for men is statistically significant at the 0.05 level. 2 Difference between estimate for women and estimate for men is statistically significant at the 0.01 level.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data

(1996–1997) and Phase II data (1997–1999).
80

Table 6.2 Length of Stay (LOS), in Days, among Substance Abuse Treatment Clients Aged

18 or Older at Admission, by Gender and Facility Type of Care

Gender

Facility Type of Care

Women Men

Number of

Clients

Average LOS

(in Days)

Number of

Clients

Average LOS

(in Days)

Outpatient nonmethadone 247,607 153.8 754,556 145.4

Nonhospital residential 72,325 34.01 264,029 60.5

Outpatient methadone 36,269 531.4 53,173 447.8

Combination 147,976 146.7 454,697 76.2

1

 Difference between LOS of women and LOS of men is statistically significant at the 0.001 level.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data

(1996–1997) and Phase II data (1997–1999).

Table 6.3 Completion of Planned Treatment among Female Substance Abuse Treatment

Clients Aged 18 or Older at Admission, by Facility Clientele Composition and

Facility Type of Care

Facility Clientele Composition

Facility Type of Care

Women-Only Facilities Mixed-Gender Facilities

Number of Clients

Completing Planned

Treatment Percent

Number of Women

Completing Planned

Treatment Percent

Outpatient nonmethadone % % 110,266 46.3

Nonhospital residential 8,898 65.2 33,905 59.3

Combination 165 13.9 80,036 62.7

*Low precision; no estimate reported.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data

(1996–1997) and Phase II data (1997–1999).

Logistic Regression Models

Gender was not associated with completion of planned treatment, after controlling for

other client and facility characteristics (Table 6.7). Control variables associated with treatment

completion were education at admission, primary source of referral for treatment, primary

expected source of payment for treatment, and facility type of care. The odds of treatment

completion were lower among adult clients with 8 to 11 years of education but with no high

school degree, those whose primary expected source of referral was not the criminal justice

system, and those whose primary source of payment was the criminal justice system compared

with high school graduates, clients whose primary source of referral was the criminal justice

system, and those whose primary expected source of payment was private health insurance. The

odds of completing treatment were 3 times higher among adult clients discharged from 
81

Table 6.4 Length of Stay (LOS), in Days, among Female Substance Abuse Treatment

Clients Aged 18 or Older at Admission, by Facility Clientele Composition and

Facility Type of Care

Facility Clientele Composition

Facility Type of Care

Women-Only Facilities Mixed-Gender Facilities

Number of Clients

Average LOS

(in Days)

Number of

Women

Average LOS

(in Days)

Outpatient nonmethadone 2,484 295.5 245,123 152.4

Nonhospital residential 13,956 83.1 1 58,369 22.3

Combination 1,454 51.9 2 146,522 147.7

1 Difference between estimate for clients at women-only facilities and estimate for women at mixed-gender

facilities is statistically significant at the 0.01 level. 2 Difference between estimate for clients at women-only facilities and estimate for women at mixed-gender

facilities is statistically significant at the 0.05 level.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data

(1996–1997) and Phase II data (1997–1999).

Table 6.5 Completion of Planned Treatment among Female Substance Abuse Treatment

Clients Aged 18 or Older at Admission, by Availability of Child Care Services

and Facility Type of Care

Facility Type of Care

Child Care Services Offered Child Care Services Not Offered

Number of Women

Completing Planned

Treatment Percent

Number of Women

Completing Planned

Treatment Percent

Outpatient nonmethadone 33,461 45.4 77,216 46.3

Nonhospital residential 454 26.4 42,349 61.3

Combination 11,819 43.1 68,382 67.5

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phases I and II data,

1996–1999.

nonhospital residential facilities than among adult clients discharged from outpatient

nonmethadone facilities.

Receiving treatment at women-only facilities or at those offering child care services was

not associated with treatment completion among women, after controlling for other client and

facility characteristics (Table 6.8). Some control variables were associated with treatment

completion among women. Women from minority racial groups, women whose primary source

of referral to treatment was not the criminal justice system, and women whose presenting

substance abuse problem was drug abuse only were less likely to complete treatment than were

white women, women whose primary source of referral was the criminal justice system, and

women whose presenting substance abuse problem was alcohol abuse only. Unexpectedly,

women at facilities offering combined substance abuse treatment and mental health services were

less likely to complete treatment than were women receiving treatment at facilities not offering
82

Table 6.6 Length of Stay (LOS), in Days, among Female Substance Abuse Treatment

Clients Aged 18 or Older at Admission, by Availability of Child Care Services

and Facility Type of Care

Facility Type of Care

Child Care Services Offered No Child Care Services Offered

Number of

Women

Average LOS

(in Days)

Number of

Women

Average LOS

(in Days)

Outpatient nonmethadone 76,348 168.4 171,259 147.3

Nonhospital residential 1,719 96.7 1 70,606 32.5

Outpatient methadone 3,731 386.8 32,538 548.0

Combination 41,069 353.0 106,906 67.5

1 Difference between estimate for women at facilities offering child care services and estimate for women at

facilities not offering child care services is statistically significant at the 0.01 level.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data

(1996–1997) and Phase II data (1997–1999).

 combined substance abuse treatment and mental health services, although this result may reflect

the larger proportion of clients with co-occurring substance abuse and mental health disorders at

facilities offering combined substance abuse treatment and mental health services. Women

receiving treatment at nonhospital residential or combination facilities were more likely to

complete planned treatment than were women receiving treatment at outpatient nonmethadone

facilities. Women receiving treatment at facilities offering prenatal care services were also more

likely to complete treatment than were women receiving treatment at facilities not offering

prenatal care services.

Survival Analysis Models

Gender was not associated with LOS, after controlling for other client and facility

characteristics (Table 6.9). Some control variables were significantly associated with LOS among

adult clients. Adult clients whose source of referral for treatment was not the criminal justice

system were more likely to leave treatment earlier than were clients whose referral source was

the criminal justice system. Adult clients discharged from nonhospital residential or combination

facilities also were more likely to leave treatment earlier than were adult clients discharged from

outpatient nonmethadone facilities. Adult clients whose primary expected sources of payment

were no payment, client self-payment, or Medicare/Medicaid stayed in treatment longer than did

adult clients whose primary expected source of payment was private health insurance.

Receiving treatment at women-only facilities or facilities offering child care services was

positively associated with LOS among women, after controlling for other client or facility

characteristics (Table 6.10). Some control variables were associated with LOS. Women who did

not complete high school, women whose source of referral for treatment was not the criminal

justice system, and women at nonhospital residential or combination facilities were more likely

to leave treatment earlier than were high school graduates, women referred by the criminal justice

system, or women at outpatient nonmethadone facilities. Contrary to expectations, receiving

treatment at facilities offering prenatal care or transportation services was associated with leaving
83

Table 6.7 Adjusted Odds Ratios (ORs) of Completion of Planned Treatment among

Substance Abuse Treatment Clients Aged 18 or Older at Admission Discharged

from Nonhospital Residential Facilities, Outpatient Nonmethadone Facilities, or

Combination Facilities

Independent Variable OR (95 Percent CI)

Female Gender 1.05 (0.85, 1.31)

Age at Admission 1.01 (1.00, 1.03)

Race (compared with white) 

All other races 0.82 (0.50, 1.35)

Unknown/not mentioned 1.08 (0.60, 1.92)

Education at Admission (compared with high school graduate/GED)

Fewer than 8 years 1.09 (0.51, 2.34)

8 to 11 years and less than high school graduate 0.59 (0.38, 0.93)

College/postgraduate 0.94 (0.71, 1.27)

Unknown/not mentioned 0.71 (0.31, 1.65)

Non-Criminal Justice Source of Referral for Treatment 0.34 (0.23, 0.52)

Primary Expected Source of Payment for Treatment (compared with private health

insurance, fee-for-service, or HMO/PPO/managed care)

No payment or client self-payment 0.69 (0.40, 1.19)

Medicare/Medicaid 0.59 (0.33, 1.08)

Criminal justice system 0.52 (0.27, 0.99)

Other funding 0.66 (0.32, 1.37)

Facility Type of Care (compared with outpatient nonmethadone)

Nonhospital residential 3.19 (1.71, 5.94)

Combination 1.82 (0.80, 4.12)

CI = confidence interval; GED = general equivalency diploma; HMO = health maintenance organization; OR =

odds ratio; PPO = preferred provider organization.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data

(1996–1997) and Phase II data (1997–1999).
84

Table 6.8 Adjusted Odds Ratios (ORs) of Completion of Planned Treatment among

Female Substance Abuse Treatment Clients Aged 18 or Older at Admission

Discharged from Nonhospital Residential Facilities, Outpatient Nonmethadone

Facilities, or Combination Facilities

Independent Variable OR (95 Percent CI)

Women-Only Facilities 0.76 (0.25, 2.38)

Child Care Services Offered 0.74 (0.25, 2.19)

Age at Admission 1.04 (1.00, 1.08)

Race (compared with white)

All other races 0.45 (0.22, 0.92)

Unknown/not mentioned 0.60 (0.27, 1.33)

Education at Admission (compared with high school graduate/GED)

Fewer than 8 years 0.36 (0.02, 8.35)

8 to 11 years and less than high school graduate 0.57 (0.21, 1.54)

College/postgraduate 0.87 (0.46, 1.63)

Unknown/not mentioned 1.84 (0.29, 11.62)

Non-Criminal Justice Source of Referral for Treatment 0.29 (0.09, 0.95)

Primary Expected Source of Payment for Treatment (compared with private health

insurance, fee-for-service, or HMO/PPO/managed care)

No payment or client self-payment 0.87 (0.24, 3.14)

Medicare/Medicaid 0.84 (0.30, 2.31)

Criminal justice system 0.71 (0.09, 5.64)

Other public funding 1.35 (0.39, 4.66)

Married/Common Law at Admission 0.90 (0.44, 1.82)

Have a Child/Children at Admission (compared with no child/children)

Have child/children 0.81 (0.33, 1.99)

Unknown/not mentioned 2.87 (0.89, 9.29)

Facility Type of Care (compared with outpatient nonmethadone)

Nonhospital residential 3.31 (1.12, 9.78)

Combination 3.65 (1.14, 11.67)

Presenting Substance Abuse Problem at Admission (compared with alcohol abuse only)

Drug abuse only 0.47 (0.23, 0.97)

Alcohol and drug abuse 0.72 (0.26, 2.01)

Substance not specified 2.07 (0.43, 10.00)

Prenatal Care Services Offered 3.65 (1.51, 8.84)

Transportation Services Offered 0.68 (0.30, 1.52)

Combined Substance Abuse Treatment and Mental Health Services Offered 0.37 (0.15, 0.90)

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data

(1996–1997) and Phase II data (1997–1999).
85

Table 6.9 Adjusted Hazard Ratios (HRs) of Length of Stay (LOS) among Substance

Abuse Treatment Clients Aged 18 or Older at Admission Discharged from

Nonhospital Residential Facilities, Outpatient Nonmethadone Facilities, or

Combination Facilities

Independent Variable HR (95 Percent CI)

Male Gender 1.02 (0.88, 1.18)

Age at Admission 1.00 (0.99, 1.00)

Race (compared with white)

All other races 0.93 (0.77, 1.12)

Unknown/not mentioned 0.91 (0.75, 1.09)

Education at Admission (compared with high school graduate/GED or more)

Less than high school graduate 1.02 (0.90, 1.16)

Unknown/not mentioned 0.82 (0.58, 1.15)

Non-Criminal Justice Source of Referral for Treatment 1.29 (1.06, 1.58)

Primary Expected Source of Payment for Treatment (compared with private health

insurance, fee-for-service, or HMO/PPO/managed care)

No payment or client self-payment 0.64 (0.49, 0.83)

Medicare/Medicaid 0.64 (0.47, 0.87)

Criminal justice system 0.72 (0.51, 1.01)

Other funding 0.66 (0.47, 0.93)

Facility Type of Care (compared with outpatient nonmethadone)

Nonhospital residential 2.38 (1.59, 3.57)

Combination 1.94 (1.33, 2.82)

CI = confidence interval; GED = general equivalency diploma; HMO = health maintenance organization; HR =

hazard ratio; PPO = preferred provider organization

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data

(1996–1997) and Phase II data (1997–1999).
86

Table 6.10 Adjusted Hazard Ratios (HRs) of Length of Stay (LOS) among Female

Substance Abuse Treatment Clients Aged 18 or Older at Admission

Discharged from Nonhospital Residential Facilities, Outpatient

Nonmethadone Facilities, or Combination Facilities

Independent Variable HR (95 Percent CI)

Women-Only Facilities 0.34 (0.13, 0.89)

Child Care Services Offered 0.51 (0.36, 0.73)

Age at Admission 1.00 (0.99, 1.01)

Race (compared with white)

All other races 0.97 (0.71, 1.33)

Unknown/not mentioned 1.26 (0.89, 1.77)

Education at Admission (compared with high school graduate/GED or more)

Less than high school graduate 1.32 (1.07, 1.63)

Unknown/not mentioned 0.95 (0.65, 1.39)

Non-Criminal Justice Source of Referral for Treatment 1.32 (1.02, 1.70)

Primary Expected Source of Payment for Treatment (compared with private health

insurance, fee-for-service, or HMO/PPO/managed care)

No payment or client self-payment 0.67 (0.46, 0.97)

Medicare/Medicaid 0.54 (0.38, 0.78)

Criminal justice system 0.51 (0.31, 0.83)

Other funding 0.74 (0.47, 1.17)

Married/Common Law at Admission 1.11 (0.87, 1.42)

Have a Child/Children at Admission (compared with no child/children)

Unknown/not mentioned 1.15 (0.74, 1.78)

Have child/children 0.83 (0.63, 1.09)

Presenting Substance Abuse Problem at Admission (compared with alcohol abuse

only)

Drug abuse only 0.83 (0.65, 1.04)

Alcohol and drug abuse 0.77 (0.60, 1.00)

Substance not specified 0.51 (0.26, 0.98)

Facility Type of Care (compared with outpatient nonmethadone)

Nonhospital residential 4.39 (2.62, 7.35)

Combination 2.65 (1.84, 3.82)

Prenatal Care Services Offered 1.48 (1.09, 2.02)

Transportation Services Offered 1.61 (1.11, 2.34)

Combined Substance Abuse Treatment and Mental Health Services Offered 0.61 (0.47, 0.80)

CI = confidence interval; GED = general equivalency diploma; HMO = health maintenance organization; HR =

hazards ratio; PPO = preferred provider organization.

Source: SAMHSA, Office of Applied Studies, Alcohol and Drug Services Study (ADSS), Phase I data

(1996–1997) and Phase II data (1997–1999).
87

treatment earlier among women. Women whose primary expected source of payment was no

payment, client self-payment, Medicare/Medicaid, or the criminal justice system stayed in

treatment longer than did women whose payment source was private health insurance. Women at

facilities offering combined substance abuse treatment and mental health services also stayed in

treatment longer than did women at facilities not offering combined substance abuse treatment

and mental health services. 

Summary

Descriptive analyses presented in this chapter suggested that

! women were less likely than men to complete treatment at outpatient

nonmethadone or nonhospital residential facilities,

! women were more likely than men to complete treatment in facilities offering a

combination of types of care, and 

! women averaged shorter stays in treatment than men in nonhospital residential

facilities.

However, gender was not associated with completion of planned treatment or LOS in treatment,

after controlling for a number of client and organizational characteristics. In addition, receipt of

treatment at women-only facilities and at facilities offering child care services was not associated

with completion of planned treatment among women, after controlling for other client and

organizational characteristics, but both components of substance abuse treatment programming

for women were associated with longer stays in treatment. It is likely that for women, treatment

programming that specifically targets their needs is an important contributor to the positive

treatment outcomes associated with increased levels of services.
88
89

Chapter 7. Conclusions and Implications

Female substance abusers have a distinct set of issues that suggest the need for substance

abuse treatment programming for women. Gender differences in substance abuse treatment

barriers, utilization, and retention, as well as substance use epidemiology, social context, 

etiology, and physiological consequences, point to disadvantages for women. Substance abuse

treatment programming for women may include such services as child care, transportation,

prenatal care, woman-focused HIV risk reduction and mental health services, and women-only

programs that create a treatment environment focused on women’s issues.

This report extends our knowledge by providing information on factors that may impact

substance abuse treatment retention among women. Valuable new information is provided on the

effectiveness of substance abuse treatment programming for women, gender differences among

substance abuse treatment clients, availability of substance abuse treatment programming for

women, and the extent to which programming for women is associated with treatment retention.

The findings are from analyses of nationally representative data on substance abuse treatment

facilities and clients. These data from the Alcohol and Drug Services Study (ADSS) enable

consideration of treatment services across the broad range of settings in which substance abuse

treatment is delivered, as well as among diverse treatment clients in programs nationwide. 

This chapter explores the implications of these findings in key areas for policymakers, the

treatment community, and researchers.

Availability and Effectiveness of Substance Abuse Treatment Programming

for Women

Chapter 2 explored the prior research on availability and effectiveness of substance abuse

treatment programming for women. Few sources of data about availability were identified.

Literature reviewed identified experimental research that showed that child care services

increased length of stay (LOS) among women, particularly in residential treatment (Hughes et al.,

1995). Women-only treatment decreased substance use and improved employment outcomes

(Dahlgren & Willander, 1989). Mental health services also increased LOS and reduced substance

use and HIV risk behaviors (O’Neill et al., 1996), prenatal care services improved birth outcomes

among pregnant women (Carroll, Chang, Behr, Clinton, & Kosten, 1995; Elk, Mangus, Rhoades,

Andres, & Grabowski, 1998), and supplemental education sessions improved attitudes about

safer sex and increased self-esteem (Hiller, Rowan-Szal, Bartholomew, & Simpson, 1996;

Volpicelli, Markman, Monterosso, Filing, & O’Brien, 2000).

Chapter 5 examined ADSS data about the availability of components of substance abuse

treatment programming for women and reported that outpatient methadone facilities were least

likely to offer child care services, even though this type of care serves the greatest proportion of

female substance abuse treatment clients. Analyses also showed that components of substance

abuse treatment programming for women are available in a minority of treatment facilities.

Women-only facilities and child care services were associated with increased LOS (but not with

treatment completion) among women (Chapter 6). Facilities treating women only served a higher

proportion of black clients than mixed-gender facilities, and facilities offering child care services
90

served a higher proportion of female clients and clients whose treatment was paid for by

Medicaid (an indicator of poverty) than did facilities not offering child care services.

Implications for Service Delivery

Findings suggest that incorporating components of substance abuse treatment

programming for women into standard care is beneficial for women and their children. Womenonly facilities may need to expand their orientation from gender-focused to culturally competent

(Trepper, Nelson, McCollum, & McAvoy, 1997) to tap into strengths in the African-American

community that may help their clients (Hill, 1993). Such strengths may include peer sources of

community/social support (Eng & Young, 1992), religiosity and faith-based leadership (Holt,

Lewellyn, & Rathweg, 2005), extended family networks (Dilworth-Anderson, 1992), and

authoritarian parenting styles that benefit children (Taylor, Chatters, Tucker, & Lewis, 1990). 

Staff at substance abuse treatment facilities may require knowledge of different cultural

perspectives and skills to use in cross-cultural situations (Brach & Fraser, 2000). This knowledge

may be gained in a variety of ways, such as training clinical staff on how to work with different

racial and ethnic groups, recruiting clinical staff of the same race and ethnic identity as clients,

and using community health workers for outreach and health promotion activities (Campbell &

Alexander, 2002 ; Howard, 2003). Tailoring treatment programs to meet special needs of certain

population subgroups not only makes treatment more attractive to those who need it, but also

helps to address many of the logistical and pragmatic barriers to treatment faced by special

populations (Weiss, Kung, & Pearson, 2003).

Variability in services offered in addition to child care across facilities may contribute to

positive treatment outcomes for women. Facilities offering child care services were more likely to

be larger facilities and to offer prenatal care services; transportation services; and special

programs for women, pregnant women, dual-diagnosis clients, and AIDS/HIV-positive clients

than were facilities that did not offer child care services. Although analyses of retention in

Chapter 6 controlled for some of these organizational characteristics, effectiveness of child care

services should be examined in controlled studies to isolate the specific effects of child care over

and above benefits of other components of substance abuse treatment programming. 

Implications for Treatment Access

Outpatient methadone facilities may need to explore creative arrangements to increase

access to child care services for the women they serve (through vouchers, subsidies, on-site dropin care, or other mechanisms). Even among types of care that more frequently offer child care

services, the quantity and accessibility of these services was not measured. In-depth study is

needed to explore whether female clients with children who need care actually receive the services

offered by facilities, versus limited numbers of child care slots prohibiting these women from

receiving timely and appropriate child care services to facilitate their entry into and retention in

treatment. In addition, research is needed to determine whether child care services in settings such

as outpatient methadone treatment are beneficial for women, since prior research has concentrated

primarily on women in residential treatment being allowed to bring their children into treatment

with them. 
91

Poor, minority women may be the primary targets of substance abuse treatment 

programming for women. Thus, policymakers may want to create financing systems to encourage

the development, expansion, or improvement of substance abuse treatment programming for

women in order to reduce health disparities. Service delivery providers should also acknowledge

and address barriers and stressors experienced by African Americans, including discrimination

(Collins et al., 2000), single-parent households (Graefe & Lichter, 2002; Lane et al., 2004),

socioeconomic stressors (Murry, Brown, Brody, Cutrona, & Simons, 2001), neighborhood

environments (Williams & Jackson, 2005), and mistrust of medical or government systems

(Gamble, 1997). Recognizing the diversity of clients at women-only substance abuse treatment

facilities also is important because diversity in health beliefs and attitudes about substance abuse

and treatment may affect the utilization of services (Levi & Easley, 1999). Programs that employ

culturally appropriate frameworks can help substance-abusing minority women enter into

treatment programs and remain in recovery (Lewis, 2004). 

Although such approaches as women-only treatment, child care services, and other

components of substance abuse treatment programming for women may help to increase access to

treatment for women, in-depth study is needed to explore whether high-risk female clients with

more severe substance use disorder–related problems are receiving the intensity of care they need.

Better information about severity of substance abuse and actual services received is necessary to

understand the impact of substance abuse treatment programming for women on treatment access,

retention, and outcomes in field settings. It is also important to note that other treatment services

and behavioral interventions not considered here may improve treatment retention and

longer-range treatment outcomes (McLellan & McKay, 1998), including the provision of case

management (Wechsberg, 1995), education and employment training (Etheridge, Hubbard,

Anderson, Craddock, & Flynn, 1997), and comprehensive mental health services (Grella, 1997).

In addition, research is needed to identify potential moderators of effectiveness, such as facility

size, client characteristics, or quality of family and social support resources. Research also needs

to evaluate costs in relation to benefits and effectiveness of women-only treatment or child care

services. 

Implications for Treatment Providers

Women-only facilities and child care services can be crucial investments for providers in

achieving critical measures of success. However, at the provider level, if provider organizations

grow larger and more centralized to capture economies of scale, it is possible that they may not be

able to fill an adequate number of treatment slots if they serve women only. It is possible that

larger facilities may need to offer women-only programming within their mixed-gender venue, for

example, by offering women-only units, programs, workshops, or groups. The effectiveness and

implementation of such arrangements would require further study. Conversely, costs of providing

other components of substance abuse treatment programming for women, such as child care or

other services, may be prohibitive for smaller facilities with lower levels of funding. Policymakers

and providers might explore the feasibility and benefits of adding such services to existing

treatment programming.
92

Gender Differences in Substance Abuse Treatment Client Characteristics

Chapter 4 explored in detail differences and similarities between female and male

substance abuse treatment clients. Female clients were more likely to have children at admission

than were male clients. In outpatient nonmethadone treatment, which represents the largest

proportion of substance abuse treatment clients, females were less likely than males to be

employed full-time. Within this service type, females were more likely than males to live with

children but no other adult(s) at admission, to be referred to treatment by a welfare office or other

social service agencies, to use Medicaid to pay for treatment, and to be admitted for drug abuse

only. 

Implications for Treatment of Specific Populations

Providers and policymakers may be in a position to support fragile families by considering

women substance abusers’ roles as primary caretakers of children. Child care services, parenting

education and support, home visiting, and mentoring are important for addressing state policies

regarding preservation and reunification of families while ensuring children’s safety and wellbeing as women seek and receive substance abuse treatment and aftercare (Chaffin, Bonner, &

Hill, 2001; Gruber, Fleetwood, & Herring, 2001; Miller, Fox, & Garcia-Beckwith, 1999).

Furthermore, because socioeconomic status among women is a potential barrier to receiving and

completing treatment and maintaining sobriety, housing, educational opportunities, job training,

employment, insurance coverage, and financial planning and management are important services

for female substance abuse treatment clients (McLellan et al., 2003). With the recent welfare

reform legislation, it may be important to examine gender differences in benefits of treatment with

respect to economic and employment outcomes (Grella, Scott, & Foss, 2005; Luchansky, Brown,

Longhi, Stark, & Krupski, 2000; Oggins, Guydish, & Delucchi, 2001). Research also is needed to

identify barriers for women entering treatment-based vocational training and job counseling to

understand how women with substance use disorders fare in employment programs (Gutman,

McKay, Ketterlinus, & McLellan, 2003). 

Treatment Retention among Women

In Chapter 6, descriptive and multivariate analyses yielded different results regarding the

roles of gender and substance abuse treatment programming for women in treatment retention.

Descriptive analyses showed that women were less likely to complete planned treatment and

averaged shorter stays in treatment than men in residential treatment facilities, despite the greater

availability of women-only treatment and child care services in this type of care (Chapter 5).

However, despite numerous treatment barriers among women, as cited in previous literature,

multivariate analyses showed that gender was not associated with retention.

Implications for Treatment Outcomes

Because retention, and especially LOS, is related to long-term treatment outcomes

(sobriety, employment, criminality, sex risk behaviors, family preservation, etc.), the lower

completion rate and shorter average stay for women in residential treatment may be a cause for

concern. Residential treatment settings typically admit patients with greater addiction severity
93

than outpatient facilities. Due to the lack of consistent findings in this study and existing

substance abuse treatment literature, more research is needed on gender differences in all types,

stages, and levels of care. In future studies of retention disparities, special attention should be

given to how gender interacts with drug use severity.

Issues in Women’s Substance Abuse Treatment Research

As noted in Chapter 2, much of the research reported upon in the literature has relied on

analyses of small, nonrepresentative samples. Large-scale data collection efforts, such as ADSS,

have made strides in improving the data available to researchers. However, these data pose

challenges as well. 

Chapter 3 noted that many ADSS measures of programming were not defined or

standardized, and services were reported as offered, but actual exposure, receipt, and intensity of

services were not measured. An important limitation of the analyses in this report is that they are

based on cross-sectional data; thus, they represent a single snapshot in time and cannot capture the

dynamic nature of treatment service programming and utilization. Also, cross-sectional data do

not allow for causal inferences (e.g., that women-only treatment or child care services cause

longer stays in treatment). Thus, confounding factors linked to client characteristics, facility

characteristics, and retention may explain findings. Although multivariate analyses controlled for

many client and facility characteristics, data on the level of treatment need and care received were

not considered. Another limitation of the analyses is that missing information about mental illness

and pregnancy prevented examination of benefits among women with co-occurrence or among

pregnant women. 

Few studies have examined the reliability and validity or overall quality of facility

administrator reports of facility size, characteristics of client populations, costs and revenues, and

other facility characteristics through reinterview techniques or checking against other documents

and collateral sources. However, as part of ADSS, investigators conducted a detailed audit of

administrator reports of client populations and cost data (Office of Applied Studies [OAS], 2003).

They found original administrator reports on client admissions to be less in need of revision than

were data on average LOS, costs, and revenues. These data considerations suggest the need for

closely controlled data collections on both client and facility characteristics, along with validation

of client and administrator reports and other data.

Although ADSS used a structured client record abstraction data collection instrument, the

quality and quantity of data collected by programs are highly variable. Records data often

underreport drug and alcohol abuse and dependence, and some services may not be recorded if

they are not reimbursed on a unit basis (Garnick, Hodgkin, & Horgan, 2002). The data are

potentially not as rich as client interview data, are often incomplete, and vary considerably in

quality and content across programs. However, client record abstracts may yield more accurate

information about sensitive behaviors than do self-reports, which are subject to considerable bias

and potential under-reporting (Harrison & Hughes, 1997). Collecting data from client record

abstracts rather than from personal interviews also decreases the considerable costs and research

burden to clients, as well as the problems associated with recall.
94

Implications for Future Research

Because performance-based programming is a priority at the national and State levels,

more detailed service and cost information will be needed. The use of uniform client assessment

procedures, as well as the development of management information systems, will enhance

performance monitoring. Standardized measures of special programming for women are necessary

for future research endeavors. More research also is needed to establish causal relationships

between programming, retention, and longer-term outcomes. Specific analyses of especially

vulnerable populations are needed, including women with co-occurring mental illness and

substance use disorders, pregnant women, HIV-positive women, impoverished women, those with

more than one child, domestic violence and child maltreatment victims, immigrants, and other

disenfranchised racial/ethnic subgroups.

Conclusions

Substance abuse treatment programming for women is increasingly available but has not

been adequately studied. This report has presented new research that helps to fill this gap. It gives

policymakers and service providers at the Federal, State, and local levels a better understanding of

why substance abuse treatment programming for women is needed, who has access to it, and 

needs of female clients that are unique from needs of male clients. 

Several overarching conclusions emerge from the findings presented. Substance abuse

treatment programming for women is beneficial for women and their children. Availability of

such programming appears to be limited, despite positive associations with LOS in treatment. In

multivariate analyses, gender was not associated with retention.

On the other hand, important differences between men and women were identified in

descriptive analyses. Women in residential facilities exhibited lower levels of retention than men.

In all types of care, female clients were more likely to have children at admission than males. In

outpatient nonmethadone treatment, females exhibited lower levels of socioeconomic status than

did males. 

High-risk populations (women who are homeless, mentally ill, HIV positive, or violence

victims) may need more intensive and specialized services. For example, a small pilot study in

South Carolina found that rural HIV-positive women benefitted from a peer counseling

intervention to help them access and begin substance abuse treatment (Boyd et al., 2005). Women

with substance use and mental disorders may experience additional economic, social, and health

problems that may adversely affect their ability to access and remain in treatment. However,

providing treatment services to these vulnerable populations presents a difficult challenge to

treatment providers because of the intensive, lengthy treatment required. 

Large national datasets, such as ADSS, are available for additional study. Such datasets

provide policymakers and researchers with an important base from which to study substance

abusing populations and the systems providing services to these populations. A key implication of

this report’s analyses is that improvement of quality of data could come from standardizing and
95

defining measures. Clear definitions are needed for assessing clients and for defining the types of

services they receive.

Managed care for substance abuse treatment services has shifted treatment from inpatient

to outpatient treatment settings, thus bringing focus to outpatient nonmethadone and outpatient

methadone facilities as settings where large proportion of women are served. Health economics

research is needed to conduct cost analyses in these two settings. More detailed information about

women, women’s services, and retention in these settings also is needed.

Although more research is needed to determine causality of associations and to examine

special populations of women, this report clearly shows that women in substance abuse treatment

have needs that are unique and that components of substance abuse treatment programming are

positively linked with treatment retention, after controlling for many potential confounders. It is

hoped that the research presented here will help to inspire increased and improved policies and

services and new research that will continue to improve the lives of women and their children.
96

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Campbell, C. I., & Alexander, J. A. (2002). Culturally competent treatment practices and ancillary

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Appendix: Statistical Methods and Limitations of the Data

This section describes detailed analytic methodology used in the report. Additional

limitations of the data are also discussed.

Suppression Criteria for Unreliable Estimates

Minimum nominal sample size suppression criteria (n = 5) were used that protect against

unreliable estimates caused by small nominal sample sizes. To maximize reliability and minimize

the need to suppress results, variable categories generally were collapsed where unweighted cell

counts were less than 5.

National Facility Rates

For each client characteristic reported by facilities (i.e., gender, race/ethnicity, age, and

payment source) in Chapter 5, an individual facility rate was calculated by dividing the number of

active clients with each characteristic by the total number of active clients for each facility. Next,

a national facility rate for each characteristic was calculated by summing individual facility

percentages and dividing by the number of facilities with active clients reporting the characteristic

across all facilities. The prevalence of selected facility characteristics (type of care, size,

ownership, special programs, and services offered) was calculated as percentages of the number of

facilities overall.

Because of this methodology, rates discussed in this report are not strictly comparable with

percentages of clients at facilities reported by other data sources. Rates represent an average of

percentages reported by facilities, regardless of the number of clients each facility served. This

calculation underestimates the true proportions of client characteristics among sampled facilities

with large numbers of clients and overestimates the proportions among sampled facilities with

small numbers of clients. However, estimates for some client characteristics reported by facilities

are similar to those reported by other national studies of substance abuse treatment clients.

Multivariate Analyses

Treatment completion and length of stay (LOS) were modeled in a series of multivariate

analyses in Chapter 6. Variables of interest were analyzed separately and together with various

combinations of control variables. Findings were consistent across various models containing

different sets of variables, indirectly implying that the models are stable.

Because many prior studies examining retention analyzed clients separately by type of care

received, descriptive analyses in the present study were stratified by type of care. Multivariate

analyses were conducted on the full samples of adult clients or adult female clients to preserve

these large samples. Accordingly, three dummy variables were included in the models indicating

treatment at residential facilities, outpatient nonmethadone facilities, or facilities offering a

combination of types of care.
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Two final comprehensive models analyzed (1) treatment completion or (2) LOS as a

function of gender, controlling for facility type of care, age at admission, race, education at

admission, primary source of referral to treatment, and primary expected source of payment for

treatment. Correlations between organizational characteristics were calculated to test for

multicollinearity of variables prior to modeling and to test assumptions about relationships

between these characteristics. Although many organizational characteristics were significantly

correlated, Pearson product-moment correlation coefficients were relatively low (range = -0.09 to

0.40), indicating that multicollinearity was not an issue in the analyses. Therefore, all

organizational characteristics were included in one model for treatment completion and one model

for LOS. These additional two final comprehensive models analyzed retention as a function of

organizational characteristics of interest, controlling for facility type of care, client age at

admission, client race, client education at admission, primary source of referral for treatment,

primary expected source of payment for treatment, marital status at admission, having children at

admission, type of presenting substance abuse problem at admission, and treatment at facilities

offering prenatal care services, transportation, or combined substance abuse and mental health

treatment services.

Analyses of LOS used survival analysis (specifically, Cox’s proportional hazard regression

analysis), which considers situations in which (1) a dependent variable represents a time to a

terminal event and (2) the duration of the study is limited in time. In this analysis, the terminal

event was discharge from treatment. Survival analysis can include both censored and noncensored

observations. An observation is considered censored by the end of the study period if the terminal

event had not yet occurred or if the observation was followed up to a certain time point, after

which there was no further information on the client. ADSS provides information on the duration

of stay in treatment for all subjects from the beginning to the end of the observation period. For

the purposes of this analysis, the time of study was determined to be 3,000 days, and observations

with a longer stay in treatment than 3,000 days were considered to be censored.

In Cox’s hazard regression analysis, it is assumed that (1) a hazard function is constant

over time and (2) all deviations are random. Under the assumption that hazard function is

constant, it is possible to say that a higher hazard ratio (HR) suggests that clients in the “exposed”

group stay in treatment a shorter time than the comparison group. Fitting the models was assessed

using criteria provided in SUDAAN® Survival Analysis (RTI International, 1995) output as

follows:

1. -2*normalized Log-Likelihood with = 0.

2. -2*normalized Log-Likelihood for a full model.

3. Approximate 2 (-2Log-Likelihood Ratio).

Target Population

An important limitation of the Alcohol and Drug Services Study (ADSS) estimates of

substance abuse treatment facility and client characteristics is that they are designed only to

describe the target populations of the study: (1) active public and private substance abuse

treatment facilities and (2) clients discharged from substance abuse treatment facilities. Although

12,387 facilities and 2.2 million clients are represented by these populations, ADSS excludes

some important and unique subpopulations that may have very different characteristics. For
103

example, the Phase I survey excludes halfway houses without paid counselors, which may have

significantly different client and facility characteristics. Client records from hospital inpatient

facilities are not included in Phase II and have been shown to involve shorter stays in treatment.

Also excluded are client records from facilities in which 100 percent of clients were treated for

alcohol abuse, a population with different client characteristics and retention rates.

Screening and Interview Response Rate Patterns

The Phase I screening facility response rate was about 79 percent, and the interview

response rate was about 91 percent. Rates of nonresponse ranged from 5 percent among

nonhospital residential facilities to 12 percent among outpatient, almost exclusively alcohol

facilities.

Item Nonresponse

Among Phase I facilities, item response rates were above 98 percent for most

questionnaire items. About 80 percent of the 240 items on the facility questionnaire had less than

1 percent missing data, 15 percent (35 items) had between 1 and 10 percent missing values, and

only 5 percent (12 items) had between 20 and 25 percent nonresponse. Logical imputations,

imputations using external sources, and imputations using statistical methods were used to fill in

missing values for key variables. Statistical methods included two nondeterministic methods:

random regression (Montaquila & Ponickowski, 1995) and random within-class hot deck (Kalton

& Kish, 1984). Imputation was performed to blocks of items at a time—point-prevalence counts,

admissions, and other items. Within each block, missing totals were imputed first, followed by

imputation of missing components of the total to produce internally consistent responses.

In Phase II, several items required data that could not be ascertained from the client

discharge abstract. To address this, variables with 15 percent or more missing data for the total

sample, or 25 percent or more missing data for one of the treatment service types, were excluded

from analyses of client characteristics in Chapter 4. For example, ethnicity was not ascertained for

26 percent of the total sample and was not included in the analyses. Lifetime use of alcohol also

was not ascertained for 7 percent of the total sample, including 29 percent of females discharged

from methadone treatment, and was not included in the analyses. In addition, because 31 percent

of records for female clients discharged from outpatient nonmethadone or nonhospital residential

treatment were missing data about pregnancy at admission, planned analyses about pregnancy

could not be conducted.

Validity of Facility Administrator Reports

Estimates of the availability of substance abuse treatment programming for women in

Chapter 5 are based on facility director reports of client and facility characteristics, and their value

depends on respondents’ truthfulness and accuracy. No studies have been published to address the

validity and reliability of facility administrator reports. Director, record, and client data may be

inconsistent because program directors may have inaccurate or incomplete information about the

logistics of their programs.
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