28

The National Rural 

Alcohol and Drug 

Abuse Network 

Awards for 

Excellence 2004

Submitted and Award-Winning Papers

TAP 28

Technical Assistance Publication Series

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

THE NATIONAL RURAL ALCOHOL 

AND DRUG ABUSE NETWORK AWARDS 

FOR EXCELLENCE 2004 

Submitted and Award-Winning Papers

Technical Assistance Publication (TAP) Series

28

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857
Acknowledgments

The content of this document was prepared 

for the Substance Abuse and Mental Health 

Services Administration (SAMHSA) by the 

American Institutes for Research (AIR) 

under contract number 270-00-6400, task 

order number 270-00-6403, with SAMHSA, 

U.S. Department of Health and Human 

Services (DHHS). Hal Krause served as 

the Government Task Order Officer. The 

publication was formatted and prepared 

for publication by JBS International, Inc., 

under the Knowledge Application Program 

(KAP) contract number 270-04-7049 with 

SAMHSA, DHHS. Christina Currier served 

as the Center for Substance Abuse Treatment Government Project Officer (GPO). 

Andrea Kopstein, Ph.D., M.P.H., served as 

the Deputy GPO.

Disclaimer

The views, opinions, and content of this 

publication are those of the authors and do 

not necessarily reflect the views, opinions, 

or policies of SAMHSA or DHHS. 

Public Domain Notice

All papers appearing in this document are 

in the public domain and may be reproduced or copied without permission from 

SAMHSA. Citation of the source is appreciated. However, this publication may not

be reproduced or distributed for a fee without the specific, written authorization of 

the Office of Communications, SAMHSA, 

DHHS.

Electronic Access and Copies 

of Publication

This publication may be accessed electronically through www.kap.samhsa.gov. For 

additional free copies of this document, 

call SAMHSA’s National Clearinghouse 

for Alcohol and Drug Information at 

(800) 729–6686 or (800) 487–4889 (TTD).

Citation

Cite individual paper and contributing 

author(s) as follows: Author list (Last name, 

First name). “Paper Title.” In The National 

Rural Alcohol and Drug Abuse Network 

Awards for Excellence 2004, Submitted and 

Award-Winning Papers. Technical Assistance Publication (TAP) number 28. DHHS 

Publication No. (SMA) 06-4183. Rockville, 

MD: Substance Abuse and Mental Health 

Services Administration, Center for 

Substance Abuse Treatment, 2006.

Originating Office

Division of State and Community Assistance, Center for Substance Abuse Treatment, Substance Abuse and Mental Health 

Services Administration, 1 Choke Cherry 

Road, Rockville, MD 20857.

DHHS Publication No. 06-4183

NCADI Publication No. BKD552

Printed 2006
iii

Contents

Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Creating and Sustaining an Adult Drug Court: Avoiding Burial in

Grant’s Tomb

The Honorable Glade F. Roper, J.D., and Dee S. Owens, M.P.A.. . . . . . . . . . . . . . . . . . 1

Empower for Recovery: An Innovative Approach To Assist Sustained 

Recovery in Rural Iowa

Deborah K. Rohlfs, M.A., LMHC, CADC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Delivering a Maternal Substance Abuse Intervention Program Along the 

Rural Route

Trudee Ettlinger, Ph.D., APRN, LADC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Socio-Demographic Profiles and Treatment Outcomes of 

Methamphetamine Abusers in Rural and Urban Areas

Kazi A. Ahmed, Ph.D., and Careema Yusuf, M.P.H. . . . . . . . . . . . . . . . . . . . . . . . . . . 35

An Environmental Scan of Faith-Based and Community Reentry 

Services in Johnson County, Iowa

Janet C. Hartman, M.A., LMSW, Stephan Arndt, Ph.D., Kristina 

Barber, M.S.M., and Thomas Wassink, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Substance Abuse Among Rural and Very Rural Drug Users at 

Treatment Entry

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

Michael Townsend. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Making the Addiction Severity Index User Friendly: An Electronic 

Display of Client Outcomes Using Shareware

James E. Sorensen, Ph.D., C.P.A., James Elzey, C.P.A., CMA, and Faith 

Stuart, M.P.A., M.S.W., LICSW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Resources on Rural Substance Abuse Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Foreword

The Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental 

Health Services Administration funded the Seventh Annual Call for Papers/Awards for 

Excellence 2004 competition hosted by the National Rural Alcohol and Drug Abuse Network 

(NRADAN). The Awards for Excellence program was initiated by the late Larry Monson, cofounder of NRADAN, who sought to recognize effective and innovative models of treatment 

and prevention services for rural populations. The Awards for Excellence publication seeks 

to promote and showcase research addressing the unique and special challenges of providing treatment services to individuals in rural and frontier areas who abuse substances and 

their families. 

In response to the CSAT/NRADAN request for papers announcement, seven papers were 

submitted and subsequently reviewed by a panel of six experts on rural/frontier substance 

abuse treatment services and research. The top three papers were selected based on high 

panel ratings of award criteria, including (1) focus on salient issues identified in the Call 

for Papers (e.g., effective multiple agency rural partnerships; lower cost modalities that 

increase access), (2) innovative or responsive program approach, (3) potential for application and replication, and (4) clarity of writing and exposition. 

The first, second, and third place papers were recognized at the Twentieth Annual National 

Rural Institute on Alcohol and Drug Abuse (NRIADA) held in Menomonie, Wisconsin, in 

June 2004. The winning authors presented highlights of their papers during a special session, and CSAT presented nominal cash awards, certificates, and award plaques to each 

researcher or research team at the Opening Plenary Session on June 14, 2004. This document contains the award-winning papers, as well as the other submitted papers.

The first place paper, “Creating and Sustaining an Adult Drug Court: Avoiding Burial in 

Grant’s Tomb,” describes the effectiveness of a self-funded drug court in Tulare County, 

California; lessons learned; and disadvantages and advantages of the self-funded approach.

The second place paper, “Empower for Recovery: An Innovative Approach To Assist 

Sustained Recovery in Rural Iowa,” describes the effectiveness of a strength- and homebased substance abuse treatment and recovery support program in rural Iowa, as well as 

the challenges, problems, and solutions related to program implementation.

The third place paper, “Delivering a Maternal Substance Abuse Intervention Program 

Along the Rural Route,” describes the development and effectiveness of an indicated-level 

substance abuse prevention program for lower income mothers living in rural Vermont, as 

well as the lessons learned and recommendations for improving implementation.
vi

The other four submitted papers address demographic and treatment outcomes of individuals who 

abuse methamphetamine, faith-based and community reentry services, people in rural and very 

rural areas who use drugs, and an electronic version of the Addiction Severity Index (ASI). 

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

Acting Deputy Administrator

Assistant Surgeon General

Substance Abuse and Mental Health Services Administration

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

Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

NRADAN Awards for Excellence 2004


Creating and Sustaining an Adult 

Drug Court: Avoiding Burial in 

Grant’s Tomb*

The Honorable Glade F. Roper, J.D. 

Dee S. Owens, M.P.A.

Contact information: 

Glade F. Roper, Judge

Superior Court

Tulare County, California

87 East Morton Avenue

Porterville, CA 93257

Phone: (559) 782–4710 

Fax: (559) 782–4805 

Dee S. Owens, M.P.A.

Director, Alcohol-Drug Information Center

Indiana University

705 East Seventh Street

Bloomington, IN 47408

Phone: (812) 855–5414 

Fax: (812) 855–4465 

Area of focus: Rural drug court and/or criminal justice programs that have demonstrated 

effectiveness in reducing recidivism and increased positive outcomes in key areas of life/

personal adjustment.

Abstract

Drug Courts are effective at reducing criminal recidivism and motivating addicted people 

to embrace the recovery process. State and Federal grants have enabled jurisdictions to 

create and operate Drug Courts, which have been effective in reducing drug use and crime. 

However, when the grants expire, some Drug Courts close while others struggle to obtain 

funds for ongoing operation. The Tulare County, California, Adult Drug Court was created 

without grant funds and continues its operation without programmatic government support by using existing resources and requiring that participants pay the cost of treatment. 

Although this seemed implausible at the outset, experience has demonstrated that addicted 

people can and will pay the cost of their own treatment and graduate successfully from a 

Drug Court program.

The Court encourages success with rewards and imposes penalties only as necessary. 

Rewards are either donated by private individuals or groups or purchased at very little 

cost; these incentives are largely symbolic in nature but very effective. Centralized drug 

testing that is paid for by the participants has been implemented for uniformity and for 

consistent application to the entire population. Modifications were made to increase the 

efficacy of the program without additional cost to taxpayers. A 3-year outcome study 

showed that fewer than 5 percent of graduates were convicted of new drug offenses.

*This paper is written from Judge Roper’s perspective, and much of the information presented is not in research or 

record but represents the judge’s opinion based on personal experience. Statements that are not supported in the 

research literature, or otherwise documented, are referred to as conclusions or actions of “the Court,” which refers to 

the Honorable Judge Roper and his Tulare County Adult Drug Court.
NRADAN Awards for Excellence 2004



Introduction

The success and benefits of a specialized 

court process for nonviolent, drug-addicted 

offenders are well documented and widely 

known. Numerous studies (Belenko, 2001; 

Hora, Schma, & Rosenthal, 1999; Lessenger, Lessenger, & Lessenger, 1999) have 

shown that when such offenders are incarcerated after conviction, recidivism is the 

norm rather than the exception. According 

to a U.S. Department of Justice study, in 

1983 50.47 percent of drug offenders were 

rearrested for a new offense within 3 years 

of release from custody. By 1994 that number had grown to 66.7 percent (Langan & 

Levin, 2002, p. 11). As drug arrests and 

convictions increased more than 10 times 

between 1980 and 1996, penal facilities 

have exceeded maximum-designed capacity. 

(See figures 1 and 2.) Continuing 

budget constraints have made construction 

of new jails and prisons difficult, while the 

advisability of constructing them has been 

actively debated. An increasingly strong 

voice contends that the policy of incarcerating addicted people is not only unacceptably costly but is also poor social policy (see 

www.ncadd.org and www.jointogether.

org). Otherwise nonviolent addicts may 

be housed with violent antisocial offenders who teach the addicts other criminal 

behaviors.

As the cost of incarceration has increased 

and the cost of new construction of penal 

facilities becomes prohibitive in this time 

of budget cutting, corrections officials have 

tried other methods of punishment, including home arrest, electronic monitoring, 

day reporting, and work release. Judges 

have also made unsupervised referrals to 

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

Self-funding a Drug Court program requires basic, no-frills treatment; wraparound services 

that could otherwise benefit participants may be absent. Other disadvantages include reduced 

training, no home visits, and dependence on treatment personnel to perform case management. These drawbacks are offset by public support for a self-sustaining program and freedom 

from worry about sources of future funding. Participants show a high degree of investment in 

their recovery. Any jurisdiction, no matter how poorly funded, can establish and operate an 

effective self-funded Drug Court.

0

70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02

10

20

30

40

50

60

Year

Rate per 100,000 Population

Incarceration	Rates	for	Drug-Related	Crimes

1970–2002


addiction treatment facilities. Although 

these actions marginally relieve the pressure on penal facilities, their value in either 

punishing or rehabilitating offenders is 

questionable to the Court. When all else 

fails, prisoners are simply released long 

before they complete their sentences. It is 

unacceptable to the Court to sentence a 

repeat offender to a year in custody only to 

have the convicted person released after 

3 months and rearrested shortly thereafter 

on new charges. Such early releases send 

the message that there is no clear consequence for undesirable behavior and in fact 

may reinforce the very behavior that society 

attempts to extinguish by incarceration. 

This revolving door undermines the integrity of and public confidence in the criminal 

justice system.

Addiction treatment courts, commonly 

called Drug Courts, were created in 1989 

in Dade County, Florida, as an alternative 

to pronouncing unenforceable sentences of 

incarceration and with the goal of sending 

defendants to effective addiction treatment. 

The success of the early Drug Courts led to 

their rapid spread across the country. By 

November 2003, 1,093 Drug Courts were 

operational, including specialized courts for 

juveniles and tribal members, and 414 were 

in planning stages (American University, 

2003). Other Family or Dependency Drug 

Courts have been created for parents who 

have neglected or abused their children, 

resulting in the children being detained by 

child protection agencies. When drug use 

by the parents is the root of the problem, 

there may be insufficient evidence to justify 

the filing of criminal charges, but the drug 

use should be addressed or the abuse and 

neglect will likely continue. Family Drug 

Courts allow the court to address the addiction so that the children can ultimately be 

returned to a stable, drug-free home.

Although specific methods vary, all Drug 

Courts use the same basic approach. 

Offenders with drug addictions are identified by themselves, by law enforcement, or 

by the court and assessed by qualified counselors for amenability to treatment. Instead 

of being sent to jail or prison, they are 

referred to treatment programs and closely 

supervised by court personnel. Offenders 

may be referred to treatment prior to entering a plea, or they may be sent to treatment 

as a term or probation after pleading guilty. 

They are tested for drug use frequently, and 

sanctions are imposed for deviating from 

Creating and Sustaining an Adult Drug Court

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

Juvenile

Adult

0

1970 1975 1980 1985 1990 1995 2000

500,000

 Number

1,000,000

1,500,000

Year

Drug Arrests by Age

1970–2002
NRADAN Awards for Excellence 2004



the treatment prescribed. The judge is a 

critical part of the process, and most Drug 

Courts require participants to return to 

court frequently to report on their progress. 

In addition to negative sanctions for violations, positive rewards are bestowed for 

milestones of progress. Treatment 

providers, probation officers, county addiction personnel, or specialized Drug Court 

caseworkers closely supervise the participants. Drug Courts are regular courts that 

adopt the caseloads and methodologies of 

addiction treatment.

Although the success of Drug Courts has 

been remarkable (American University, 

2003; Belenko, 2001), the cost of implementing them is always a challenge. Placing 

offenders in treatment programs saves the 

cost of incarceration, but the treatment cost, 

usually a fraction of that for jail or prison, 

still must be paid. For example, in California it costs approximately $26,000 to incarcerate one person for 1 year in the State 

prison system, whereas the cost of a year 

in a county jail varies between $12,500 and 

$40,000 (California Department of Alcohol 

and Drug Programs & the Judicial Council 

of California, 2002, p. 15). Effective addiction treatment can cost as little as $3,000 

for 1 year. In addition, testing and supervision are critical elements of a Drug Court, 

and each incurs a significant cost.

The cost of starting a Drug Court can 

be considerable, and courts commonly 

apply for State or Federal grants to cover 

costs. The U.S. Department of Justice 

awards competitive grants, providing up 

to $300,000 to reimburse costs for startup, 

implementation, or enhancement within the 

first 3 years of operation of a Drug Court. 

Some State agencies have provided grants 

to assist in implementing or enhancing 

Drug Court operations. For example, in 

1995, Oklahoma established the first Stateoperated Drug Court in the Nation, blending both State and Federal funding and 

incorporating ASAM (American Society of 

Addiction Medicine) standards into statute.

Once their grants expire, many Drug 

Courts are threatened with closure because 

replacement funds are often not available. 

Some courts have actually closed when 

grant funds ran out. Other jurisdictions 

wish to create a Drug Court but are unable 

to qualify for a grant or lack the resources 

to write a competitive application. The 

experience of the Tulare County, California, Superior Court demonstrates that a 

successful Drug Court can be created and 

sustained without external government 

funding. More than a year after the Drug 

Court had been in operation, the county 

did receive a Federal grant. However, the 

long-term sustainability of the Drug Court 

was not ensured in the grant structure. The 

principles discussed in this paper allowed 

the Drug Court to remain in operation. 

Program Origins

Tulare County is located in the San Joaquin 

Valley in the center of California and is 

rural in character. It is routinely the first or 

second most productive agricultural county 

in the Nation; in 2001, Tulare secured the 

number-one position as the leading county 

in the Nation and reached $3.49 billion in 

agricultural value (California Department 

of Food and Agriculture, 2002, p. 4). Much 

of the agriculture is dependent on migrant 

farm workers, most of whom live at a subsistence level of income. Many residents live 

in poverty, with 23.9 percent of the population and 18.8 percent of families below the 

poverty line. Out of the total number of 

people living in poverty, 32.6 percent are 

under the age of 18 and 10.5 percent are 65 

or older, leading to significant social problems that tax county government (Tulare 

County, California, 2000; California Department of Finance, 2004). Rates for teenage 

pregnancy are 77.2 per 1,000 teens and are 

the highest in the State (California Department of Health Services, 2004, p. 51), and 

8.6 percent of residents receive public aid 

(U.S. Census Bureau, 2000). Unemployment hovers around 20 percent at times, 


especially during economic downturns or 

agricultural events, such as freezes that 

harm the crops and decrease the need for 

agricultural workers. In March 2004, the 

unemployment rate was 18.5 percent, compared to 6.7 percent for California and 6 

percent for the Nation (California Employment Development Department, 2004).

The court noticed that, beginning about 

1990, Tulare County experienced a rapid 

increase in arrests for drug offenses, principally due to the influx of methamphetamine 

(meth) into the county. Methamphetamine, 

which has numerous street names including 

“speed” and “crank,” is an illicit stimulant 

that is highly addictive. It is relatively easy 

to manufacture locally with readily available chemicals, as opposed to cocaine and 

heroin, which require importation of substances usually grown outside the country. 

With an investment of $5,000, meth dealers 

can quickly turn a profit of up to $100,000, 

according to addicts in the Drug Court. The 

addictive properties of methamphetamine 

rapidly ensnared people of all ages throughout the county. The courts sentenced these 

drug offenders, many of whom were seriously addicted to methamphetamine, to jail 

in increasing numbers. As inmate populations grew, the jail facilities were unable 

to accommodate them all, and prisoners 

were released early from their sentences. 

More serious offenders who had been sent 

to the State prison were returned to Tulare 

County on parole, pursuant to State law. 

It is well known that many drug offenders 

are arrested for new drug-related charges 

within 3 years of release from jail or prison; 

the California arrest rate for Drug Court 

graduates after 2 years is 85 percent less 

than their arrest rate for the 2 years prior 

to entering the Drug Court (California 

Department of Alcohol and Drug Programs 

& the Judicial Council of California, 2002, 

p. 14). As judges became aware that the 

same people were returning to court time 

after time, it also became obvious that the 

standard practice of incarcerating addicts 

was a poor use of public funds. A high-level 

meeting was held in 1995 involving law 

enforcement, judiciary, county government, 

and mental health officials. A judge and 

officials from a neighboring county presented the concept of a Drug Court and provided convincing testimonials of the success 

of the Drug Court in their county. Many 

who attended the meeting were excited 

about the concept, and a series of further 

planning meetings was held in which there 

were mixed support and opposition for 

establishing a Drug Court. Although there 

was a high level of support from the court, 

the probation department, local treatment 

providers, and the mental health department, the general feeling was that no funds 

were available with which to implement a 

Drug Court.

It was the perspective of the court that 

no additional judicial resources would be 

required, since the defendants would be 

either involved in the Drug Court or proceeding through the normal criminal 

justice process. If only a few defendants 

opted for Drug Court by pleading guilty 

without proceeding to jury trials, a great 

deal of court time would be saved, not to 

mention the reduction in recidivism and 

renewal of lives as promised by the experience of the neighboring county. A probation 

officer was assigned to each division of the 

court, and these probation officers were 

willing to take on the additional burden 

of administering the Drug Court. 

A major obstacle was funding treatment. 

Although the Tulare County Alcohol and 

Other Drug Program administrators 

expressed support for the concept, they 

indicated that they had no funds to contribute to the provision of treatment. Despite 

the fact that four alcohol-rehabilitation 

programs existed, providers said there 

was very little expertise in treatment for 

non-alcohol drug addiction in the county. 

The owner of the local program for drivingunder-the-influence-of-alcohol offenders 

was involved in the Drug Court planning 

Creating and Sustaining an Adult Drug Court
NRADAN Awards for Excellence 2004



sessions and proposed that participants 

be sent to this program, with some modifications made, and pay the cost of their 

treatment. At first this seemed unrealistic, as many people in the county with 

untreated addiction are destitute. The 

argument was that, if addicts are paying 

up to $200 per day for drugs, they could 

afford to pay $50 per week for treatment. 

The difficulty with this concept was that 

they were stealing, prostituting, or selling 

drugs to finance their drug use, all of which 

behaviors the court wanted to eradicate 

rather than encourage. However, another 

treatment provider, himself in recovery, 

indicated that such behaviors are inconsistent with the process of recovery and that 

addicts would not steal, sell drugs, or prostitute to pay for recovery. Another judge 

from a neighboring county with experience 

in a Drug Court laughed out loud when 

presented with that idea, saying, “Addicts 

are not going to waste their money from 

stealing on treatment!”

With no other resources to draw upon, the 

Court was faced with the harsh reality of 

either starting the program by requiring 

participants to pay for their own treatment 

or not having a Drug Court at all. Given 

those options, it seemed preferable to at 

least experiment with self-funded treatment rather than abandon the concept 

entirely. So with some judicial skepticism, 

the Drug Court began.

Potential participants were identified by 

the judges and referred to the probation 

officer for an interview in which the program was explained and background information about the defendant was obtained. 

If the probation officer determined that the 

defendant was interested in changing his or 

her life, would embrace recovery, and could 

pay the cost of treatment, the defendant 

was offered the Drug Court. A set of formal 

terms of probation was signed that constituted an agreement to comply with Drug 

Court requirements. The defendant was 

then referred back to the judge and was formally sentenced into the Drug Court.

The Court initially referred almost every 

participant to an outpatient program. The 

very few who were deemed to be unable 

to benefit from outpatient treatment were 

referred to existing residential programs. 

Those who could not refrain from drug use 

after several weeks of outpatient treatment 

were also referred to residential treatment. 

Because of long waiting lists, those referred 

to residential treatment were frequently 

required to wait in jail for several months 

until a bed became available at the residential facility. Experience and court records 

showed, however, that more than 90 percent of participants who graduated were 

able to succeed with outpatient treatment 

alone.

The original design consisted of a 1-year 

program divided into three phases. Phase 

1 treatment provided two 90-minute group 

sessions, 1 hour of individual counseling, 

and attendance at two 12-step self-help 

meetings each week. Participants came 

to court every week and showed proof of 

attending 12-step meetings on a card provided by the treatment provider and signed 

by the secretary of the 12-step group. The 

counselors assigned to the participants 

filled out a simple, one-page form reporting their progress for the week. This form 

was provided to the Court the day before a 

participant’s scheduled hearing and placed 

in the participant’s file by the court clerk.

Prior to each Drug Court session, the treatment providers met with the judge and probation officer to discuss every participant 

and appropriate responses to deviations 

from treatment. Prosecutors and defense 

attorneys were invited to attend, but 

because of understaffing and their opinion 

that supervision of the participants was the 

province of the court and probation, the district attorney and public defender chose not 

to attend. During the weekly Drug Court 

session, each participant was called up 


individually to discuss progress, make 

changes to the treatment program, and 

receive a reward for good behavior or a 

sanction for undesirable behavior. The 

counselors conducted drug testing as they 

felt necessary.

Phase 1 lasted a minimum of 2 months. 

Advancement to phase 2 required at least 

30 days clean and sober and substantial 

compliance with all treatment requirements. The only change in phase 2 was a 

2-week interval between court appearances. 

This phase lasted 3 months. 

Advancement to phase 3 reduced individual 

counseling sessions to every other week, 

with 1 month between court appearances. 

At the end of the 7 months of phase 3, if the 

participants had been clean and sober for at 

least 180 days, they were graduated out of 

the Drug Court. They remained on probation but were encouraged to apply for early 

termination of probation pursuant to the 

normal statutory scheme for all criminal 

cases.

Participants always had the option of voluntarily leaving the Drug Court and accepting the court sentence that would have 

been imposed had they initially decided 

not to participate in the Drug Court. They 

were not sentenced with greater terms of 

incarceration because they attempted to go 

through treatment. Even those who were 

terminated from the program were given 

the same sentence that they would have 

received without trying the Drug Court. 

Very few were terminated involuntarily, 

as the goal of the Drug Court was to keep 

the participants engaged in treatment as 

long as they were making progress. This 

was a subjective decision that was made by 

the judge after input from the treatment 

program and the probation officer. More 

frequently, participants voluntarily asked 

to be sent to jail or prison because they 

were unwilling or unable to continue to pay 

the cost of treatment or to abide by the program’s strict requirements. In the Court’s 

experience, about one-quarter of those 

beginning the Drug Court were terminated 

prior to successful graduation.

Subsequent Refinements and 

Lessons Learned

Although there was very little prior experience with drug addiction treatment in the 

county, the Drug Court in Tulare County 

proved immediately effective in reducing drug use and motivating people to 

accept and embrace recovery. Experience 

quickly taught that many changes were 

necessary to improve outcomes. Because 

the treatment was based on the classic 

12-step model, mandatory attendance was 

increased to five meetings per week until 

the participant acquired a sponsor and then 

attendance was reduced to four meetings 

per week for the duration of the program. 

More emphasis was placed on completion of 

the 12-step process, and participants were 

expected to know the meaning of each step. 

Phase 1 was increased to 13 weeks, phase 

2 remained at 13 weeks, and phase 3 was 

reduced to 26 weeks.

Additional treatment providers have 

approached the Drug Court, wanting to be 

involved. Initially, all were accepted until 

it became apparent to the Court that some 

programs were substandard, so standards 

were adopted that all participating treatment programs must meet. They must 

have certified treatment counselors, and 

although most programs are certified by 

the State, some faith-based programs participate that have chosen not to be certified 

and regulated by the State. The Court and 

probation department watch these programs and procedures closely.

Inconsistencies in drug testing were a 

concern, and different programs tested 

at different frequencies. There were also 

allegations that some counselors were not 

observing the collection of samples. In 

addition, different laboratories provided 

Creating and Sustaining an Adult Drug Court
NRADAN Awards for Excellence 2004



reports in varying formats that proved difficult to decipher in a court review. Differing 

cutoff levels among laboratories meant that 

participants were treated unequally after 

using drugs. To overcome this disparity, a 

protocol was developed and a solicitation 

was issued for proposals from testing agencies. One testing agency was selected, and 

now all participants are sent to a central 

testing location.

For drug testing, each participant is 

assigned to a group based upon the phase of 

treatment. Every morning, each participant 

is expected to call the testing agency before 

9 a.m. and listen to a recorded message that 

indicates which groups are to be tested that 

day. The short message lasts less than 30 

seconds, so it requires only a very brief call. 

If their group number is announced, participants must report to the testing facility 

and leave a urine sample before 5 p.m. that 

same day. The hope is that participants will 

begin each day focusing on what is required 

for recovery that day.

Originally various sanctions were imposed 

for missed tests, and according to the testing agency, up to 10 percent of participants 

failed to test on designated testing days. A 

wide range of reasons was given for missing tests, from death of relatives to malfunctioning vehicles to work requirements. 

Because testing is such a critical part of 

Drug Court supervision, the severe sanction of incarceration was finally imposed for 

missing each test, and compliance increased 

dramatically. It is explained to all participants that a positive test is viewed as a 

clinical issue indicating that some increased 

treatment should be used. Failure to test 

is treated as a behavioral issue, because it 

prevents the treatment provider from knowing whether the participant is responding to 

treatment. At present, less than 1 percent 

of participants fail to test when scheduled. 

The Drug Court judge has joked openly that 

sending people to jail for missing tests has 

tremendously improved the health of the 

participants’ relatives and their vehicles.

In addition, it is important to note that 

the Court views lying about drug use as a 

behavior issue. In cases in which a client 

does not pass a drug test, it is the act of 

attempting to mislead the counselor and/or 

the court about recent substance use that 

precipitates consequences, not the positive 

drug test itself.

A standard sanction list was adopted as 

a minimum response to deviations from 

treatment. These minimum sanctions are 

the general rule, with some agreed upward 

departure imposed for aggravated violations. The list has been modified somewhat 

over time. The philosophy of the Drug Court 

has been that behavioral issues are penalized, whereas abstinence and drug use are 

considered treatment issues. Sanctions are 

intended to encourage compliance rather 

than to punish participants. Importantly, 

sanctions are imposed as soon as possible 

to relate the sanction to the undesirable 

behavior. (See the list of progressive 

sanctions in table 1.)

It quickly became apparent to the Court 

that most participants responded more 

favorably to rewards than to negative sanctions, and the Court adopted the goal of 

helping participants feel better about themselves when they left court than when they 

came in. Verbal accolades were given freely, 

and small steps were recognized. For example, the courtroom audience was encouraged 

to applaud for milestones of sobriety, such 

as 30, 60, 90, or 180 days. As a humorous 

interlude, one participant was presented 

with a toy beach ball upon moving from 

phase 1 to phase 2. Everyone laughed, but 

when the next participant was advanced, 

he asked, “Where is my beach ball?” It 

became the standard protocol to award participants small “trinkets” for milestones, 

most of which were obtained without cost. 

For example, court personnel donate miniature bottles of shampoo or lotion and 

bars of soap from hotel stays, and these are 

presented to recognize periods of sobriety. 

Pens, pencils, key chains, and similar useful 


items that are picked up on vacation trips 

are given freely to recognize improvement.

As the success of the Drug Court has 

become apparent, other donations have 

been received and used as rewards. A 

nonprofit foundation was created with a 

board of local community leaders who support the concept of recovery rather than 

incarceration. Although donations are not 

actively solicited, the foundation has a balance of about $5,000. A business owner who 

employs a participant in a key position has 

donated $500 to purchase key rings with a 

Drug Court logo and the message “Recovery 

is a process that lasts a lifetime.” These are 

awarded to participants moving into phase 

2. The testing agency has donated mugs 

with a special Drug Court logo; these are 

presented to participants moving into 

phase 3. Rotary Clubs have donated 

T-shirts with a logo to those graduating 

from the program. Some graduates donate 

to the foundation, giving $5 to $100 for each 

year of sobriety.

The Court noted that a significant number 

of recent graduates experienced relapse, 

and counselors indicated from interviews 

that many graduates felt a sense of abandonment when involvement in the program 

ended suddenly. To remedy this, a 6-month 

“aftercare” phase was added. Following 

graduation, participants attend one aftercare group every other week, continue 

testing on the same schedule, attend four 

12-step meetings every week, and come 

to court after 3 and 6 months, after which 

they qualify for completion. The additional 

6 months of involvement reduced relapse 

and allowed a more gradual severance from 

the Drug Court—a cushioned release rather 

than a hard drop.

Table 1. Tulare County Adult Drug Court

Tulare County Adult Drug Court Minimum Sanctions

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

Second time: Sit in jury box, make up meetings

Third time: Spend night in jail, make up meetings

Fourth time: Spend weekend in jail, make up meetings

2. Missing Test or Taking

Unauthorized Medication First time: Spend night in jail, may move back a phase.

If in aftercare, 1-month extension

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

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

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

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

next phase

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

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

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

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

expulsion

6.	 Missing Aftercare Meeting Extend aftercare 1 month

Creating and Sustaining an Adult Drug Court
NRADAN Awards for Excellence 2004

10

As a further reward to the graduates, an 

annual graduation ceremony has been 

held. Prominent figures in recovery have 

been keynote speakers, including musicians David Crosby and Dallas Taylor and 

actors Larry Hagman, Mackenzie Phillips, 

and Todd Bridges. As evidenced by a full 

house, more than 1,600 people attend the 

annual graduations, which are emotional 

events for participants, family members, 

and interested members of the community. 

Dignitaries, including law enforcement officials, prosecutors, legislators, city council 

members, and mayors, routinely attend and 

shake the hands of the graduates.

The initial plan was to accept no more than 

50 people into the Drug Court and then 

evaluate success. Because the program’s 

positive effect was so immediately apparent to the Court, the population of the Drug 

Court quickly rose above 50. Because participants pay their own treatment costs, 

each additional participant only slightly 

increases the burden on the system, principally in time needed to review their cases. 

Larger populations actually improve the 

efficiency of the program because of economies of scale. For example, larger numbers 

help keep the cost of drug testing low, 

as fixed costs for the testing agency are 

spread among more clients. The treatment 

providers are able to add more counselors 

as needed to accommodate greater client 

bases. It has worked so well that currently 

more than 500 people participate in the 

Tulare County Adult Drug Court.

To have a significant impact on the county’s 

drug problem, the Drug Court tries to direct 

as many people as possible into treatment. 

A system was developed whereby the prosecutors screen every offender based on 

agreed criteria, and a summary sheet is 

filed with the criminal complaint indicating whether the offender is eligible to participate in the Drug Court. If eligible, the 

offender is offered this option at the first 

pretrial conference, thereby encouraging an 

early settlement of the case and avoiding 

additional court hearings.

The concept that was implemented with 

skepticism—that people can and will pay 

for the cost of their addiction treatment—

has flourished and enabled hundreds of 

people every year to avoid incarceration, 

embrace recovery, and return to a normal 

lifestyle. To date, there is no evidence that 

any participant has committed theft, drug 

sales, or prostitution to pay for treatment.

Outcomes

Anecdotal evidence indicated that the 

Tulare County Adult Drug Court was a 

huge success. To verify this, a physician 

and a psychologist teamed up to do an 

analytical study of the results of the first 

3 years of operations (Lessenger, Lessenger, & Lessenger, 1999). Everyone considered for placement in the Drug Court was 

tracked from the entrance interview to the 

close of the study period. Studied subjects 

were divided into four groups for research 

purposes, depending on their involvement 

in the program: those who were considered 

for the Drug Court but found unsuitable, 

those who were found suitable and offered 

the Drug Court but declined to participate, 

those who began participating in the Drug 

Court but either voluntarily left to do custody time or were terminated involuntarily, 

and those who successfully graduated from 

the Drug Court. 

As shown in table 2, 5 percent of the graduates were convicted of new drug charges 

during the course of the 3-year study 

period, compared to nearly 41 percent of 

those who were rejected for admission into 

the Drug Court and 27 percent of those who 

were found suitable but declined. In interpreting these figures it is important to note 

that those who graduated were at liberty 

the entire 3-year period (except for some 

short-term incarcerations, never more than 

a few days, as sanctions). Those who were 

rejected or who declined spent all or a large 

part of the 3-year period in custody, where 

they were much less likely to be arrested for 

new drug charges.
11

As funds are not available to conduct a 

followup study, there is no current information about outcomes after 7 years of 

operation. It is the sense of the Drug Court 

team (composed of the judge, probation 

officers, and treatment providers) that this 

trend has continued but that recidivism 

of the graduates has probably doubled to 

about 10 percent, which is consistent with 

other studies of Drug Courts around the 

Nation. In California, two of three parolees 

are rearrested before parole is completed, 

within 18 months of release (Warren, 2003). 

The stark difference between a 10-percent 

recidivism rate for Drug Court graduates 

and a high recidivism rate for incarcerated 

offenders demonstrates the need for more 

Drug Courts. 

Although adequate data to establish a 

direct connection do not exist, it is interesting to note that incarceration rates for drug 

offenses began a sharp drop about 1997, as 

shown previously in figure 1. This is about 

the same time that Drug Courts began to be 

well established in this country. It appears 

to the authors that Drug Courts have had 

a strikingly salutary effect on the drug 

problem.

Disadvantages of the 

Self-Funded Approach

Publicly funded Drug Courts have the 

advantage of much greater supervision of 

participants. These courts are frequently 

able to hire coordinators and case managers who see the participants frequently and 

make home visits to ensure that they are 

in full compliance. These courts also enjoy 

the full participation of prosecutors and 

defense attorneys, who add valuable perspectives to the Drug Court team. The selffunded approach, as that of Tulare County, 

requires treatment providers to do much 

of the case management, along with the 

probation officers. In jurisdictions in which 

a probation officer is not available to dedicate to the Drug Court, treatment providers 

would be required to perform all case 

management functions.

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

Outcome

Rejected

N=111 Persons*

Declined

N=74 Persons*

Terminated

N=122 Persons*

Graduated

N=142 Persons*

Number

(Percent)

Number

(Percent)

Number

(Percent)

Number

(Percent)

Nondrug Convictions 27 (22.2) 15 (20.0) 21 (16.5) 4 (2.8)

Drug Convictions: 47 (40.7) 20 (27.0) 27 (21.5) 8 (5.0)

— Possession 31 (27.9) 12 (16.2) 16 (13.2) 2 (1.4)

— Under Influence 14 (12.6) 8 (10.8) 9 (7.4) 4 (2.8)

— Transport 2 (1.8) 0 (00.0) 1 (0.7) 0 (0.0)

— Sales 2 (1.8) 0 (00.0) 3 (2.4) 0 (0.0)

— Paraphernalia 6 (5.4) 2 (2.7) 3 (2.4) 2 (1.4)

County Jail 42 (37.8) 24 (32.4) 30 (24.7) 5 (3.5)

State Prison 22 (19.8) 7 (9.5) 10 (8.2) 2 (1.4)

Driver License Suspension 94 (84.7) 50 (67.6) 75 (61.9) 9 (6.4)

From Lessenger, J. E., Lessenger, L. H., & Lessenger, E. W. (1999). An outcome analysis of Drug Court in 

Tulare County, California (p. 30). Porterville, CA: Unpublished report.

*Numbers do not match population totals and percentages may not total 100 due to multiple offenses/

arrests by the same person.

Creating and Sustaining an Adult Drug Court
NRADAN Awards for Excellence 2004

12

The greatest disadvantage of the selffunded approach is that many defendants 

who would otherwise be eligible to participate and are desirous of doing so are 

excluded because they cannot bear the cost 

of treatment. Many participants in the 

Tulare County Adult Drug Court are personally unable to pay for treatment initially 

but have relatives or other supporters who 

are willing to advance the cost of treatment 

for some period of time, noting to the Court 

that it is money well spent due to the high 

level of supervision provided by the court, 

which forcefully encourages compliance. 

Many family members who said they have 

abandoned hope for their relatives with 

addictions are willing to pay treatment 

costs for several months because they know 

that if participants do not comply with 

requirements, they will be immediately corrected. If these relatives return to drug use, 

the relapse will be dealt with swiftly before 

they can return to a full drug-using life. 

The Court expects this support from others 

to end within a few months of entry into 

the Drug Court because participants are 

required to obtain employment and become 

self-supporting. 

Lack of funding prevents an ongoing study 

of the outcomes and hinders Drug Court 

administrators from substantiating its success for policymakers who might otherwise 

be willing to contribute public funds. This 

setback is partly offset by the annual Drug 

Court graduation ceremony that celebrates 

the productive return to society of those 

who have graduated during the past year. 

At the ceremony, photographs of the participants at arrest are displayed next to current photographs, visually and powerfully 

showing the changes made by participation 

in the Drug Court. As related by policymakers to the judge, publicity from these 

graduations has made it clear that the Drug 

Court is a valuable asset to the county’s 

criminal justice programs.

Treatment is necessarily no-frills and 

basic, kept as inexpensive as possible. All 

counselors are State-certified and supervised by those licensed to do so, but they 

need ongoing training. Inexpensive education and training can be found at local community colleges that offer human services 

degrees with an emphasis on addiction 

treatment and through involvement in 

State continuing education programs. The 

counseling provided to participants in the 

Tulare County Adult Drug Court is worth 

far more toward recovery than the minimal 

costs they pay.

The lack of public funding also means that 

the Drug Court team is responsible for payment of ongoing training that is specific to 

Drug Courts. For example, membership in 

the National Association of Drug Court Professionals requires substantial annual dues, 

and the cost of attending its annual training conference is considerable. Expenses 

can be offset somewhat by State associations that also provide training and by 

other training opportunities. For example, 

the National Rural Institute on Alcohol and 

Drug Abuse at the University of Wisconsin offers annual training for Drug Courts, 

subsidized by the Office of National Drug 

Control Policy and the U.S. Department of 

Justice. Participants can receive scholarships to this training, including the full cost 

of travel, lodging, and tuition.

Advantages of the Self-Funded 

Approach

Despite the disadvantages previously discussed, the self-funded approach offers 

many advantages. Chief among them is the 

freedom from concern about locating the 

next funding source. The economic downturn following the September 11, 2001, 

tragedy caused some Drug Courts to close 

for lack of funding. Other Drug Court coordinators have had to scramble and spend 

many hours searching and applying for 

grants, thereby diverting them from their 

intended purpose of coordinating the Drug 

Court. Under the self-funded approach, 
13

economic downturns that result in government budget cuts will not affect the 

operation of the Drug Court. The judge and 

administrators know from where the next 

dollars will emanate. The self-funded Drug 

Court team is free to operate its court considering local needs and circumstances. The 

court can adapt quickly to local changes, 

trends, and resources. There are no reports 

and forms that must be submitted to grant 

providers or those whose political agenda 

does not include Drug Courts. The most 

significant, overriding advantage of the 

self-funded approach is that it allows any 

jurisdiction, no matter how poorly funded, 

to have a Drug Court. 

The public in Tulare County is highly supportive of the self-funded approach. The 

Drug Court is not a government program 

that uses more taxpayer dollars squeezed 

from already strapped budgets. The Drug 

Court judge and other team members can 

proudly speak about the efficacy of the 

program, all without additional cost to 

taxpayers. Service clubs and other civic 

groups are very supportive after speeches 

in which the judge relates that those who 

violated the law in the first place are paying for their own treatment. A study by 

the California Department of Alcohol and 

Drug Programs and the Judicial Council 

of California completed in March 2002 

showed that California Drug Courts saved 

taxpayers more than $43,400,000—more 

than $200,000 for every 100 participants. 

These savings are enhanced when the cost 

of treatment is borne by the participants; 

resources can then be provided for other 

services (p. 15).

Many wraparound services, such as medical 

care, employment training, vocational and 

educational counseling, housing, parenting 

classes, and childcare can be provided from 

existing government programs. Alert team 

members can make arrangements with 

such programs to give special attention to 

Drug Court participants. For example, the 

Adult School and Adult Literacy Programs 

in Tulare County found that the Drug Court 

participants are highly motivated to succeed because, barring disability, completion of their education is a requirement of 

participation in the Drug Court. If they do 

not follow through on commitments to these 

programs, they face expulsion from the 

Drug Court and incarceration. With appropriate waivers, periodic reports can inform 

the judge of progress, and any necessary 

corrective measures can be applied to put 

the participants back on the right track.

Finally, the Court’s experience has shown 

that participants value something according 

to their investment to obtain it. The Tulare 

County Adult Drug Court emphasizes to 

the graduates that they can be proud of 

the fact that they paid for their treatment 

and are responsible for their own success in 

achieving recovery. Graduates leave with 

an unprecedented feeling of pride in their 

accomplishments. Many say they have 

never done anything deserving of positive 

public recognition. For example, one man in 

his 30s stood silently for more than a minute, looking at his certificate after graduating, then looked up with tears in his eyes 

and said, “This is the first thing I have ever 

accomplished.” Most have lengthy criminal 

records and suffer feelings of worthlessness 

upon entry into the Drug Court. This lack of 

self-esteem contributes to the cycle of helplessness and hopelessness that spirals into 

ongoing and increasing drug use. Instilling a sense of pride in accomplishment, 

bolstered by paying for treatment, is a key 

element in participants’ future sobriety. 

Graduates leave knowing that their sobriety came dearly purchased, and they guard 

it closely.

Conclusions

It might well be said that those who live 

by the grant will die by the grant. Whereas 

grants can be a useful tool in creating a 

Drug Court, it is shortsighted to create a 

project without planning for sustainability 

Creating and Sustaining an Adult Drug Court
NRADAN Awards for Excellence 2004

14

after the grant expires. To avoid having a 

successful project entombed by the expiration of grant funds, sustainability must be 

considered from the inception of Drug Court 

planning. Startup grants can provide much 

needed resources to get a Drug Court off the 

ground; planning for reliance on existing 

resources, rather than using grant funds to 

create new ones, will ensure ongoing operation of a Drug Court.

Although Drug Courts funded with public resources can offer participants more 

expansive treatment and supportive wraparound services, there are tangible advantages to creating a self-supporting Drug 

Court. Basic treatment services can be provided at a reasonable cost to most eligible 

defendants, and those who graduate are 

highly motivated because of the substantial 

commitment they have made toward their 

own recovery. When economies fluctuate, 

there is stability in the program, and all 

resources can be directed toward providing 

quality services directly to the participants 

instead of concentrating on raising funds. 

Private community resources and public– 

private partnerships can enhance the 

program through voluntary donations and 

provision of many additional services for

the Drug Court.

Because participants come to court for 

regular reviews, the judge and probation 

officer can ascertain whether participants 

are complying with requirements to pursue 

education and employment goals. Those 

who successfully complete the Drug Court 

leave knowing that they have contributed 

the lion’s share toward their own recovery, 

and they tend to value it more highly than 

those to whom it was provided gratis. More 

than 1,000 people have graduated from the 

Tulare County Adult Drug Court in the past 

7 years, at very little cost to the taxpayers, 

and a great majority has avoided further 

convictions for drug offenses. For Tulare 

County, the choice of whether to have a 

Drug Court is clear. Any jurisdiction can 

create and sustain a self-supporting Drug 

Court with a little ingenuity, creativity, and 

the political will to make it succeed.

References

American University. (2003). Summary 

of Drug Court activity by State and 

county, November 7, 2003. www.

american.edu/academic.depts/spa/

justice/publications/drgchart2k.pdf

[Accessed April 30, 2004].

Belenko, S. (2001). Research on Drug 

Courts: A critical review. New York: 

The National Center on Addiction 

and Substance Abuse at Columbia 

University.

California Department of Alcohol and Drug 

Programs & the Judicial Council of 

California, Administrative Office of the 

Courts. (2002). Drug Court Partnership 

Act of 1998, Chapter 1007, Statutes of 

1998: Final Report. Sacramento, CA: 

California Department of Alcohol and 

Drug Programs.

California Department of Finance. (2002). 

California statistical abstract: Gross 

State product, income, and cost-of-living, 

section D table D-22. www.dof.ca.gov/

html/fs_data/stat-abs/sec_D.htm

[Accessed May 31, 2004].

California Department of Food and 

Agriculture. (2002). California 

agricultural statistical review. Resource 

Directory 2002. www.cdfa.ca.gov/

card/card_new02.htm [Accessed 

May 31, 2004].

California Department of Health Services 

& California Conference of Local Health 

Officers. (2004). County Health Status 

Profiles 2004 (p. 51). Sacramento, 

CA: California Department of Health 

Services. www.dhs.ca.gov/hisp/chs/

PHweek/CProfile2004/Profile2004.

pdf [Accessed May 31, 2004].

California Department of Justice, Criminal 

Justice Statistics Center. (n.d.). 

Incarceration rates for drug-related 
15

crimes, 1970–2002. www.caag.state.

ca.us/cjsc/glance/cht17.htm [Accessed 

December 4, 2003].

California Employment Development 

Department. (2004). Tulare County 

industry employment and labor force 

data. www.calmis.ca.gov/file/

lfmonth/tularpr.txt [Accessed May 31, 

2004].

Hora, P. F., Schma, W. G., & Rosenthal, J. 

T. (1999). Therapeutic jurisprudence 

and the drug treatment court 

movement: Revolutionizing the criminal 

justice system’s response to drug abuse 

and crime in America. Notre Dame Law 

Review, 74(2), 455.

Langan, P. A., & Levin, D. J. (2002). 

Recidivism of prisoners released in 1994.

Washington, DC: U.S. Department of 

Justice, Office of Justice Programs, 

Bureau of Justice Statistics.

Lessenger, J. E., Lessenger, L. H., & 

Lessenger, E. W. (1999). An outcome 

analysis of Drug Court in Tulare 

County, California (p. 30). Porterville, 

CA: Unpublished report.

Tulare County, California. (2004). In 

Wikipedia: The free encyclopedia. www.

fact-index.com/t/tu/tulare_county_

california.html [Accessed May 31, 

2004].

U.S. Census Bureau. (2000). Table DP1. Profile of general demographic 

characteristics: 2000 statistics for Tulare 

County, California. censtats.census.

gov/data/CA/05006107.pdf#page=2. 

[Accessed May 31, 2004].

U.S. Department of Justice, Office of 

Justice Programs, Bureau of Justice 

Statistics. (2003). The estimated number 

of arrests for drug abuse violations 

decreased slightly from 2001 to 2002: 

Drug arrests by age, 1970–2002. www.

ojp.usdoj.gov/bjs/glance/drug.htm

[Accessed December 3, 2003].

Warren, J. (2003, November 14). Panel 

calls prison policies costly failure. Los 

Angeles Times, p. B1.

Creating and Sustaining an Adult Drug Court

17

Empower for Recovery: An 

Innovative Approach To Assist 

Sustained Recovery in Rural Iowa

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

Contact information:

Community and Family Resources

916 Superior Street, Suite 115

Webster City, IA 50595

Phone: (515) 832–5432 

Fax: (515) 832–5432

Area of focus: Rural strength- and home-based substance abuse treatment and recovery 

support program.

Abstract

Empower for Recovery is a targeted treatment approach that has demonstrated both its 

effectiveness and successful outcomes with rural/frontier substance abusers, their families, and significant others. This home-based program provides early intervention utilizing 

DiClemente and Prochaska’s stages of change. The program emphasizes pretreatment, 

posttreatment, case management, and family services to families in whom substance abuse 

has been identified as a possible problem. Those in rural areas face unique challenges in 

obtaining and maintaining sobriety. They face issues such as geographical distance from 

services including Alcoholics Anonymous, Al-Anon, and Ala-Teen. Transportation can be 

an obstacle to obtaining and maintaining sobriety. Families often have very few resources 

for obtaining support and education surrounding substance abuse. Other issues, such as 

financial pressure, domestic violence, and Department of Human Service involvement, can 

overwhelm a family. Providing a comprehensive strength-based approach that empowers 

individuals in the families’ home results in positive outcomes. According to reported 1-year 

postdischarge outcomes, 80 percent of substance abusers maintain sobriety with this inhome program. 

Introduction

Rural Iowa. The words create the image 

of rolling cornfields and an idyllic lifestyle. 

However, a different picture is hidden 

behind that image—methamphetamine 

labs and substance abuse. The image of 

an idyllic lifestyle disguises the misery 

caused by substance abuse. Treating those 

caught up in the web of substance abuse 

is challenging, especially in rural areas. 

Those who seek help encounter many barriers. Treatment facilities can be as much 

as 100 miles away, with no public transportation available. Losing a driver’s license 

or having financial difficulties can make 

participating in treatment difficult if not 

impossible. Services to assist families of 

persons involved in substance abuse are 

also very limited. Even common support 
NRADAN Awards for Excellence 2004

18

systems such as Al-Anon and Ala-Teen are 

few and far between. Most communities 

have Alcoholics Anonymous (AA) groups, 

but they usually meet only once a week.

The challenges of achieving and maintaining sobriety are daunting. Community and 

Family Resources (CFR), a State-funded 

treatment agency located in rural Iowa, 

began to look for creative ways to overcome 

some of these barriers in their catchment 

area. 

At the same time, recognizing that solutions to problems are best decided at a local 

level, State legislators created a statewide 

Empowerment Board. This board provides 

funding for local empowerment areas to use 

creative methods to address stated needs in 

their communities. The target population 

served by these funds is families with children up through age 5 as well as pregnant 

women. The goal is to provide a safe and 

stable family environment so children can 

develop in an appropriate manner and be 

prepared for school. 

In 1999, the rural counties of Hamilton, 

Humboldt, and Wright were declared a local 

empowerment area. The counties cover 

1,592 square miles and have a combined 

population of 40,782, or 25.6 people per 

square mile. The largest population center 

has 8,176 residents. 

In the local empowerment area, substance 

abuse—especially methamphetamine 

use—was identified as a significant problem that needed an additional creative 

approach to produce better treatment outcomes. A new goal was set through creative 

planning and discussion by a multitude of 

community providers, the local empowerment group, and the executive director of 

the Empowerment Board, Ann Stewart. 

This new goal of the local Empowerment 

Board was to provide in-home services for 

families of substance abusers as well as 

those who abuse substances. The executive 

director of CFR, John Hostetler, and therapist Deb Rohlfs designed the details of the 

program services. These services would not 

be treatment specific but would assist in 

case management, premotivational services, 

posttreatment followup and support, and 

services to the family. These services would 

be provided in the client’s home, making it 

easier for the family to access the services. 

This program would work in collaboration 

with other in-home programs that provide 

services to families.

After the first year, the local Department 

of Human Services (DHS) also chose to 

participate in the program. By providing funding from the Promoting Safe and 

Stable Families Program, services were 

expanded to include children older than 

age 5. This expansion assisted families in 

achieving reunification when children had 

been removed from the home because of 

substance abuse.

Purpose

The purpose of the Empower for Recovery 

Program is to assist families in which substance abuse has been identified as a risk 

factor for the children in the home. Substance abuse in a home can create chaos 

and instability. Many studies have shown 

that children raised in homes where substance abuse occurs suffer from neglect 

and abuse at a higher rate than in the 

non-substance-using population (Semidei 

et al., 2001). When families are living in 

chaos related to substance abuse, helping 

their children with developmental activities is not a priority. The children are at 

risk of falling behind developmentally. 

According to Semidei et al. (2001), children 

raised in homes where substance abuse is a 

problem are at greater risk of experiencing 

adjustment disorders, behavioral problems, 

conduct disorders, and Attention Deficit 

Disorder. When the children enter school, 

these problems may continue, possibly for 

the rest of their lives.

To help the children, the family must 

receive help with the substance abuse 
19

issues. This program does not specifically 

identify the person who is abusing substances as the “client.” Instead, the program 

considers the whole family as being in need 

of assistance. Through this process, it is 

hoped that the person who is abusing substances will come to a point of seeking help 

and choosing to live an abstinent life style. 

Methods

A strength-based approach was chosen 

as the most effective. All families have 

strengths, but often they do not recognize 

or use those strengths to make changes. By 

first looking at their strengths, the family 

could start to use both the resources they 

had and their natural support systems to 

start to make changes. The counselor could 

then help them identify what was not working and help the family to discover better 

ways to achieve the change. The counselor 

would also act as a case manager to help 

the family access resources they still needed 

to become more successful. This assistance 

would include helping the substance abuser 

to identify and find the appropriate level of 

substance abuse service. 

This program also incorporated two theories—stages of change (Connors et al., 2001) 

and motivational interviewing (Miller & 

Rollnick, 2002). Families involved with 

this program are at all points of the stages 

of change model. Some are just starting to explore the possibility of changing, 

whereas others have made a commitment 

to change and need ongoing support. The 

concept of change as a process (Connors et 

al., 2001) can be very helpful in working 

with families. Many people relapse during 

their process of change; hope is encouraged 

when relapse is explained with the stages 

of change model. People see that a relapse 

does not necessarily constitute failure but 

can be used as a tool to examine what was 

not working and what changes must occur. 

The stages of change can also help the 

family understand the process people go 

through when trying to change behaviors. 

Families can also use the stages of change 

model as they try to change any enabling 

behaviors they may have. 

Motivational interviewing also works well 

in the context of this program. Part of 

the premise of motivational interviewing 

involves joining with the clients where they

are (Miller & Rollnick, 2002). Joining with 

the family, instead of dictating what needs 

to occur, empowers the family to find a way 

to make changes that make sense to them. 

Subjects

Involvement in this program requires a 

problem with substance abuse within the 

family system. Referrals come from many 

agencies, primarily the County’s Public 

Health agencies and the DHS. If agencies 

are working with a family, and substance 

abuse is suspected, the family can be 

referred to the program. Treatment facilities also make referrals when their clients 

are preparing for discharge. 

The Empower for Recovery Program began 

early in 2000. Referrals have continued 

to increase steadily over the past 4 years. 

Since the program’s inception, 61 families 

have received services. During screening, 

nine of the families were in crisis situations and were referred to more appropriate 

services. Thirty families have completed 

the program, dropped out, or were referred 

elsewhere.

Screening Tools

After families were referred to the program, 

a screening tool created by the empowerment coordinator was used to assess the 

family’s needs. If a person admitted having 

a substance abuse problem, a regular evaluation was completed to determine the level 

of treatment needed. An appropriate referral was made for any other areas of need 

the screening tool identified.

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Program Description 

Every family is unique and thus has unique 

needs. Empower for Recovery was developed with maximum flexibility to meet each 

family where they are and to assist them in 

achieving their goals. The main components 

of the program are intertwined and often 

overlap. As described below, the program 

has five main parts: (1) pretreatment, (2) 

posttreatment, (3) case management, (4) 

family issues, and (5) collaboration.

Pretreatment

When some families are referred to the program, the family member who is abusing 

substances is not ready to admit having a 

problem. In the stages of change model, this 

situation would be identified as a precontemplation stage. Some characteristics of 

this stage include defensiveness, resistance 

to the suggestion of a problem, lack of commitment to treatment, avoidance of steps to 

change behavior, and feeling coerced (Connors et al., 2001). 

The rest of the family may be angry and 

frustrated with the substance abuser. 

Often, a great deal of friction exists. In this 

situation, the needs of all family members 

must be addressed. The substance abuser is 

offered the opportunity to explore his or her 

substance abuse and is given permission to 

feel free to examine his or her ambivalence 

about stopping. According to Miller and 

Rollnick (2002), exploring ambivalence is 

crucial in the process of change. By allowing this exploration, resistance is lowered. 

When confrontation is used, the person 

often becomes more resistant; he or she 

does not want to be told what to do. The 

family is allowed to explore the benefits of 

the substance abuse as well as the cost to 

the family. This exploration often allows the 

family to make choices that will work for 

them. 

The family is given an opportunity to 

express its feelings. Family members 

often have conflicting feelings regarding substance abusers and their continuing substance use. They may fear for the 

health and safety of the abuser; they may 

feel anger, disappointment, and conflicting degrees of love and hate. They have 

not always had the opportunity to express 

these feelings, even to themselves. Family members are educated regarding substance abuse and addiction. They also learn 

about enabling, family systems, and the 

family dynamics often found where substance abuse is a problem. Family members develop their own plan to take care 

of themselves, and they learn ways to stop 

enabling the user. The stages of change are 

also explained to the family. They explore 

these stages in regard to changes the family might experience due to the absence 

of substance abuse. They also examine 

changes they might experience individually. Once again, the family members decide 

what changes they are willing to make. 

The program focuses on the client and his 

or her decisions, not what the counselor 

feels is the best choice for the family. Referrals to Al-Anon and other similar self-help 

programs are given. Unfortunately, such 

programs are not available in many rural 

areas, so online groups may be listed as an 

option.

Sometimes the substance abuser chooses to 

continue substance abuse. In keeping with 

the goals of this program, which include a 

safe and stable environment for the children, family members decide whether they 

can live with the ongoing substance abuse 

or whether they need to leave. If they 

choose to leave, case management services 

are available to assist. If the family chooses 

to stay, services are available to develop 

safety plans. It is hoped the families will, 

at the least, change their reactions to the 

substance abusers. At times, this change 

will also force the substance abuser to 

decide what is most important—family or 

substance use. 
21

External factors—usually involvement 

from DHS—may make the user feel that he 

or she is being forced to participate in the 

program. When a family is at this point, it 

is important for program personnel to join 

with them. This concept comes from motivational interviewing theory (Miller & Rollnick, 2002). It is important to let the family 

know the counselor is willing to start where 

the family members are and listen to what 

they want as goals. Their first goal may be 

getting DHS out of their life. If so, the counselor can discuss what would have to happen to accomplish this goal. Although they 

may have to address several issues, substance abuse is certainly one of them. Many 

substance abusers are not sure they want 

to quit at this point. As program counselors, 

we discuss with them their ambivalence. 

They must come to their own conclusion 

that they want to quit. We then can develop 

goals to help them accomplish this. Substance abusers seem less resistant to stopping the use of drugs and alcohol if stopping 

is only part of the overall plan to make the 

changes DHS is requesting. If substance 

abusers feel that the substance abuse is the 

most important issue, resistance seems to 

become greater. Once again, the substance 

abuser is given the choice to stop or not. 

However, the substance abuser must also 

be willing to accept the consequences of continuing use. If the person chooses to quit, he 

or she is given assistance to gain entrance 

into an appropriate program. Referrals to 

AA or Narcotics Anonymous (NA) are also 

given.

If substance abusers are to enter residential 

treatment, issues often arise surrounding 

making arrangements for their families. 

The Empower for Recovery Program works 

with families who have children. If the children are still living in the home, arrangements must be made for their care if the 

primary caretaker goes through treatment. 

Some programs are available for women 

who want to bring their children into treatment with them, but these programs do not 

work for all families. For some families, a 

relative or friend must be found who will be 

willing to care for the children. If the person 

seeking treatment is holding a job, arrangements also must be made at work. In addition, financial obligations must be covered 

while a person is in treatment. Sometimes, 

substance abusers—especially those who 

are single parents—can feel overwhelmed 

with all this preparation. Single parents 

often have less support and feel all of the 

responsibility. For the counselor, a fine line 

exists between doing too much for the client 

and helping the client make the arrangements. Without some assistance, however, 

some substance abusers will have a difficult 

time following through with entering residential treatment. 

If the children have been removed from the 

home already, entering residential treatment can be less complicated. However, visitation can become problematic, especially if 

the children live a long way from the treatment facility. The substance abuser cannot 

leave residential treatment to visit the children, and both the DHS and foster parents 

are often reluctant to allow the children 

to visit the treatment center. At the same 

time, it is important for clients to have visitation to promote successful reunification 

of the family. The Empower for Recovery 

counselor is instrumental in coordinating 

family visitation and encouraging future 

reunification.

Posttreatment

This program also provides posttreatment 

services. As the person nears discharge, 

the primary treatment counselor, the client, and the Empower for Recovery in-home 

counselor will sit down and discuss the 

discharge plan. Some of this discussion 

will become incorporated in the goals the 

client sets for the Empower for Recovery 

Program. When a person leaves treatment 

and goes home, more stress often occurs 

within the family. The family has worked 

around the addiction for such a long period 

Empower for Recovery
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of time that suddenly not having the addiction present can create a difficult transition 

period. Families usually need assistance 

in working through this transition period. 

Substance abusers typically become frustrated when family members do not believe 

they will change. Family members, on the 

other hand, do not know why they should 

suddenly believe someone who has consistently lied to them. The substance abuser, 

however, leaves treatment and wants to go 

back into the family and start taking back 

responsibilities that had been ignored. 

These responsibilities may include paying 

the bills and making decisions that affect 

the family. The spouse might be resentful 

about this change. The spouse may have 

handled all the responsibilities in the past 

and is now not sure about trusting the 

recovering person. Disciplining children 

also may be difficult, as children have 

learned how to manipulate the substanceabusing parent. The substance abuser also 

may have difficulties in returning to work 

and facing issues left behind when entering treatment. Attendance at AA/NA meetings may also cause conflict. The family 

sometimes resents the time spent at the 

meetings and feels the meetings are not so 

necessary. The family may see only that the 

substance abuser is taking time and financial resources to drive to meetings. 

All these stresses can become overwhelming 

and contribute to relapse. The client might 

still be in outpatient or aftercare treatment, 

but the counselors in this program find that 

the person in recovery often does not share 

these issues. The counselor often does not 

have much access to the family members 

who are not in recovery, so it is difficult for 

the counselor to address issues with the 

couple or other family members. 

For couples who are both in recovery, especially those who completed treatment at the 

same time, even more issues arise. These 

couples must rebuild their relationship. 

Often, they have not known each other as 

sober persons, and they must learn different ways to communicate, have fun, and 

spend time together. These issues are often 

brought up when the counselor is in their 

home, where these couples seem more 

relaxed and more open to discuss the issues. 

Many other issues surround the posttreatment period. Poverty frequently is seen in 

the population served by the Empower for 

Recovery Program. Even in those families 

with employed adults, low wages make it 

difficult for the family to have a balanced 

budget. Their substance abuse may have 

interfered with education and job performance (Karoll & Poertner, 2002). Many 

single parents, especially, have been on welfare for a period of time. The recent 5-year 

limit on welfare is starting to affect some 

persons. Many lack medical insurance. 

Available and affordable childcare is difficult to find. Many former substance abusers have difficulty finding transportation. 

They do not have a reliable vehicle, they do 

not have a license, they cannot afford insurance, and public transportation is very limited. All these difficulties pose challenges 

to their finding employment, because they 

are often limited to small towns that have 

few available positions (Karoll & Poertner, 

2002). The Empower for Recovery Program 

can assist clients in examining these issues 

and resolving the problems. For example, 

some programs offer short-term assistance, 

but families are often not aware of these 

programs; therefore, referrals can be very 

helpful.

Many of the women have been involved in 

abusive relationships. Surviving in these 

relationships is often more important 

to them than maintaining sobriety. The 

women feel trapped due to economic situations (Dore & Doris, 1998). Again, referrals 

made by the Empower for Recovery counselor can be beneficial. 

Frequently, a history of child abuse, both 

physical and sexual, has occurred and 

results in ongoing mental health issues. 
23

Persons in recovery often have not had positive models for parenting and therefore lack 

parenting skills (Karoll & Poertner, 2002). 

When DHS becomes involved and either 

removes their children or adjudicates their 

children as Children in Need of Assistance, 

women may become overwhelmed and find 

it difficult to maintain sobriety. Part of the 

Empower for Recovery Program is assisting 

these families, as discussed in the next component of the program—case management.

Case Management

A study conducted by Dore & Doris (1998) 

suggests that achieving and maintaining 

sobriety requires extensive support over a 

long period of time. Part of the problem in 

a rural area is finding that type of support. 

Groups in most communities can offer support, though sporadic and limited, for maintaining sobriety. However, issues other than 

not drinking or using occur, such as those 

mentioned in the previous section (poverty, 

DHS involvement, court involvement, insurance, transportation, and parenting). Usually, the persons’ families have struggled 

with these issues for years. While persons 

were abusing substances, they tended not to 

worry about paying bills, found illegal ways 

to support themselves, or ignored the problems. Other family members were left to 

try to deal with these issues on their own. 

Now that the persons in recovery are trying to develop a sober lifestyle, they tend to 

feel overwhelmed by all the issues they are 

facing. The case management component of 

the Empower for Recovery Program assists 

families in this area. 

One goal of the program is family financial independence. The family must work 

through this process and often needs assistance in reaching that goal. Some families 

have used every resource they could find 

in their area and thus have exhausted any 

further assistance. These families need help 

in learning how to develop a budget and to 

find ways to make enough money to follow 

the budget. They may need to learn living 

skills, such as learning to cook instead of 

depending on fast food. They may need to 

learn how to shop more effectively. They 

may need to look at getting job training 

or more education to obtain better paying 

employment. Some people do not have sufficient skills to maintain employment. For 

instance, they may not have learned good 

communication skills or may have difficulty in managing their emotions. After the 

persons return to the home setting, these 

issues become more evident than they were 

during treatment. Not addressing these 

issues can lead to failure in employment 

and/or personal relationships. Any failure 

at this point in their recovery can lead to 

relapse. These issues can be addressed best 

in the home situation. Referrals can be 

made to provide more assistance with areas 

in which a person lacks skills. At times, just 

offering support is helpful for the family.

Families who are struggling financially can 

be referred to appropriate agencies. Not 

all families are aware of all the programs 

for which they qualify. These programs 

can assist the family to become financially 

stable and move forward. 

Parenting is another issue that commonly is 

important early in recovery. Many families 

in the Empower for Recovery Program are 

involved with DHS. But even in the families without DHS involvement, difficulties 

often arise in parenting while sober. By 

providing services in the home, a program 

can address parenting issues in the family’s 

normal setting and normal circumstances. 

Referrals can also be made to collaborating 

agencies that provide parenting programs 

in the home.

The Empower for Recovery Program often 

discovers mental illness within the family. Mental health services are limited in 

the rural area and can be difficult for the 

families to obtain. Many families do not 

know where to start looking for help. Paying for medications may also be difficult. 

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Case management services assist in finding 

resources that enable families to receive 

the care they need. It is important for the 

Empower for Recovery counselor to have 

a background in mental health. The counselors involved in the CFR Empower for 

Recovery Program have a master’s degree 

in mental health services and are Certified 

Substance Abuse Counselors. 

Health insurance is another important 

issue. Many families do not have health 

insurance and are not aware of the programs that offer low rates for children. 

Referrals can also be made to some free 

clinics. The Empower for Recovery counselor can assist clients in finding appropriate health care for the family.

Transportation issues can hinder a family’s 

recovery. If families do not have access to 

transportation, they cannot attend outpatient services. They often have a difficult 

time making appointments with DHS, housing assistance, and other agencies. These 

services may be as much as 40 miles away. 

Families may have difficulty in finding 

someone who has 3–4 hours to spend bringing the family to the appointment, waiting, 

and coming back. Through the Empower 

for Recovery counselor, persons can receive 

assistance with transportation or find other 

transportation resources through local 

volunteer agencies. The families are often 

unable to access these resources directly 

because an agency must make referrals. 

Families learning new ways of coping in the 

early stages of recovery often find themselves in crisis. These crises can usually be 

dealt with during a phone call. All families 

are given a phone number for such crisis 

situations. At times, families will need to 

schedule an extra appointment to deal with 

a crisis.

A wide variety of other issues are brought 

up by families. By having the program 

services provided in the home and readily 

available, referrals can be made quickly, 

and assistance is readily available. 

Family Issues

Family issues can be difficult for those in 

recovery. Family members are often left 

out of the treatment process. The Empower 

for Recovery Program has found that other 

members of the family often are angry and 

frustrated. Providing services in the home 

provides an opportunity for dealing with 

these family issues. Issues surrounding 

family roles and the unspoken rules often 

found in the homes of substance abusers are 

discussed and resolved. Family members 

can gain an understanding of their enabling 

behaviors and learn ways to offer healthy 

support.

Older children often have much built-up 

anger, both toward the substance abuser 

for continuing to use and toward the other 

parent for staying in the situation. For 

example, one teen had been referred to the 

Empower for Recovery Program because 

of the poor choices she was making. As 

she started to improve, she expressed her 

anger toward her father for his continued 

promises to stop using and his continued 

return to drugs and alcohol. She reported 

being tired of “being the parent” in her family and wanted to be a “normal” teenager. 

She was also angry at her mother for refusing to leave her father and start a new life. 

Finally, she was placed in foster care at her 

request. 

Another component of the family-centered 

services is Family Team Conferencing. This 

concept was adapted from the model used 

by The Child Welfare Policy and Practice 

Group (Vincent, 2003). First, the Family 

Team concept is explained to the client. 

They can then choose whether to participate. If they chose to use a Family Team 

Conference, they decide who their support 

system includes—usually family members, 

friends, and service providers. If DHS is 
25

involved, they are also included. Those persons identified by the client are notified and 

invited to a meeting. During this time, family strengths are identified. Those invited 

can bring up concerns they have regarding 

the substance abuse and related issues. 

The entire group then develops a plan to 

assist the family in reaching the family’s 

goals and identifies who will provide what 

assistance. Safety plans are developed in 

case of relapse. This approach has proved 

to be extremely helpful. Those invited tend 

to become more involved because they have 

participated in developing the plan. The client also feels more of a sense of ownership. 

Collaboration

A very important component of the 

Empower for Recovery Program is collaboration with other agencies. To ensure nonduplicated services and provide coordinated 

case management, a strong collaborative 

network has been developed. This collaboration eliminates fragmented services and 

ensures that all programs provided to the 

family are working toward the same goal. 

Developing a strong, collaborative, wellworking relationship with other agencies 

is a process that takes time, patience, and 

persistence when starting a program like 

Empower for Recovery.

To provide helpful collaboration, meetings 

are often set with the family and all providers involved with the family. This is a more 

informal, smaller version of the Family 

Team Meeting. Releases of information are 

signed, allowing service agencies involved 

with the family to share information. The 

family is asked to share its goals. Any problems with the goal are discussed at this 

time. The family is asked what assistance 

it will need to achieve its goals. The providers then make suggestions on ways they 

believe they could help. A plan is created 

that identifies which providers will do what. 

The meeting also helps the providers speak 

with each other when working with families 

they all serve. Review meetings are set up 

on a regular basis so that movement toward 

the goals can be examined and any changes 

can be made. As a very strong component 

of the Empower for Recovery Program, collaboration not only helps address substance 

abuse issues but helps the family deal with 

underlying issues that might contribute to 

relapse. Involving service agencies in an 

integrated approach provides families with 

the tools needed for successful recovery.

Discharge

Discharge planning begins after any initial 

crisis period has passed. Often, if the referral is made during a crisis episode, this 

crisis must be resolved first. The family and 

the counselor discuss what goals the family 

would like to set. They also discuss what 

the family would look like when services 

are discontinued. This goal is reviewed 

periodically. 

Dependency on the counselor is always a 

risk in this program. The counselor must 

be aware of interactions with the family 

and encourage autonomy. If a counselor 

notices dependency starting to develop, it 

is appropriate to discuss it with the family 

and incorporate a goal of family autonomy. 

Weekly review of the cases by a supervisor 

and/or peer counselor will help the therapist to remain objective and focused on the 

mission of the program. 

Counselor Safety

When counselors go to a family’s home, the 

counselor’s safety is always in question. In 

the Empower for Recovery Program, this 

aspect is addressed by training the counselors. Basic training for safety includes a 

variety of approaches, such as safety information from other providers and referral 

sources. Also, having specific training in 

mental health and substance abuse makes 

the counselor more aware of common 

Empower for Recovery
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characteristics of those who use specific 

drugs and individuals who may be under 

the influence. This training helps the counselor identify when not to stay and provide 

services. As in all situations, “gut instincts” 

are good indicators of what to do or not to 

do. Every counselor in the program has 

total control of engagement and disengagement as well as modifying interactive 

approaches.

This program also has very few first contacts in which the counselor does not have 

information from another agency. Almost 

all clients have been referred. Releases are 

obtained, and the family’s situation is discussed with the referral agency. Any safety 

issues are brought up at that time. Each 

counselor also carries a cell phone at all 

times. Any time a counselor feels uncomfortable or unsafe, he or she can leave the 

situation.

Challenges, Problems, and 

Solutions

One of the biggest challenges in developing 

Empower for Recovery was establishing collaborative relationships. According to the 

original grant, the Empower for Recovery 

Program was to work with the Hopes/Building Families Programs in all three counties. 

Public Health nurses carry out these programs with families with children who are 

prenatal through age 5. The nurses work 

with the children’s health issues as well as 

with child development and appropriate 

parenting skills. The initial collaborative 

efforts were awkward and challenging. No 

agency was sure how this process should 

work or how the Empower for Recovery Program would fit in with current programs. 

The programs Public Health was working 

with were also somewhat new. They were 

not sure how to present the Empower for 

Recovery Program to their clients. Persons 

in all agencies spent time getting to know 

each other, developing a common language, and being open to trying some new 

approaches. Cross-trainings helped to create a common language and approaches. As 

the program developed, the helpfulness of 

the collaboration became apparent. Families achieved better outcomes in a shorter 

amount of time. Although the Public Health 

nurses had some knowledge of substance 

abuse, and the staff of Empower for Recovery understood child development, by using 

our strengths and trusting the other agency 

to work from its strengths, the work with 

the family was both more effective and 

easier for the staff. As the collaboration 

between Public Health and Empower for 

Recovery developed, other agencies began 

to be drawn in to the collaborative process (such as advocates against domestic 

violence, social workers from DHS, school 

counselors, and persons from other agencies 

providing family-centered services). During 

the past 4 years, the agencies involved in 

collaborative processes have gained overall 

strength and become more effective in providing services.

Another challenge Empower for Recovery 

encountered was the expense of the program. Providing in-home services over a 

large geographical area has proved to be 

expensive. Much time is spent driving. 

However, when comparing the expense of 

a family’s completing the program versus 

the long-term cost to the community of 

continued substance abuse, the cost does 

not seem so high. For example, helping a 

young, pregnant woman abstain during her 

pregnancy reduces her chances of having a 

child with Fetal Alcohol Syndrome (FAS). 

A child born with FAS can cost a county 

more than $3 million over a lifetime (Fetal 

Alcohol Syndrome, 2003). The program may 

also save the cost of foster care—approximately $900 per month in Iowa (Doug 

Koons, personal communication, January 

2001). In addition, substance abusers who 

are in recovery are not reentering the legal 

system. Because these are long-term costs, 

they are often overlooked. In fact, persons 

who are in recovery are usually employed 

and contributing by paying taxes.
27

Outcomes of the Program

Families who participated in the program 

were involved for an average period of 6 

months to 1 year. The program has tracked 

several specific outcomes, including maintained sobriety, measured at 6 months 

and at 1 year; founded charges of child 

abuse after entry into the program; and an 

increase in community involvement.

Thirty families have been discharged from 

the program. Of these families, nine were 

crisis situations and received services only 

two to three times. During these visits, 

the family situation was evaluated, and 

more appropriate sources of assistance 

were found. Six families dropped out of the 

program. Fifteen families have completed 

the program. At the end of 1-year postdischarge, eight substance abusers have maintained sobriety. One has reached 6 months. 

Four families have left the substance 

abuser, because the substance abuser has 

refused to stop using at this time; thus, the 

children are now in a safer situation. Two 

substance abusers have relapsed, but they 

have accessed services sooner than during 

previous relapses. 

Case Study

Amy

Amy was a methamphetamine user who 

was failing in treatment due to continued 

use. She had had several previous treatment episodes. She was currently living 

with her husband, their common child (a 

3-year-old son), her 18-year-old child from 

a previous marriage, and his two children 

from a previous marriage. Animals accessed 

the home through holes. The couple had 

debts of approximately $60,000. Amy’s 

husband was manufacturing meth in the 

garage, although she denied knowing where 

he was manufacturing the drug. A history of domestic violence included several 

threats on her life. Amy also suffered from 

depression but was not being treated.

Amy was referred to the Empower for 

Recovery Program. When the Empower for 

Recovery counselor visited the home, she 

found the water and electricity had been 

disconnected. Amy had stopped opening the 

mail 3 months earlier, because she did not 

want to deal with any more bills. Therefore, the family had not received their food 

stamps and had not completed paperwork 

to receive any further assistance. 

With assistance from the counselor, the 

local Domestic Violence Center, and Public 

Health, Amy was able to leave her husband. 

She felt this was the only way to maintain 

her sobriety, as he was not willing to stop 

using or manufacturing methamphetamines, nor was he willing to meet with 

the Empower for Recovery counselor. Amy 

obtained suitable housing, has been drug 

free for more than 2 years, and has completed some vocational technical education. 

She is employed and has followed through 

with treatment for her depression. Amy also 

paid off her share of their debt after the 

divorce.

Recommendations

This program began as part of an innovative program through the local Empowerment Board. At first, it was not known 

exactly how this program would fit with the 

other programs in existence. Through the 

work of Deb Rohlfs, this program has been 

refined and developed over the past 4 years. 

It would be beneficial to perform a formal 

research project on this program at this 

time. 

Other screening tools are currently being 

examined to provide even better screenings and referrals. Motivational interviewing is a large component of the program’s 

approach. However, at this time no formal 

tools are used to assess the clients’ motivation. Addition of such a tool might prove 

advantageous. Exploring the use of mental 

health screening tools also might be useful.

Empower for Recovery
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The program has demonstrated some promising outcomes. Further study and refinement of the program might provide a more 

helpful approach in working with rural and 

frontier substance abusers.

References

Connors, G. J., Donovan, D. M., & 

DiClemente, C. C. (2001). Substance 

abuse treatment and the stages of 

change. New York: Guilford Press.

Dore, M. M., & Doris, J. M. (1998). 

Preventing child placement in 

substance-abusing families: Research 

informed [Electronic Version]. Child 

Welfare, 77, 407–427. Retrieved 

October 17, 2003, from Professional 

Development Collection database.

Fetal Alcohol Syndrome. Retrieved 

November 10, 2003 from www.acbr.

com/fas/fasmain.htm.

Karoll, B. R., & Poertner, J. (2002). 

Judges’, caseworkers’, and substance 

abuse counselors’ indicators of family 

reunification with substance-affected 

parents [Electronic Version]. Child 

Welfare, 81, 249–260. Retrieved 

October 17, 2003, from Professional 

Development Collection database.

Miller, W. R., & Rollnick, S. (2002). 

Motivational interviewing (2nd ed.). 

New York: Guilford Press. 

Semidei, J., Radel, L. F., & Nolan, C. 

(2001). Substance abuse and child 

welfare: Clear linkages and promising 

responses [Electronic Version]. Child 

Welfare, 80, 109–129. Retrieved October 

17, 2003 from Professional Development 

Collection database. 

Vincent, P. (2003). Training from The Child 

Welfare Policy and Practice Group. 

Montgomery, AL. Phone: (334) 264–

8300.
29

Delivering a Maternal Substance 

Abuse Intervention Program Along the 

Rural Route

Trudee Ettlinger, Ph.D., APRN, LADC

Contact information:

Trudee Ettlinger

P.O. Box 85

Underhill Center, VT 05490

Work: (802) 485–2612

Home: (802) 899–3737

Fax: (802) 899–3677

E-mail: trudeern@earthlink.net

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

Abstract

We sought to design and deliver an indicated-level substance abuse prevention program for 

lower income mothers living in rural Vermont. The Rocking Horse program employed best 

practices for working with rural mothers, used sensitive outreach, and built the program 

in the community. This 10-week psychoeducation group modality, led by a maternal/child 

specialist and a licensed substance abuse treatment professional, provided education about 

the risks of alcohol and illegal drugs for women’s health during pregnancy, and for young 

children living in substance-abusing families. Health education was delivered in a highly 

supportive format that emphasized building personal competencies. The short-term results 

suggest that this program is increasing knowledge of the harms caused by substance abuse 

and bolstering personal capacity to move away from this behavior.

Introduction

According to the National Household 

Survey on Drug Abuse (Substance Abuse 

and Mental Health Services Administration, 2002), the estimated rates of problem 

drinking and illegal drug use for women 

are climbing, and rural women are included 

in these trends (Rural Women’s Work 

Group, 2000). Yet getting rural mothers 

the help they need to move away from 

this harm is challenging because they 

often hesitate to admit problems (Boyd, 

1998). For many, revealing heavy drinking and drug use in the family may bring 

threats from close family members (Booth 

& McLaughlin, 2000); carry community 

disapproval toward them for behavior 

unbecoming a mother (Ettlinger, 2000); 

and capture attention from child welfare 

authorities. The limited availability of 

treatment services (Fortney & Boothe, 

2001), the hurdles barring access to the 

programs, and the need for childcare and 

transportation (Bushey, 1997) further 

discourage them from seeking help early. 

For poor and nearly poor rural mothers 

involved with substance abuse firsthand 
NRADAN Awards for Excellence 2004

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or secondhand, the rural poverty hardships 

they face may loom larger in their lives 

than the destructive nature of substance 

abuse. All too often, cultural norms, access 

barriers, and personal issues keep these 

women from getting help until they are in 

crisis. These observations, and the absence 

of prevention-level programs for this population, prompted a Vermont group of maternal/child professionals and substance abuse 

specialists to develop an alcohol and other 

drugs (AOD) intervention that might keep 

low-income mothers out of harm’s way.

The Rocking Horse (RH) program attempts 

to intervene with these at-risk mothers 

before their circumstances escalate into a 

treatment crisis. The program was designed 

as an indicated-level prevention effort to 

interrupt the progression of risk. During 

the past 2 years, this Vermont program has 

served an estimated 225 lower income rural 

mothers who are at risk of substance abuse. 

Our evaluation suggests that this program 

is helping mothers build knowledge and 

skills to repair the personal and family 

harm that results from problem drinking 

and illegal drug use.

Getting Started: Designing the 

Rocking Horse Program

The RH program realizes that substance 

abuse is a part of our world and strives to 

reduce its tragic effects on maternal health 

by intervening early, both to decrease the 

vulnerability to this health threat and to 

increase the capacity to move away from 

this risky behavior. The program believes 

that changing risky behaviors depends 

on strengthening knowledge and skills 

through a caring approach that respects the 

women’s culture and their traditions. The 

program also recognizes the harms from 

alcohol and illegal drug use that are specific 

to women’s experiences (Ramlow, White, 

& Watson, 1997). Central to the program’s 

framework are the concepts found in effective prevention efforts. Effective prevention at the individual level is based on 

building mastery, self-worth, and life skills 

and establishing rewarding relationships 

(Schinke, Brounstein, & Gardner, 2002).

Four main principles guided program development. First, the RH program recognizes 

that these mothers are nested in a background where sets of social and cultural 

factors may place them at risk for substance use. RH helps them recognize risk 

factors and provides strategies to reduce the 

harm. Second, RH also understands that 

substance abuse has grave consequences 

during pregnancy, and parental substance 

abuse places young children at risk. The 

program provides education on the serious 

outcomes of substance abuse during pregnancy and teaches skills to bolster safe and 

nurturing care of the young child. Third, 

the program realizes that these mothers 

face hardship, and their support networks 

may not be dependable. RH underscores 

substance abuse as a major factor in 

destabilizing personal development, family strength, and reliable friendships. The 

program model highlights setting goals, 

making decisions, managing stress, and recognizing healthy, rewarding relationships. 

Fourth, the RH program recognizes that 

these mothers are cautious and guarded 

for many reasons. Reaching and engaging these women call for using culturally 

matched approaches and sensitive outreach 

and lowering the barriers to access.

Delivering and Managing the 

Program

The RH program is a group modality that 

follows a 10-week curriculum. The content of the weekly groups has four major 

domains. Guided discussion explores substance abuse and women’s health, substance abuse and relationships, substance 

abuse and young children, and substance 

abuse and life troubles. A maternal/child 

specialist and a licensed substance abuse 

treatment professional lead the weekly 
31

groups. These leaders are women who live 

and work in the same rural communities 

and have a deep understanding of the culture and lives of the women they serve. 

The groups are conducted in nonagency 

community settings, and onsite childcare 

and transportation are provided. A particular feature of this program is providing the mothers with a small incentive at 

each weekly meeting. These small gifts 

recognize that being a mother is hard work 

and reward their efforts to solve problems. 

Additionally, special emphasis is placed 

on making the climate inviting and caring. 

The setting is private and comfortable, and 

snacks are provided for the mothers and 

their children.

The group process is sensitive to the culture 

of the mothers. Group leaders are mindful of the intergenerational patterns of 

substance abuse in families; often, healthy 

role models are lacking. The leaders function as teachers, mentors, and role models. 

They are very supportive and encourage the 

women to support one another in rewarding 

ways. Relational approaches and thoughtfulness are the key processes in group interaction. The groups close each meeting with 

a ritual that emphasizes self-care. 

The mainstay of the RH program is its 

community aspect. It is not seated in any 

agency, nor is it part of an outpatient or 

residential substance abuse treatment program. Professionals from the network of 

programs that serve the local population 

collaborate to deliver the program. Multidisciplinary community teams of maternal/child, substance abuse, early childhood, 

mental health, and child protection workers, as well as family visitors, manage the 

program in their community. The group 

leaders who coordinate the groups receive 

supervisory and administrative oversight. 

The supervisory level maintains program 

integrity and gathers feedback from the 

field to refine the program. The administrative level concentrates on program 

accountability.

Program Evaluation Methods

The RH program was piloted for 3 years 

(1997, 1998, and 1999) in rural Vermont 

locations and served an estimated 60 

women. The observational data from pilot 

groups in two communities suggested that 

the program was both reaching and engaging an at-risk group of younger mothers. 

The group leaders’ findings suggested that 

the women were responsive, their attitudes 

were changing, and their binge drinking 

patterns decreased. In 2000, RH groups 

were implemented across the State, and an 

objective, measurable, evaluation component was developed. 

Three methods are used to evaluate the 

program. The women complete a preparticipation and postparticipation survey and 

add narrative comments, and the leaders 

also complete a focused questionnaire. The 

preprogram and postprogram surveys are 

self-administered at the first and last group 

sessions. Each survey uses forced choice 

questions that are scored on a Likert scale. 

The 23 items are measures from the Center for Substance Abuse Prevention Core 

Measures Initiative (1999). These measures 

look for shifts in perception of handling 

stress, managing parenting, self-esteem, 

and establishing supportive relationships. 

The measures seek changes in perception 

about the risks of alcohol, tobacco, and illegal drugs in relation to women’s health and 

pregnancy as well as their effects on young 

children. The tool gathers demographic data 

from the mothers and asks questions about 

their personal alcohol consumption and illegal drug use and that of their partner(s).

The leaders complete a log that records the 

number of women served and notes the time 

needed for program management. This log 

also records the number of women referred 

for treatment services. The postprogram 

survey that leaders complete elicits leaders’ impressions about conducting the program, observations of the women attending, 

and comments about both the program’s 

strengths and areas for improvement.

Delivering a Maternal Substance Abuse Intervention Program
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Results from Year 1 and Year 2

The data were analyzed using a t-test for 

matched pairs of preprogram and postprogram surveys. The following results are 

based on 124 completed sets of questionnaires (from a total of 167 surveys returned 

from the field) for groups conducted in 14 

towns across the State in 2001 and 2002. 

Missing data reflect incomplete forms and 

unmatched surveys. The data suggest that 

29 percent of the women do not complete 

the 10-week program, and more than onethird are repeating the program.

The demographic data show that the majority of the women are 22–35 years old, and 

two-thirds are single parents. Sixty-eight 

percent had their first baby during their 

teenage years; half of these women had not 

completed a high school education. More 

than 80 percent of the women had children 

under age 5, and 36 were pregnant. More 

than 60 percent of the mothers were not 

working and receiving Temporary Assistance for Needy Families benefits. About 

25 percent of the women reported heavy 

drinking, and 40 percent reported that their 

partners were heavy drinkers. Almost 80 

percent of the women stated that they had 

used illegal drugs in the past.

Data from year 1 and year 2 suggest several 

significant changes: a shift in perception of 

handling stress more effectively (p = .008), 

increased perception of risk from alcohol 

for women’s health and during pregnancy 

(p = .01), increased perception of strong 

interpersonal support (p = .003), and an 

increased perception of self-worth (p = 

.01). Although not statistically significant, 

the data also suggest an increased perception of parenting skills and an increased 

understanding of substance abuse behavior 

patterns. The results show a reported 9 

percent decline in their own binge-drinking 

behavior. The women’s narrative comments 

are consistent across the 2 years with four 

major perceptions: The women report a very 

strong positive opinion of the group experience; they cite the importance of having a 

trusted space where they can talk about the 

effects of alcohol and drugs on their lives; 

they state that they have built new ways to 

manage their lives and feel more capable 

taking care of their babies and children; 

and they want to see this program continue 

because it is “worthwhile.”

The leaders reported that they observed 

uninterrupted attendance; the women 

dressed up to come to the group; the group 

was referred to as “class”; dropping out 

was influenced more by the partner than 

by the attendee; the women often commented on being afraid to talk about AOD 

for fear of retribution; and the women had 

a startling lack of knowledge about sexually transmitted infections. The leaders 

suggested that 10 group meetings were not 

enough and recommended that the program 

be extended. The leaders also commented 

that this program was serving as an entry 

point for bridging many of the mothers into 

other services. The group leaders reported 

personal satisfaction in conducting these 

groups. They expressed alarm, however, 

about the norm of heavy drinking among 

these younger mothers and their great 

vulnerability to the mounting presence of 

drugs in the rural towns.

Despite the data suggesting that this program is having positive results, the findings 

must be viewed with caution. The evaluation design is empirically weak with only 

a preprogram and postprogram survey of 

the attending women. The results may be 

biased because the women are alerted to 

the postprogram survey questions by taking the initial questionnaire. No control of 

confounding variables was attempted. Additionally, missing data may have affected the 

results.

Discussion

Although the evaluation process has weaknesses, we nonetheless believe that the RH 
33

program is leaving an imprint. The program 

is reaching and engaging a population that 

is at increased risk for substance abuse. 

The findings from this prevention effort 

suggest that the program is effectively 

delivering health education about the risks 

of substance abuse and helping the mothers 

increase their awareness about how AOD 

jeopardizes themselves, their pregnancies, 

and their young children. The women in the 

program also appear to be building coping 

skills and gaining self-confidence to manage their lives. The experience of genuine 

support also seems to help them identify 

healthy, rewarding relationships.

The group leaders and other professionals involved with the program view the 

program as greatly needed by this population of mothers. Until this program was 

launched, prevention efforts were absent. 

The treatment network stepped in when the 

women were in crisis—a demanding and 

often unfriendly entry point for treatment. 

The community teams note that early intervention may have interrupted a crisis situation for some of the mothers; for others, 

the program sparked recognition that they 

needed treatment. The community teams 

commented positively on their personal 

satisfaction in delivering this program. As 

well, the community teams have found that 

the structure of the program (not nested 

within an agency) has promoted shared 

ownership among the service providers.

Program Lessons Learned and 

Recommendations

We set out to address a profound maternal 

health risk for a population that usually 

keeps this risk well hidden. We discovered 

that “country mothers” are at risk of AOD 

and in need of prevention programming. We 

also learned that matching approaches to 

the intended population is an important key 

to engage people in helper programs. We 

believe that the strength and followthrough 

in the RH program rests with the collaborative efforts of the community teams. This 

program was based on grassroots participation of the many providers who work with 

these mothers. As this program was developed and discussed, these professionals 

came forward to head up implementation in 

their communities. It is clear that involving 

others from the beginning is a critical part 

of a program’s success.

All programs need to be evaluated, and 

the methods and processes of the evaluation must be sound and objective. We have 

come to realize that field evaluation processes must be stringent. During the past 2 

years, approximately 48 groups have been 

conducted in 14 communities by 11 teams 

of group leaders. Data accuracy problems 

have prompted a more structured and monitored data gathering process. Additionally, 

a strong evaluation design is needed to 

better determine the effectiveness of a program. Presently, we are moving ahead with 

a stronger experimental design that will 

include a comparison group and measure 

results of the comparison group against 

results of the intervention group. Without 

such a comparison, program outcomes are 

questioned.

Summary

Poor and nearly poor rural mothers face 

a collection of health threats. We encourage all professionals who work with these 

women not to overlook the possible presence 

of substance abuse in their lives. During 

the past 2 years we have found that we are 

drawing to the attention of the service system the issues of substance abuse among 

this population. The program is gaining recognition, and the referrals are growing.

Is the RH program making a difference? 

The short-term outcomes support the conclusion that we are engaging our intended 

population and helping these mothers 

increase their knowledge of AOD abuse 

and build skills to move away from AOD. 

Delivering a Maternal Substance Abuse Intervention Program
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Equally important, the program is highlighting, at both program and system levels in our State, the presence of substance 

abuse for this group.

Finally, our findings support the need for 

both substance abuse treatment programs 

for rural mothers and further research 

into the strategies that will provide effective interventions for this population. We 

advance the notion that all efforts, from 

prevention to treatment, recognize that 

AOD is interwoven in the life fabric of these 

women. Therefore, addressing this problem must include attention to all the background influences that place these women 

at risk. Additionally, initiatives must recognize the strengths that these women possess as well as their attachments to their 

families. We also suggest that incorporating 

treatment programs into various community provider teams may create a spirit of 

engagement and promote shared ownership. These collaborations are often the key 

to a program’s sustainability and growth.

References

Booth, B., & McLaughlin, Y. (2000). 

Barriers to and need for alcohol services 

for women in rural populations. 

Alcoholism: Clinical and Experimental 

Research, 24, 1267–1275.

Boyd, M. (1998). Substance abuse in rural 

women. Nursing Connections, 11(2), 

33–45.

Bushey, A. (1997). Mental health and 

substance abuse: Challenges to 

providing services to rural clients. 

Bringing excellence to substance abuse 

services in rural and frontier America. 

Technical Assistance Publication 

(TAP) number 20. DHHS Publication 

No. (SMA) 97-3134. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, Center for 

Substance Abuse Treatment.

Center for Substance Abuse Prevention. 

(1999). Core Measures Initiative Phase 

I Recommendations. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration.

Ettlinger, T. (2000). In harm’s way: 

Recognizing and addressing alcohol 

risk for rural disadvantaged pregnant 

mothers. Public Health Nursing, 17(3), 

207–210.

Fortney, J., & Boothe, B. (2001). Access to 

substance abuse services in rural areas. 

Recent Developments in Alcoholism, 15, 

177–197.

Ramlow, B., White, A., & Watson, D. (1997). 

The needs of women with substance 

abuse problems: An expanded vision 

for treatment. Substance Use & Misuse, 

32(10), 1395–1404.

Rural Women’s Work Group. (2000). The 

behavioral health care needs of rural 

women. In Report of the Rural Task 

Force of the American Psychological 

Association. New York: American 

Psychological Association.

Schinke, S., Brounstein, P., & Gardner, 

S. (2002). Science based prevention 

programs and principles. DHHS 

Publication No. (SMA) 03-3764. 

Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

Center for Substance Abuse Prevention.

Substance Abuse and Mental Health 

Services Administration. (2002). 

Summary of the findings from the 2001 

National Household Survey on Drug 

Abuse. DHHS Publication No. (SMA) 

02-3759. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, Office of Applied 

Studies.
35

Contact information: 

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

JBS International, Inc. 

8630 Fenton Street, 12th Floor

Silver Spring, MD 20910

Phone: (301) 495-1080

Area of focus: Socio-demographic characteristics of methamphetamine abusers in rural and 

urban areas.

Abstract

This study compares methamphetamine abusers in rural and urban areas, specifically their 

socio-demographic characteristics, actual use behavior, and drug use and nondrug treatment outcomes. Data are derived from a larger dataset that is part of the Treatment Outcomes and Performance Pilot Studies Enhancement Inter-State Study. This larger study 

measured functioning or behavior of substance abuse treatment clients at admission, discharge, and posttreatment (6 months postdischarge or 9 months postadmission).

Both urban and rural methamphetamine abusers were predominately white and male. In 

urban areas, however, nonwhite methamphetamine abusers were more racially and ethnically diverse. More methamphetamine abusers sought treatment in urban areas, and these 

clients were more likely to be homeless. The average age of methamphetamine abusers 

was lower in rural areas, and these clients also had significantly more dependent children 

living with them. Posttreatment data showed that both rural and urban methamphetamine abusers saw significant decrease in number of arrests and significant improvement 

in employment status (full-time and part-time), independent living, and abstinence from 

methamphetamine use over the past 30 days. This study brings to light the shift in sociodemographic characteristics of methamphetamine abusers (e.g., from only white, blue-collar 

males) and also highlights the increase of methamphetamine use in rural areas. Prevention 

and treatment initiatives need to focus on these changes to better target the groups who 

need these services.

Socio-Demographic Profiles and 

Treatment Outcomes of 

Methamphetamine Abusers in 

Rural and Urban Areas

Kazi A. Ahmed, Ph.D.

Careema Yusuf, M.P.H.
NRADAN Awards for Excellence 2004

36

Introduction

Methamphetamine is an odorless, white 

crystalline powder—a powerfully addictive stimulant that can be snorted, smoked, 

injected, or taken orally. It dramatically 

affects the central nervous system, and 

long-term abuse can lead to aggression, violence, memory loss, psychotic behavior, and 

cardiac damage (NIDA, 2000; Volkow et al., 

2001a; Volkow et al., 2001b). Because it can 

be synthesized using relatively inexpensive 

over-the-counter ingredients, methamphetamine can be made and subsequently distributed easily (NIDA, 2002).

In the 1950s, in the United States, methamphetamine was manufactured legally 

as tablets for medical use. However, nonmedical use spread among college students, 

truck drivers, and athletes. In the 1960s, 

with the introduction of injectable methamphetamine, this pattern changed and 

in 1970, the Controlled Substances Act 

severely restricted the legal production of 

injectable methamphetamine. Methamphetamine often goes by such street names 

(slang) as “crank,” “chalk,” “meth,” “speed,” 

“crystal,” “ice,” “sparkle,” “clear,” and “peanut butter” (ONDCP, 2001; NIDA, 2002). 

Methamphetamine abuse has been the 

dominant drug problem in the San Diego, 

California, area for a long time (NIDA, 

2002). However, methamphetamine abuse 

has now spread across the United States, 

no longer concentrated in California. It 

has spread to other sections of the West 

and Southwest, and Midwest portions of 

the country. Methamphetamine abuse has 

also spread from urban to rural areas, and 

the users themselves are no longer purely 

white, male, blue-collar workers (NIDA, 

2002). The National Institute on Drug 

Abuse’s Community Epidemiology Work 

Group reported in June 2001 that treatment admissions showed that methamphetamine was the leading drug of abuse among 

treatment clients in the San Diego area 

and Hawaii, which differs from treatment 

admissions in areas in most Midwestern 

and Eastern States, for example, 

Minneapolis-St. Paul and St. Louis, 

where methamphetamine abuse accounted 

for about 3 percent of total admissions, 

and Baltimore, where no stimulant-related 

admissions were reported for the first 

half of 2000 (NIDA, 2002). In 1999, 15 

of the 50 States and the District of 

Columbia reported that 6 to 25 percent of 

the total substance abuse clients admitted 

for treatment identified methamphetamine 

as the primary substance of abuse. Of the 

15 States, 7 were Midwestern States with 

admission rates between 6 and 16 percent 

(SAMHSA, 2001). The number of methamphetamine laboratory seizures in California 

reported to the Drug Enforcement Administration in 1997 increased to 1,273 from 

879 in 1996. During that time period a significantly higher number of methamphetamine laboratories were also seized in the 

Midwestern States of Arkansas, Kansas, 

Missouri, and Oklahoma (California Border 

Alliance Group, 1998). This trend reflects 

the widespread proliferation of methamphetamine manufacture, trafficking, and 

use across the West and Midwestern States. 

The shift in methamphetamine abuse from 

California to other sections of the country 

and the change in the demographic profile 

of the methamphetamine abuser are further 

supported by the results provided in this 

paper. Treatment samples from across the 

country provide clear evidence of the geographical spread pattern of methamphetamine abusers in the country. Treatment 

data from a representative sample of treatment centers from 19 States collected under 

the Treatment Outcomes and Performance 

Pilot Studies Enhancement (TOPPS II) 

Inter-State Study provide direct evidence 

of a general pattern of diffusion of this drug 

from its West Coast origin to Midwestern 

and Southern States (see table 1). Whereas 

methamphetamine abuse is highest in the 

West and Southwest, it is conspicuously 

absent or insignificant in East Coast States. 

Prevalence of methamphetamine abuse in 
37

the Midwestern and Southern States also 

signals the spread of the abuse into rural 

communities.

Purpose

As indicated above, the abuse of methamphetamine is not limited to urban areas 

only; it has spread to rural communities 

as well. Because very little systematic 

research has been done to document the 

abuse of this drug within rural populations, 

this study attempts to fill this knowledge 

gap by focusing on the socio-demographic 

characteristics of rural methamphetamine abusers who entered a substance 

abuse rehabilitation program. The study 

also describes the actual use behavior of 

treatment clients and their drug use and 

nondrug treatment outcomes. The study 

compares these results to characteristics 

of urban methamphetamine abusers. 

Specifically, the study addresses the following exploratory research questions:

• Do socio-demographic characteristics 

of methamphetamine abusers in rural 

areas differ significantly from those of 

methamphetamine abusers in urban 

areas?

• Do the two user groups vary in frequency 

of use and the route of administration of 

the drug?

• Is there a significant difference in the 

drug treatment outcomes (abstinence from 

using methamphetamine) and nondrug 

treatment outcomes (posttreatment 

employment status, criminal justice 

involvement, and living arrangement) of 

the two user groups?

Methods

Program and the Research Description

This study is part of a larger study (TOPPS 

II Inter-State Study) conducted under a 

cooperative agreement grant funded by the 

U.S. Department of Health and Human 

Services, Substance Abuse and Mental 

Health Services Administration in September 1998 with 19 States (see table 1 for 

a complete list of TOPPS II participating 

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

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

States

Percentage of Treatment

Clients Reporting

Methamphetamine Use

(Primary, Secondary, or

Tertiary Problem) (n)

States

Percentage of Treatment

Clients Reporting

Methamphetamine Use

(Primary, Secondary, or

Tertiary Problem) (n)

California 48.8 (13,381) New Hampshire 2.8 (389)

Utah 43.3 (667) Massachusetts 1.6 (442)

Arkansas 34.2 (1,206) Illinois 1.2 (1,569)

Oklahoma 24.5 (1,144) Virginia 1.0 (955)

Arizona 24.4 (512) New York 0.6 (855)

Washington 22.9 (14,977) Rhode Island 0.8 (353)

Iowa 17.3 (400) Connecticut 0.8 (385)

Missouri 15.4 (475) Maryland 0.4 (10,090)

Texas 10.3 (892) New Jersey 0.3 (1,002)

Kentucky 7.1 (604)

Socio-Demographic Profiles and Treatment Outcomes of Methamphetamine Abusers
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38

States). A major purpose of the TOPPS II 

Inter-State Study was to develop an integrated picture of substance abuse treatment 

effectiveness in the participating States. To 

achieve this purpose, a prerequisite was to 

define common measures of client status 

and substance abuse treatment effectiveness and apply them to the data collected 

by participating States. The Inter-State 

Study used a single-group quasi-experimental pretest–posttest design with measures 

at three defined time periods. By measuring 

functioning or behavior at admission, discharge, and posttreatment (6 months postdischarge or 9 months postadmission), the 

design allowed consideration of posttreatment changes and their temporal stability. 

Sixteen States collected primary data, while 

three States extracted records of comparable data elements for the same time period 

from their existing Management Information System (MIS).

Sampling Strategies

The 16 Primary Data States (PDS) 

employed a two-stage sampling design to 

collect the data for the study. At stage one, 

the States selected a sample of treatment 

providers that constituted a good representation of the four modalities: intensive 

outpatient/standard outpatient, inpatient/

residential rehabilitation, methadone, and 

other (such as case management, community living, continuing care, and extended 

care). Then, at stage two, the States sampled the clients receiving treatment from 

the selected treatment providers. 

The States provided data that correspond 

to the standardized TOPPS II 31-item core 

dataset. Repeated measures were taken for 

most of the items at postdischarge followup 

from a sample of adult (18 years or older) 

clients. Data were collected by treatment 

center staff at admission and discharge. 

The 9-month postadmission followup data 

were collected by independent research 

organizations hired by the TOPPS II States. 

Data were sent to the TOPPS II Technical Assistance Center for the Inter-State 

Study analysis. The PDS provided a sample 

of 24,087 clients. Posttreatment followup 

completion rates ranged from a low of 17.1 

percent to a high of 92.38 percent, with an 

average of 62.15 percent. A limited number of the core data items were collected at 

discharge. The Secondary Data States provided records for 38,187 clients from their 

MISs. These States were able to extract 

from their interagency databases a limited 

number of core dataset items pertaining to 

posttreatment outcomes. The two sources 

generated a total of 62,274 cases. The 

study protocols of participating States were 

reviewed and approved by an Institutional 

Review Board. 

A subset of the larger dataset was used for 

this study. This study is based on a total of 

17,588 samples submitted by 142 treatment 

providers from 7 States (Arkansas, California, Iowa, Kentucky, Missouri, New York, 

and Utah). Samples from the seven States 

were used in this study because they had 

either the most methamphetamine users 

or provided the larger proportion of rural 

clients. Approximately 7 percent of the 

samples (n=1,182) were clients receiving 

services from providers in rural settings.

Variables of Interest

Variables used in this study are a subset from the larger TOPPS II Inter-State 

Study. Variables were selected based on 

their predictive value as well as substantive 

value. The importance of these variables 

has been very well documented by previous 

studies in the substance abuse field (McLellan, Belding, McKay, Zanis, & Alterman, 

1997; Hubbard, Mardsen, Rachal, Harwood, 

Cavanaugh, & Ginzburg, 1989; Hubbard, 

Craddock, Flynn, Anderson, & Etheridge, 

1997; Aglin & Hser, 1990; Hubbard, 1992; 

McLellan, Woody, Metzger, McKay, Durrell, 

Alterman, & O’Brien, 1996; Mirin, Gosset, 

& Grob, 1991; Ball & Ross, 1991; D’Aunno 
39

& Vaughn, 1992; McLellan, Alterman, 

Cacciola, Metzger, & O’Brien, 1992; Ahmed, 

Yusuf, Hussain, Cacciola, Foltz, McKay, & 

Weiss, 2003).

Three types of variables were included in 

this study—a set of socio-demographic variables, methamphetamine use-related variables, and methamphetamine treatment 

outcomes variables. The socio-demographic 

variables included gender, age (18–20, 21–

29, 30–39, and 40 or older), race (American 

Indian/Alaska Native, Asian, African American, Native Hawaiian/Pacific Islander, 

white, Hispanic, other, and multiracial), 

marital status (married/remarried/widowed, 

separated/divorced, and never married/

single/cohabitating), employment status 

(full-time [30 hours or more per week], parttime, not working but looking for a job, and 

not in the labor force), education (< high 

school, high school degree, and some college 

or college degree), dependent children (no 

children, one child, and two or more children), and living arrangement (homeless, 

living with someone as a dependent, and 

living independently).

There were three methamphetamine userelated variables: age at first use of methamphetamine (<11, 11–17, 18–20, 21–34, 

35–44, and 45+), frequency of methamphetamine use (no use in the past month, 

1–3 times in the past month, 1–2 times per 

week, 3–6 times per week, and daily), and 

the route of administration (oral, smoking, 

inhalation, injection [IV/Intramuscular], 

and other).

Methamphetamine treatment outcomes 

variables included treatment completion 

status, rate of change in use behavior from 

admission to 9 months postadmission (frequency of use variable at the three time 

periods used), rate of change in arrest rate 

from admission to 9 months postadmission, 

rate of change in employment from admission to 9 months postadmission, and rate of 

change in living arrangement from admission to 9 months postadmission.

Methamphetamine was one of the 18 specified drugs for which a client at intake was 

asked to provide frequency of use, age at 

first use, and route of administration. The 

response regarding frequency of use of a 

particular drug helped the counselor or 

data collector determine whether that drug 

use was a primary, secondary, or tertiary 

drug problem. In this study, all three types 

of drug problems were included in the 

analysis.

Designation of Rural and Urban Areas

A provider is designated as rural if the 

county in which it is located has a population of fewer than 50,000; otherwise it is 

designated as urban. The population size of 

counties is based on 2000 Census information. Because a majority of clients reside in 

the area in which they are receiving treatment, they are accordingly described as 

rural or urban clients. Kentucky, Arkansas, 

California, Iowa, and Utah contributed 

most of the sample of rural clients in the 

study. Approximately 7 percent (n=1,182) of 

the study sample was rural clients.

Data Analyses and Statistical

Procedures

As mentioned previously, a subset of a 

larger dataset was selected for the purpose 

of this study. Descriptive analysis was used 

to obtain the frequencies and percentages. 

The chi-square significance test was used 

to test for statistical significance of two categorical variables (e.g., gender of methamphetamine abuser by rural-urban setting). 

The independent t-test was also used to 

test for significant differences in continuous 

variables (e.g., age). Finally, McNemar’s 

chi-square test for a 2 x 2 contingency table 

was used to test for the significance of the 

differences of repeated measures (e.g., use 

or abstinence at admission versus use or 

abstinence at followup).

Socio-Demographic Profiles and Treatment Outcomes of Methamphetamine Abusers
NRADAN Awards for Excellence 2004

40

Socio-Demographic 

Characteristics of Rural and 

Urban Clients

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

the sample follow.

Gender

In both rural and urban locations, treatment clients were predominantly male. 

However, there were proportionately more 

male rural clients (68 percent) than urban 

clients (59 percent).

Race and Ethnicity

The majority of the clients were white, with 

56 percent receiving treatment in an urban 

setting and 85 percent in a rural setting. 

Some other rural racial groups abusing 

methamphetamine were African Americans (3 percent), Hispanics (2 percent), and 

American Indians (2 percent). The proportion of Hispanics and African Americans 

was much higher in the urban sample—15 

percent and 18 percent, respectively. In 

both settings, a significant proportion identified themselves as multiracial—3 percent 

in rural areas and 5 percent in urban areas. 

In the urban sample, 20 percent listed 

their ethnic origin as Hispanic or Latino, 

compared to 5 percent in the rural sample. 

Ninety-six percent of the clients who were 

multiracial were of Hispanic origin.

Age at Admission

There was a small but statistically 

significant difference in the average ages 

of rural and urban clients in the sample. 

The average age of rural clients was 33 

years, whereas the average age of urban 

clients was 35 years. The median ages 

were 34 and 38 years, respectively.

Education

In both settings, 34 percent of the clients 

had no high school education. The percentage of clients with high school degrees was 

slightly higher in the rural areas—47 percent versus 44 percent. This distribution 

indicates that the majority of the clients 

had a high school or college education.

Employment Status

The employment rate was higher among 

rural clients. In the rural sample, more 

than 43 percent of the clients were 

employed either full time or part time, 

compared to 35 percent in the urban 

sample. Consequently, far fewer rural 

clients reported not being in the labor 

force—29 percent versus 40 percent for 

rural and urban clients, respectively. 

However, the unemployment (looking for 

job) rate was slightly higher among rural 

clients (28 percent versus 25 percent).

Marital Status

The proportion of married, remarried, or 

widowed clients was higher in the rural 

sample (27 percent versus 21 percent). 

The majority of the clients had either 

never married or were separated/divorced. 

Although the divorced rate was higher 

among rural clients (26 percent), the prevalence of never married/single status was 

much higher among urban clients, with 46 

percent compared to 36 percent in the rural 

areas. Rural clients had a higher percentage 

of cohabitation (2 percent) than urban 

clients (less than 1 percent).

Number of Dependent Children

The number of dependent children (no child 

or one or more children) was virtually the 

same for the rural and urban clients (41 

percent with no children, 21 percent with 

one child, and 37 percent with two or more 

children).
41

Living Arrangement

Homelessness among the clients was more 

prevalent in the urban areas. Only 3 percent of the rural clients were homeless, 

compared to 15 percent of the urban clients. 

When the homelessness category is merged 

with those living as dependents, the percentage of clients at risk of being homeless 

(i.e., homeless and dependent) increases to 

33 percent among urban clients, compared 

to 19 percent among rural clients.

Major Findings

Socio-Demographic Characteristics of

Methamphetamine Users in Rural and

Urban Areas

The study sample revealed differences in 

the prevalence rates of methamphetamine 

abuse among rural and urban clients. For 

example, in the urban sample, more than 

43 percent reported that they were in treatment for using methamphetamine (primary, 

secondary, or tertiary drug problem), as 

compared to 28 percent in the rural sample. 

This difference was statistically significant.

No significant difference was observed in 

the number of male and female methamphetamine abusers in the two settings. In 

each case, a little more than half of the 

users were male.

The average age of rural methamphetamine abusers was slightly lower than 

that of urban users—30 years compared to 

33 years. This difference was statistically 

significant.

More than 90 percent of the rural methamphetamine abusers were white. Hispanics (3 

percent) and American Indians (3 percent), 

however, were also using the drug. There 

were virtually no African American users in 

the rural areas in the sample. On the urban 

side, although the majority of urban clients 

were white, the rate was much lower than 

in rural areas—only 67 percent white. The 

urban sample included 17 percent Hispanics, 4 percent African Americans, 3 percent 

American Indians, and 3 percent Asians. 

The racial mix of urban abusers was more 

diverse than that of rural abusers (see 

table 2).

The marital status of rural and urban 

methamphetamine abusers did not vary 

significantly. Approximately 20–22 percent 

were married/remarried/widowed, 34–36 

percent were separated/divorced, and 

42–47 percent were never married/single or 

cohabitating.

Users did vary significantly in the number 

of dependent children living with them. 

Thirty to thirty-six percent of rural and 

urban abusers did not have any children 

living with them. Twenty to twenty-three 

percent had one child living with them. Half 

of the rural clients, compared to 42 percent 

of the urban clients, had two or more children living with them.

Homelessness among methamphetamine 

abusers was much more prevalent among 

urban clients than among rural clients. In 

rural settings, 5 percent of the methamphetamine abusers were homeless, compared to 15 percent in urban settings. Users 

in a dependent living status, however, were 

more likely to be rural clients. One-quarter 

of the rural clients reported a dependent 

living arrangement, compared to 19 percent 

of the urban clients. In both settings, the 

majority of the users were living independently: 71 percent for rural and 66 percent 

for urban. When controlling for gender, 

female methamphetamine users (55 percent) were more likely to be homeless or at 

risk of being homeless than male users (39 

percent). The pattern for urban areas was 

similar, with a slightly lower rate than that 

in rural areas.

Roughly one-third of the clients in both 

rural and urban areas were employed: 34 

percent of the rural clients and 28 percent 

Socio-Demographic Profiles and Treatment Outcomes of Methamphetamine Abusers
NRADAN Awards for Excellence 2004

42

Table 2. Socio-Demographic Characteristics of Rural and 

Urban Methamphetamine Abusers and Nonabusers

SocioDemographic

Characteristics

Location

Rural Urban

Not a

Methamphetamine

Abuser % (n)

Methamphetamine

Abuser % (n)

Not a

Methamphetamine

Abuser % (n)

Methamphetamine

Abuser % (n)

Race

American Indian/

Alaska Native 56 (14) 44 (11) 50 (176) 50 (178)

Asian 100 (2) 0 (0) 45 (162) 55 (196)

African American 99 (80) 1 (1) 91 (2,735) 9 (268)

Native Hawaiian/

Pacific Islander 100 (2) 0 (0) 39 (28) 61 (43)

White 70 (700) 30 (296) 48 (4,356) 52 (4,748)

Hispanic 45 (9) 55 (11) 54 (1,308) 46 (1,105)

Other 80 (4) 20 (1) 51 (100) 49 (97)

Multiracial 80 (32) 20 (8) 50 (427) 50 (430)

Marital Status

Married/Remarried/

Widowed 77 (242) 23 (74) 61 (2,070) 39 (1,325)

Separated/Divorced 70 (283) 30 (120) 56 (3,013) 44 (2,376)

Never Married/Single/

Cohabitating 68 (299) 32 (140) 55 (4,108) 45 (3,324)

Employment Status

Employed Full Time 81 (295) 19 (69) 60 (2,325) 40 (1,521)

Employed Part Time 71 (98) 28 (39) 57 (1,068) 43 (820)

Unemployed, Looking for

a Job 65 (213) 35 (115) 52 (2,088) 48 (1,959)

Not in Labor Force 67 (221) 33 (111) 58 (3,826) 42 (2,776)

Dependent Children

No Children 79 (364) 21 (98) 64 (4,302) 36 (2,431)

One Child 73 (177) 27 (65) 53 (1,849) 47 (1,624)

Two or More Children 62 (260) 38 (160) 50 (3,027) 50 (2,983)

Living Arrangement

Homeless 56 (19) 44 (15) 57 (1,372) 43 (1,023)

Dependent 57 (105) 43 (80) 54 (1,516) 46 (1,317)

Independent 75 (682) 25 (231) 57 (6,201) 43 (4,628)

Education

Less than High School

(<12 Years) 71 (286) 29 (115) 53 (2,979) 47 (2,601)

High School Degree

(12 Years) 70 (387) 30 (165) 53 (3,774) 47 (3,334)

Some College or Higher

Degree 74 (160) 26 (55) 69 (2,497) 31 (1,132)

Age Categories

18–20 65 (76) 35 (41) 53 (500) 47 (435)

21–29 66 (229) 34 (120) 44 (1,804) 56 (2,266)

30–39 68 (272) 31 (125) 52 (3,041) 48 (2,826)

40+ 84 (268) 16 (50) 72 (3,980) 28 (1,551)
43

of the urban clients reported being unemployed or looking for a job. One-third of the 

rural clients were not in the labor force, 

compared to 39 percent of the urban clients. 

The differences are statistically significant.

Methamphetamine users in rural and urban 

areas did not differ significantly in their 

educational status. Approximately 34–37 

percent had no high school education, 47–49 

percent had a high school degree, and 16 

percent had some college or a higher degree.

Drug Use and Nondrug Outcomes

in Rural and Urban Areas

The rate of completion of treatment 

was slightly lower among rural clients 

(37 percent) than among urban clients 

(39 percent). In rural areas, the percentage 

of clients not completing treatment due to 

incarceration was slightly higher (6 percent 

versus 3 percent in urban areas). The rate 

of clients leaving treatment against professional advice, however, is higher in the 

urban settings (43 percent versus 39 percent in rural settings).

There was no significant difference in the 

average age at first use of methamphetamine between rural and urban clients—

20 years (see table 3).

Although smoking methamphetamine was 

the most common route of administration 

for both rural and urban clients, urban clients (51 percent) used it more often than 

the rural clients (37 percent). The percentage of users inhaling the drug was slightly 

higher among rural clients (29 percent) 

than among urban clients (26 percent). 

Similarly, the percentage of users injecting 

Socio-Demographic Profiles and Treatment Outcomes of Methamphetamine Abusers

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

for Rural and Urban Methamphetamine Abusers

Use-Related Variables Rural % (n) Urban % (n)

Age at First Use

<11 1 (4) 1 (73)

11–17 47 (153) 43 (3,001)

18–20 20 (67) 21 (1,443)

21–34 27 (90) 30 (2,116)

35–44 4 (14) 5 (373)

45+ 0.3 (1) 0.2 (12)

Frequency of Use

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

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

1–2 times per week 8 (25) 8 (544)

3–6 times per week 7 (24) 9 (615)

Daily 8 (28) 8 (581)

Route of Administration

Oral 7 (22) 4 (275)

Smoking 37 (118) 51 (3,619)

Inhalation 29 (97) 26 (1,797)

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

Other 0.9 (3) 1 (77)
NRADAN Awards for Excellence 2004

44

methamphetamine was higher among rural 

clients (28 percent) than among urban clients (18 percent). Also a higher percentage 

of rural clients (7 percent) than urban clients (4 percent) were taking the drug orally.

The frequency of use among rural and 

urban clients was almost identical. Approximately 60 percent of both rural and urban 

clients reported at intake no use of methamphetamine in the 30 days prior to admission. It may be noted that no use in the 

past 30 days could be attributed to several 

factors, including living in a controlled environment (e.g., jail), a treatment provider’s 

requirement of no use for a certain amount 

of time before treatment could begin, or 

other external pressures (e.g., monitoring by the criminal justice system through 

probation or parole). Of those who reported 

using the drug at the time of admission, 

16–19 percent were using it 1 to 3 times per 

month, 8 percent were using it 1 to 2 times 

per week, 7–9 percent were using it 3 to 6 

times per week, and 8 percent were using it 

on a daily basis.

Treatment outcomes for methamphetamine 

abuse in both rural and urban settings were 

virtually identical. In both locations, 92–93 

percent of the treatment clients reported 

abstinence from methamphetamine abuse 

for the past 30 days at the posttreatment

(9 months postadmission) followup (see 

table 4).

The three nondrug outcomes measured 

were arrest records, living arrangements, 

and employment. In rural settings, at 

admission 53 percent of the clients reported 

having been arrested in the past 6 months. 

At posttreatment followup this percentage 

was 22 percent. In urban settings, at admission 40 percent of the clients reported having been arrested during the past 6 months, 

and at followup the rate was 16 percent.

At admission 22 percent of the rural methamphetamine treatment clients were either 

homeless or at risk of being homeless. At 

followup, this figure dropped to 17 percent. 

In urban settings the percentage of homeless or at risk of being homeless clients was 

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

Rural % (n) Urban % (n)

At Admission At Followup At Admission At Followup

Frequency of Use

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

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

Arrest Incidence

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

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

Employment Status

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

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

Living Arrangement

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

Independent 77 (116) 83 (124) 70 (1,046) 76 (1,146)
45

30 percent at admission. At followup the 

figure had dropped to 24 percent.

In urban settings, the full-time and parttime employment status of clients increased 

from 33 percent to 56 percent from admission to followup. The employment rate 

among rural treatment clients increased 

from 31 percent at admission to 64 percent 

at followup.

Conclusion and Discussion

Judging from the use behavior of treatment clients, methamphetamine is very 

much an urban phenomenon. Almost half 

of the treatment clients in the urban setting presented methamphetamine as their 

primary, secondary, or tertiary problem. 

The use of methamphetamine among rural 

populations, however, has become very 

common too. In some States (California 

and Utah), almost half of the drug users 

are methamphetamine abusers. One of the 

major reasons cited for the spread of methamphetamine in the rural areas and deserts 

is the ease with which it can be manufactured there (because the telltale odors of 

the production process are less likely to be 

detected). Mobile labs in campers and vans 

have been reported on some major highway 

routes. In addition to increased manufacture of methamphetamine in rural settings, 

there is increased usage of methamphetamine by rural populations, as this study 

has shown.

The socio-demographic profile reveals that 

methamphetamine abusers in rural settings 

are younger than their urban counterparts. 

Although rural methamphetamine abusers 

have similar educational background, marital status, and gender distribution when 

compared to urban methamphetamine 

abusers, they do vary significantly in their 

racial makeup, family size, and employment status. Whereas smoking is the most 

common route of administration for both 

groups, rural methamphetamine abusers 

are more likely to be injecting or inhaling 

the drugs. Regarding treatment outcomes, 

rural clients have a slightly higher probability of involvement with criminal justice and 

have a higher treatment dropout rate. With 

regard to the rate of posttreatment abstinence from using methamphetamine, the 

treatment outcomes were the same for the 

two groups. In general, the nondrug treatment outcomes (employment status, arrest 

rate, and living arrangements) showed 

significant positive results for both groups. 

However, the rate of change varied by location: the decrease of arrest incidents in the 

past 6 months was much higher in the rural 

areas, the decline of homelessness was 

slightly higher in the rural areas, and the 

recovery from unemployment at posttreatment is much slower in the rural areas.

This study has potential limitations that 

may require the results to be interpreted 

with some caution. The designation of rural 

or urban status was assigned poststudy 

based on the location of the treatment center. There is a possibility that this assignment might lead to some misspecification 

of the clients’ residential status. Although 

the overall size for the rural sample was 

adequate, some estimates of rates may 

be biased due to small cell size for certain 

categories. Also, the treatment outcomes 

of clients should be used with caution. The 

attrition rate of samples at 9 months postadmission was rather high, leading one to 

wonder what type of bias may have been 

introduced in the sample due to the absence 

of input from nonrespondents.

An important treatment implication of 

the findings of this study is the association of treatment completion with positive 

outcomes. As has been documented in the 

larger TOPPS II study, treatment completion was associated at followup not only 

with abstinence, but also with employment 

and independent living. Treatment completion appears to be a reasonable overarching treatment goal that providers can help 

clients achieve. The study has shown that 

Socio-Demographic Profiles and Treatment Outcomes of Methamphetamine Abusers
NRADAN Awards for Excellence 2004

46

the rate of dropout from treatment is higher 

for rural clients. This implies that unless 

treatment providers can help decrease the 

dropout rate of rural clients, treatment 

outcomes such as abstinence, employment, 

and independent living will be negatively 

impacted. Because treatment completion 

is important, it may be helpful to focus on 

enhancing motivation or other strategies 

of treatment engagement to support the 

likelihood of both treatment completion and 

abstinence. Abstinence prior to admission 

was related to treatment completion and 

to abstinence at discharge and followup. 

Specifically, clients who achieved a period 

of abstinence (30 days in this case) prior to 

entering a substance abuse rehabilitation 

program were more likely to complete treatment and maintain abstinence. This suggests that initial abstinence for whatever 

reason, such as recent time spent in a controlled environment or internal or external 

pressures (e.g., monitoring by the criminal 

justice system through probation or parole), 

provides the clinician with an opportunity 

to support and build on positive behavioral 

change that already has been initiated.

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Socio-Demographic Profiles and Treatment Outcomes of Methamphetamine Abusers

49

An Environmental Scan of Faith-Based 

and Community Reentry Services in 

Johnson County, Iowa

Janet C. Hartman, M.A., LMSW

Iowa Consortium for Substance Abuse 

 Research and Evaluation 

University of Iowa 

Stephan Arndt, Ph.D.

Iowa Consortium for Substance Abuse 

 Research and Evaluation and 

Department of Psychiatry, College 

 of Medicine and Department 

 of Biostatistics

College of Public Health

University of Iowa

Kristina Barber, M.S.M.

Iowa Consortium for Substance Abuse 

 Research and Evaluation 

University of Iowa

Thomas Wassink, M.D. 

Department of Psychiatry 

College of Medicine

University of Iowa

Contact information:

Corresponding Author: Stephan Arndt, Ph.D.

Iowa Consortium for Substance Abuse Research and Evaluation 

University of Iowa

100 Oakdale Campus

Iowa City, IA 52242–5000

Phone: (319) 335–4488

E-mail: Stephan-Arndt@Uiowa.edu

Area of focus: Community corrections, substance abuse treatment providers and faith-based 

organizations supporting reentry clients.

Abstract

Although the numbers are often ignored, each year nearly 500,000 people are released 

from incarceration in the United States and this number continues to grow. During 2001, 

one in four probationers failed in the community because of a drug law violation, and 

another 18 percent failed due to a charge of driving while intoxicated. Many offenders also 

are estranged from family, jobs, and other social support systems. Rural communities are 

burdened uniquely because lack of transportation and childcare challenge accessibility to 

resources located in larger communities. Individuals are left to their own means and must 

seek whatever services they can find within their local rural communities.

Establishing connections with a crime- and substance abuse-free community is critical to 

success. Faith-based organizations are frequently a point of contact for rural adults and 

families experiencing problems. Faith-based organizations have unique strengths in providing services and assistance to those in most need. However, little is known about the kinds 

of services and the tremendous amount of support they provide. 
NRADAN Awards for Excellence 2004

50

Three groups were identified to provide information regarding community outreach in 

Johnson County, Iowa: community corrections; substance abuse treatment providers; and 

13 faith-based organizations, each having a unique mission to serve those in need. Faceto-face interviews and focus groups assessed the services in Johnson County that might be 

beneficial to reentry clients either coming home to communities or relocating to new ones.

Faith-based organizations provide both a wide variety of direct practical services and the 

opportunity to establish a sense of community belonging. Both corrections and substance 

abuse treatment representatives reported that faith-based communities might benefit from 

training concerning reentry clients. Improved communication among these groups would 

improve the faith-based communities’ capacity to deal with reentering adults. Training, 

support, and a small infrastructure would vastly increase groups’ capacity to provide 

benefits to larger numbers of reentering individuals.

Introduction

Over the past 2 years, the State of Iowa 

has experienced severe budget cuts. Budget shortfalls directly affect human service 

agencies across the State. Rural communities experience the greatest effect of the 

cuts, because many human services in these 

small towns are eliminated. Barriers to 

accessibility to services in larger communities are lack of transportation and lack 

of childcare. Individuals are left to their 

own means and must seek services within 

their communities. A common belief is that 

faith-based organizations are frequently the 

first point of contact for rural people and 

families experiencing problems. Faith-based 

organizations have a long history of reaching and aiding individuals and families in 

need, and these organizations often fill service gaps in public support. 

Special population segments—such as exoffenders or individuals leaving substance 

abuse treatment who are attempting to 

reenter their communities—require support 

and safety mechanisms to facilitate reintegration. Little attention and few resources 

have been given to assist systematically 

and comprehensively with the successful 

reentry transition for people released from 

incarceration. Faith-based and communitybased organizations have unique strengths 

in providing services and assistance to 

those most in need. They have a strong 

understanding of the needs of a community; 

however, we know little about the kinds of 

services and the tremendous amount of support they provide.

Nationally, more than one half million 

(561,020) sentenced prisoners were released 

from State or Federal correctional institutions in 1998 (Bureau of Justice Statistics, 

2000). Nearly one half of all released offenders fail to reenter the community successfully, and they return to prison within 3 

years (Langan & Levin, 2002). Increasing 

an offender’s chance to integrate successfully back into the community would have 

substantial and widespread benefits. 

In Iowa, 4,342 reentered the community 

in 1998. As shown in figure 1, the number 

of released prisoners has grown steadily 

over the last two decades (Bureau of Justice Statistics, 2000). In 2001, Iowa’s prison 

population reached 8,116, along with 26,670 

offenders who were being supervised by 

Community Corrections. In 2001, 5,250 left 

prison and reentered the community (Harrison & Karberg, 2003). Each month, more 

than 400 offenders enter Iowa’s prison system and more than 400 leave for reentry. 

The Iowa Department of Corrections plans 

to increase its use of community corrections; 

thus even more offenders will be struggling to integrate into the community (Iowa 

Department of Corrections, 2002). 
51

Most reentering offenders face many barriers to successful integration. A large 

number of people in prison (Mumola, 1999) 

and on probation (Mumola & Bonczar, 

1998) have a history of drug and alcohol 

abuse and dependence. During 2001, one in 

four probationers failed in the community 

because of a drug law violation, and another 

18 percent failed due to a charge for driving while intoxicated (Glaze, 2002). Many 

offenders are also estranged from family, 

jobs, and other social support systems. The 

above factors make integration into the 

community difficult. Connections with a 

crime- and substance abuse-free community 

are critical to their success. Faith-based 

communities offer just such a combination. 

Faith-based communities also offer other 

services to individuals and groups. These 

range from free lunch programs, to smaller, 

less formal services, spiritual counseling, 

and use of the organization’s property to 

host Alcoholics Anonymous meetings. Additionally, these organizations offer opportunities to integrate into a community and a 

social support network. Given the variety of 

such possible services, the need for multiple 

supports for reentering offenders, and the 

lack of information about such offerings, we 

decided to initiate an environmental scan of 

these types of activities in Johnson County. 

We also were interested in how faith-based 

organizations would react to government 

grant support for their efforts. In addition, we contacted community corrections 

(probation and parole) officers and a local 

substance abuse treatment and prevention agency for their views and perceptions 

of client needs and their relations, and we 

examined their current relationships with 

local faith-based organizations.

Method

The Consortium identified three target 

groups with a potential to provide information regarding community outreach in this 

area:

(1) Sixth Judicial Correctional Services, 

Coralville, Iowa, is the Johnson 

County community-based organization 

Figure 1. Number of Sentenced Prisoners Released From State or 

Federal Jurisdiction: Iowa 1977–1998

An Environmental Scan of Faith-Based and Community Reentry Services

1977 1980 1983 1986 1989 1992 1995 1998

500

0

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

Number of Offenders Released

Year
NRADAN Awards for Excellence 2004

52

providing correctional supervision for 

probation and parole clients reentering 

the community. 

(2) The Mid-East Council on Chemical 

Abuse (MECCA) in Iowa City is the 

local community-based organization 

that provides treatment and prevention 

services to adults, children, and families 

in Johnson County. MECCA’s input 

is valuable because the majority of 

its residential clients are correctional 

clients as well. Such an agency can 

provide information about faith-based 

connections that are currently available 

and assist in assessing the needs of 

clients reentering the community. 

(3) Johnson County faith-based 

organizations have developed their own 

unique outreach missions, and several 

organizations are part of an interchurch 

coalition that addresses larger issues on 

a countywide basis. 

The Consortium developed a template for a 

semistructured interview process to gather 

specific information concerning corrections, 

substance abuse prevention and treatment, 

and faith-based organizations. Phone calls, 

face-to-face interviews, and focus groups 

were conducted to collect assessment data 

regarding the services in Johnson County 

that might be beneficial to reentry clients 

either coming home to communities or relocating to new ones. 

The Consortium conducted a 1-hour focus 

group with five staff members from the 

Sixth Judicial District parole/probation 

unit. The group included administrators, 

supervisors, parole/probation officers, and 

counselors. A 1-hour face-to-face interview 

with the Director of Services at the Sixth 

Judicial District also was completed. The 1-

hour focus group session with six members 

of the MECCA staff included counselors, 

case managers, clinical supervisors, and 

residential support technicians. 

Efforts to survey faith-based organizations 

in Johnson County in regard to their 

outreach and community service work were 

initiated by contacting a convenience 

sample of 15 rural and urban organizations. 

The organizations approached were diverse 

in size and included Christian, Jewish, and 

Muslim faiths. The phone contact invited 

participation in a 45-minute interview 

with Consortium representatives. The 

Consortium staff completed 11 face-to-face 

interviews from April 8 through May 27, 

2003. 

Results

1. Sixth Judicial District Community

Corrections

The administrators, supervisors, parole/

probation officers, and counselors from the 

Sixth Judicial’s focus group identified several challenges facing clients as they work 

to reenter the community after incarceration. Information from the focus group 

session is summarized below:

The group estimates that 80–85 percent 

of its probation and parole clients also are 

working to remain clean and sober while 

they seek a more supportive community 

structure. The group noted that clients 

must work hard to change their associations and their community support in 

relation to criminal behavior and substance 

abuse. 

Appropriate jobs are much less available 

than 4 or 5 years ago, and the hourly wage 

has also decreased. Many clients do not 

have driving privileges and/or cannot afford 

vehicles or insurance. Medical services 

are often unavailable because of unsettled 

debts from back bills left unpaid, lack of 

insurance, and inability to pay hospital 

fees. Unless a crisis situation demands 

emergency care, mental health waiting lists 

through local community mental health 

systems are backlogged 12–16 weeks for 

assessment/evaluation. Limited beds for 

detox are a huge problem as relapse 

occurs. At times, relapsing adults end 
53

up reincarcerated or are sent home with 

family members who are not skilled in provision of safe care, simply because detoxification services or immediate treatment is 

not available. 

Interview respondents reported 

that their client assessments 

include questions about interest in 

church or other spiritual avenues. 

When a client expresses an interest in faith-based support, however, correctional staff members 

often feel they do not have enough 

information to be of assistance. 

No formal organizational links 

exist between faith-based initiatives and 

corrections, but several staff members, as 

individuals, have referral ideas for clients 

interested in faith-based support. 

Johnson County has a Circles of Support 

and Accountability Group which follows a 

restorative justice model that asks clients 

who are about to reenter the community 

to make a commitment to a self-selected 

support group. This “circle” meets regularly with the individual to hold him or her 

accountable for remaining crime free, drug 

free, and alcohol free, as well as to provide 

support when the individual faces difficult 

times and challenges. Circles of Support 

and Accountability programs are in their 

infancy in Johnson County. 

Focus group respondents expressed interest 

in improving the linkages with faith-based 

initiatives. They think their clients would 

respond in a positive way. Community 

churches and synagogues would be a positive place to begin the long road to establishing or reuniting the individual with a 

supportive, healthy community. 

The parole and probation officers suggested 

that some assistance would be helpful, such 

as brochures that list county faith-based 

initiatives, referral contact information, and 

a brief description of what it would be like 

to go to a service. Clients often report hesitation about starting over at a church, wondering what they would need to wear, and 

having many fears about what others will 

think “when people find out what they have 

done and where they have been.” 

Respondents also felt that educational 

assistance would be beneficial for community volunteers who want to serve this 

reentry population. Often the best of intentions in volunteers can lead to frustration 

due to lack of understanding about how 

many obstacles reentry adults face and how 

addiction recovery plays a significant role in 

their success. It would be important for the 

collaboration and communication between 

faith and mandated services to be open and 

clear so that Sixth Judicial Services could 

help volunteers understand what needs 

to happen from a community corrections 

perspective. The group felt that, through 

education, people could truly help and not 

enable reentry persons to continue to take 

advantage of a system that is not effectively 

linked. 

Respondents concluded by stressing that 

sustainability of community support is the 

answer to success. Band-aid services and 

professional organizations that assist in 

early reentry are great for short-term support, but the long hard work of staying free 

of crime and substances is dependent on 

how supportive the community is long after 

the professionals are no longer providing 

services. To ensure that, years down the 

road, a reentry client has the support needed 

to be successful, the service provision for 

support must come to the neighborhood and 

not the reverse. Faith-based initiatives could 

“Going to a new church is a great 

vulnerability for most of the clients.... 

It would help me to know I was sending 

them to a welcoming place.”

An Environmental Scan of Faith-Based and Community Reentry Services
NRADAN Awards for Excellence 2004

54

start small with social meetings that allow 

people to meet and learn about one another. 

Faith-based organizations are viewed as an 

excellent way for clients to begin to make 

new supportive choices for themselves and 

as a chance for them to contribute rather 

than just benefit from outreach services. 

2. MECCA Substance Abuse Services

Counselors, case managers, residential 

support technicians, and clinical supervisors who participated in the focus group 

reported the following criminal justice 

involvement for clients receiving services:

Outpatient

Clients

Residential

Clients

Probation/Parole

Involved

50–60% 40–50%

Criminal Justice

Involved, Including

DUI

95% 70%

The group was asked to list the greatest 

obstacles facing recovering reentry adults 

who are reestablishing themselves in the 

community. The responses included:

• Clients must establish a new community 

that supports their new choices to be 

substance free.

• Johnson County has an affordable 

housing shortage. A shortage of beds for 

the homeless and transition shelter beds 

is also a problem.

• Limited employment options for reentry 

clients place a tremendous strain on 

clients. If there is a job, the wage is often 

not enough to get clients out the financial 

hole most find themselves in when leaving 

treatment.

• Clients face transportation barriers in 

seeking and maintaining employment—

they have no driver’s license or vehicle.

• Social Security Disability program 

qualification procedures are too difficult 

for most clients with co-occurring 

disorders to move through to get disability 

status, even though they need it. For 

example, a client with schizophrenia may 

have a difficult time following through 

on a required series of appointments 

and tasks long enough to qualify for the 

assistance to receive needed medication. 

• Most clients have no insurance. 

• Mental health service access is a 

substantial problem. The waiting time for 

mental health evaluation referrals from 

MECCA is 8–10 weeks right now, except 

for a crisis or emergency.

• Clients have little ability to pay for 

medications that may be prescribed after 

the evaluation. 

• Clients sometimes do not fit the 

parameters for assistance and fall 

through the cracks when attempting to 

qualify for services. 

• Mental health transition resources are 

very hard to find, and delays in service 

can lead to relapse. 

• Respondents working with adolescent 

clients expressed frustration with how 

difficult it is to get schools to see the 

amount of substance use in schools as well 

as how difficult reentry to school is for 

clients.

MECCA employs case managers who work 

to set up client reentry. Their job is to 

establish relationships for the client with 

community resources. Case management 

success is driven by how effectively a case 

manager develops relationships and learns 

about available resources. Case management and client success are also affected 

by the effectiveness of the relationship 

between these individuals and how successfully the client’s motivation for change is 

identified. 

Respondents reported that physicians often 

are hard to work with because they do not 

have the training they need to value the 
55

importance of probing questions to assess 

addiction in clients. Physicians may 

dispense addictive medications and/or may 

switch an antidepressant the client is using 

and never know that the prescribed medication is not working because of daily alcohol 

or marijuana use. 

Respondents would like community leaders 

to know that the community still has much 

to learn about how substance abuse affects 

every part of an individual’s life as well as 

the cost of substance abuse to society in 

every layer of social structure. 

Spiritual wholeness is part of the education process for clients in treatment as case 

managers inform clients of the need for 

physical, mental, emotional, and spiritual 

health. Discussions are open and nondenominational. MECCA is considering reincorporating a chaplain into the treatment 

setting, but no funding is available at this 

time. If a client’s particular motivation is 

toward faith and church options, that client 

is encouraged to see whether that faithbased organization could be a place where 

he or she could establish a new community. 

Neither MECCA nor faith-based organizations contact one another formally 

regarding clients. Only an interested client 

initiates any contact. MECCA is concerned 

that some faith-based organizations are 

used by some clients who network with 

each other to take advantage of free assistance. Although they are grateful that community faith-based services are available to 

help, respondents thought that volunteers 

in various organizations need education to 

better understand substance abuse and how 

to best offer help to clients. All respondents 

agreed that both the potential for a new 

community and support for the needed life 

changes could naturally emerge from an 

enhanced network between agencies providing treatment services and local faith-based 

activities. 

3. Faith-Based Organizations

Eleven ministerial, rabbinical, and administrative respondents who participated 

in the individual face-to-face interviews 

represented both rural and urban settings 

in Johnson County. The range of 40–650 

members provided information on small 

churches getting started and renting worship space as well as large congregations 

that have been established in Johnson 

County for decades. Smaller organizations 

were mostly dependent on the member volunteers for service and mission offerings, 

while larger churches had associate ministers and support staff working to provide 

services to the congregation and the general 

community. Regardless of size or economics, all agreed that faith-based organizations could easily provide a perfect fit for 

someone needing to establish new friends, 

new community ties, and new support for 

their reentry into a life free of substance 

abuse and criminal activity. Although only 

three interviews described specific activities 

or missions geared to reentry concerns, all 

were certain that the regular program offerings for their memberships would equally 

serve any population, regardless of situation. The basis of their service is to provide 

for anyone in need. As one respondent said, 

“Everyone is looking for a place to belong. 

In one sense, we are a big anonymous support group. There is no requirement to 

reveal your history at our door in order to 

come in and be welcome.”

Particular activities and endeavors that 

would assist an adult looking for a new 

start include the following listed by the 

organizations interviewed:

• Study groups

• Weekly services

• Choir and music ministry

• Social justice and peace groups

An Environmental Scan of Faith-Based and Community Reentry Services
NRADAN Awards for Excellence 2004

56

• Mentoring youth

• Moms’ groups

• Men’s groups

• Bible or scripture study groups

• Sports leagues

• Spiritual retreats

• Journey-in-faith groups

• Basic faith education classes

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

including:

• Rental assistance

• Emergency housing support

• Food and clothing banks

• Transportation assistance

• Conflict resolution education

• Free lunch programs

• Free medical clinics

• Yard work assistance

• Elderly assistance projects

• College student services/counseling

• Daycare for those who cannot afford it

• Open and affirming support for the 

gay, bisexual, lesbian, and transgender 

communities

• Circles of Support and Accountability 

groups

• Various 12-Step meetings

All respondents recognized the existence 

of adults struggling with substance abuse 

issues within their memberships, whether 

the adults are concerned family and friends 

or congregation members. Three of the 

faith-based organizations have active programs to assist recovery clients in spiritual 

growth. They provide the support needed to 

understand how an affirming spiritual faith 

can enhance and enrich an individual’s 

desire to remain in recovery. Those respondents suggested that education regarding 

substance abuse, addiction treatment processes, and correctional procedures would 

be helpful to volunteers who are working 

with this particular population. 

All respondents reported general satisfaction with Johnson County’s referral network. All believed they had sufficient access 

to find resources to help anyone who came 

to them with a particular need, substance 

abuse included. Most respondents have 

developed an extensive informal system for 

making referrals. For instance, if someone 

requested a referral for substance abuse 

treatment, a minister might ask another 

member of the congregation who, the minister knew, had received treatment.

According to those interviewed, no formal 

organizational contacts currently exist 

between MECCA, Sixth Judicial Services, 

and faith-based organizations. Respondents 

interviewed generally agreed that such 

networking would improve the opportunities for adults who are reentering the community and express interest in connecting 

or reconnecting to a faith-based group. One 

respondent strongly suggested that treatment agencies improve their process of 

releases. Agencies need to make sure that 

clients receiving treatment, who are active 

in a church and request such help, are 

allowed to pursue the consents and releases 

of information necessary to have clergy 

involved and active in their treatment transition. Several respondents indicated that 

misperceptions regarding the separation of 

church and State have created barriers to 

working together. 

Almost unanimously, Johnson County faithbased organizations want the community to 

know that they are open, accepting, more 

welcoming, and less judgmental than their 

counterparts of 20–30 years ago. 
57

The respondents were asked to comment on 

Federal support for faith-based initiatives 

that serve those in most need. Most respondents reported curiosity, but they had little 

confidence that the Government would be 

able to offer funding without compliance 

and accountability issues so rigid that the 

money could not be accepted. Varied comments and concerns included:

• We need staffing money to continue what 

we already do.

• We don’t need to start something new 

here; we have plenty going on; we simply 

need better financial support.

• Our faith community has grave 

concerns that competition for funding 

would disrupt an already successful 

collaborative effort. 

• Society should provide a baseline 

of care regardless of faith, and our 

current administration is shirking that 

responsibility and putting it on us. 

• If the government would effectively fund 

the mandated programs for children, 

the disabled, the mentally ill, and those 

addicted, we could do our spiritual work 

with no funding needed. 

• Some expressed concerns that the funding 

provisions would be for Christians only.

• This type of funding is viewed as just one 

more costly layer of bureaucracy.

• Some are concerned about “coercion to 

convert before service provision.”

• More money should be channeled to 

families, peace efforts, and not the 

military war machine.

• Give the money to those who have a 

good service track record, and let them 

continue or expand what they are doing. 

• Federal money would restrict and deny 

our religious freedom rights as well as 

our work with substance-abusing adults. 

Some consider addiction a spiritual issue 

that can be solved by accepting and 

following Christ. 

• Some doubt that the government could 

give money without demanding an 

impossible return.

• Outreach is service—what we do, how we 

live—not a reason to apply for money or 

count how many and whom we serve. 

• A longstanding antichurch bias has 

changed the United States from a nation 

based on “freedom of religion” to a nation 

based on “freedom from religion.” 

Summary and 

Recommendations

Faith-based organizations in Johnson 

County provide a wide variety of services 

to the community. Some services are direct 

giving (e.g., housing assistance, yard work 

assistance, clothing, food, and transportation), either by the organization or by 

smaller groups of people within the community. Other services are less direct but offer 

support to the community, such as housing 

Alcoholics Anonymous meetings and supporting free lunch programs and medical 

clinics. The service provision also varies 

widely, ranging from a formalized free 

lunch program to individual members working together to assist an individual. The 

informal nature of many services makes it 

difficult to determine the exact numbers of 

individuals served, how often, or how many 

services are provided.

Both the correctional staff and the substance abuse treatment staff felt that faithbased communities need some education to 

deal with the reentry population. Several 

topics mentioned would protect both the 

faith-based community and the person 

seeking integration from potentially 

unrealistic expectations. For example, substance abuse treatment professionals and 

An Environmental Scan of Faith-Based and Community Reentry Services
NRADAN Awards for Excellence 2004

58

the probation/parole officers did not want 

the faith-based community to burn out or 

have a sense of failure when an individual 

relapsed to substance abuse, particularly 

because substance abuse is a chronic disease with a continual chance of relapse. 

Improved communication among the 

Department of Corrections, substance 

abuse treatment providers, and the faithbased community would improve the faithbased community’s capacity to deal with 

reentering people. Because much of the 

faith-based community’s referral network 

is based on informal knowledge and word 

of mouth, individualized and personal contacts would likely be the most effective and 

self-sustaining.

This project provides a first look at the role 

faith-based organizations play in assisting 

people reentering the community. We suspect that these organizations play a much 

greater role than our introductory scan suggests, because the informal nature of their 

assistance is not well documented. Given 

the opportunity, these communities could 

do even more to enhance people’s chances 

for successful reintegration and to reduce 

recidivism. Training, support, and even a 

small infrastructure would vastly increase 

these organizations’ capacity to provide 

these benefits to a larger group of reentering individuals.

References

Bureau of Justice Statistics, U.S. 

Department of Justice. (2000). Total 

sentenced prisoners released from State 

or Federal jurisdictions. Washington, 

DC: Bureau of Justice Statistics, 

National Prisoner Statistics Data Series 

(NPS-1). (Web site: www.ojp.usdoj.

gov/bjs/dtdata.htm#corrections, 

filename:corpop22.wk1.)

Glaze, L. E. (2002). Probation and parole in 

the United States, 2001. NCJ 195669. 

Washington, DC: U.S. Department of 

Justice, Bureau of Justice Statistics.

Harrison, P. M., & Karberg J. C. (2003). 

Prison and jail inmates at midyear 

2002. NCJ 198877. Washington, DC: 

U.S. Department of Justice, Bureau of 

Justice Statistics.

Iowa Department of Corrections. (2002). 

Strategic plan 2002. Des Moines, IA: 

Iowa Department of Corrections. 

Langan, P. A., & Levin, D. L. (2002). 

Recidivism of prisoners released in 

1994. NCJ 193427. Washington, DC: 

U.S. Department of Justice, Bureau of 

Justice Statistics. (Web site: www.ojp.

usdoj.gov/bjs/pub/pdf/rpr94.pdf.)

Mumola, C. J. (1999). Substance abuse and 

treatment, State and Federal prisoners, 

1997. NCJ 172871. Washington, DC: 

U.S. Department of Justice, Bureau of 

Justice Statistics.

Mumola, C. J., & Bonczar, T. P. (1998). 

Substance abuse and treatment of 

adults on probation, 1995. NCJ 166611. 

Washington, DC: U.S. Department of 

Justice, Bureau of Justice Statistics. 
59

Substance Abuse Among Rural and 

Very Rural Drug Users at Treatment 

Entry*

Marlies L. Schoeneberger, Ph.D.

Carl G. Leukefeld, D.S.W.

Matthew L. Hiller

Michael Townsend

Center on Drug and Alcohol Research

University of Kentucky Medical Center

Lexington, KY 

Contact information:

Corresponding Author: Marlies Schoeneberger, Ph.D. 

2868 Central Park Boulevard

Denver, CO 80238

Phone: (303) 371–8155

Fax: (303) 307–2514

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

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

Abstract

Historically, researchers and policymakers concerned with the problems of substance abuse 

have focused their attention almost exclusively on urban America. However, this focus now 

includes the special needs of rural areas. In the past, rural areas were more sheltered from 

the problems of mainstream America, but now mass communication has decreased the 

isolation of rural areas. This study examines rural and very rural drug users. The distinction between rural and very rural is discussed in this paper, acknowledging that there are 

different definitions. This paper classified rural areas as those with populations between 

2,500 and 19,999 people and very rural areas as those with populations fewer than 2,500 

people. Topics include: (1) demographic and other selected background characteristics of 

rural and very rural drug users admitted to substance abuse treatment, (2) lifetime drug 

use patterns, (3) current drug use, (4) age of first drug use, (5) recognition of drug abuse as 

a problem, and (6) correlates of drug use behavior to identify potential predisposing factors. 

It was hypothesized that drug users from very rural areas would be more sheltered and that 

the severity of their involvement with drug use would be less than that of drug users from 

rural areas. Between November 15, 1999, and January 31, 2001, face-to-face interviews were 

conducted in three geographic regions of Kentucky (N = 604): in Eastern Kentucky (n = 206) 

and in South Central Kentucky (n = 165)—both frequently considered rural (N = 371)—and 

in Western Kentucky (N = 233)—which is considered more urban. More than one half (57 

*This project was supported by the Center for Substance Abuse Treatment and Substance Abuse and Mental Health 

Services Administration Cooperative Agreement, Grant number: 6 UR1 TI11613-01-1
NRADAN Awards for Excellence 2004

60

Introduction

Historically, researchers and policymakers who were concerned with substance 

abuse problems focused their attention 

almost exclusively on urban America. 

More recently, however, this focus shifted 

to include the special needs of people in 

rural areas. For example, chronic economic 

disadvantages in rural areas have been 

highlighted as one of the main reasons for 

persons in those areas having increased 

health risks, which include emotional, 

behavioral, and substance use problems 

(Conger & Elder, 1994). In the past, rural 

areas may have been more sheltered from 

the problems of mainstream America. 

Because of mass communication, however, 

rural areas are no longer isolated.

Evidence is increasing of a symbiotic relationship between urban and rural drug 

traffickers, as urban drug dealers find new 

drug markets in rural areas, and rural 

drug manufacturers sell in urban areas 

(O’Dea et al., 1997). This symbiosis is also 

visible in the substance abuse prevalence 

rates in urban and rural areas. Epidemiological trends show that substance abuse 

in urban and rural areas of the United 

States has become similar (Wagenfeld et 

al., 1994), although the drugs of choice vary 

somewhat. For example, in earlier studies 

comparing urban and rural treatment populations, marijuana, amphetamines, and 

sedatives were the preferred drugs among 

rural clients, whereas urban clients preferred opiates (Brown et al., 1977; 

NASADAD, 1991).

The rural environment has changed the 

fortunes in rural America. Although some 

rural people are wealthy, most of rural 

America has experienced devastating economic setbacks in the farming, manufacturing, and mining industries (Conger, 1997) 

during the past two decades. As a result, 

the myth of rural America as a stress-free 

bastion of serenity and health has been 

dispelled. Indeed, research has shown that 

rural Americans suffer socioeconomic disadvantages similar to persons living in poor 

urban neighborhoods (O’Hare & CurryWhite, 1992). Furthermore, economic stress 

is associated with a greater risk for mental 

disorders and functional impairment in 

rural as well as urban settings (Brody et 

al., 1994; Conger et al., 1994; Kessler et al., 

1994; McLoyd et al., 1994).

Chronic economic stress has had a long 

history in many parts of the rural South. 

Among the manifestations of economic 

stresses in rural areas is what Davidson 

(1996) called “America’s Rural Ghetto.” 

Characteristically, such areas have the 

most disadvantaged and elderly proportion 

of the population—due to the out-migration 

of the most affluent, educated, and younger 

rural people—not unlike inner-city urban 

areas (Wilson, 1996). Whether such rural 

economic stresses are chronic or recent, economic deprivation is a common characteristic of social environments that increase the 

risk for substance abuse (Conger, 1997).

In an effort to establish criteria for what 

they called “the underclass,” O’Hare and 

Curry-White (1992) used census data to 

percent) of the participants were admitted to outpatient treatment. The majority of participants were male (75 percent), were white (94 percent), had no religious preference (51 percent), and had been referred to by the criminal justice system (64 percent); 55 percent had 

a prior history of substance abuse treatment. Findings indicate that being from very rural 

areas may be somewhat protective, with lower current drug use and older age at drug use 

initiation. While alcohol remains the most used substance in terms of lifetime and current 

use, cocaine use was three times higher in rural areas than in very rural areas. Implications are discussed and recommendations are presented for substance abuse treatment 

providers and policymakers.
Substance Abuse Among Rural and Very Rural Drug Users at Treatment Entry

61

define four common characteristics of this 

group. They tend to (1) have not completed 

high school, (2) receive public assistance, 

(3) be single mothers, or (4) be long-term 

unemployed males. O’Hare and CurryWhite (1992) also found that in 1990, 3.4 

percent of inner-city residents could be 

categorized as underclass, compared to 2.4 

percent of rural residents. Only 1.1 percent 

of urban residents not in the inner-city met 

the underclass criteria. These findings demonstrate differences within urban populations. If these kinds of distinctions occur in 

urban populations, it could be hypothesized 

that similar distinctions will occur in rural 

populations. If inner-city and not-innercity populations are different, then perhaps rural populations can be compared by 

examining rural areas and very rural areas.

In 1990, according to the Bureau of the 

Census (1993), about 62 million Americans (24.8 percent of the total population) 

lived in rural areas; the other 75.2 percent 

resided in places defined as urban. Implicit 

in the above comparison is that the definitions of rural and urban are not entirely 

clear. For example, the definition of “rural” 

has been applied to places with populations 

of less than 20,000 as well as to populations 

of less than 2,500 (Conger, 1997; Dahmann 

& Dacquell, 1992; Edwards, 1997; Patton, 

1989). Places with 50,000 or more inhabitants are often referred to as urban (Hewitt, 

1989; Leukefeld et al., 2002; Ricketts, 

Johnson-Webb, & Taylor, 1998; Warner & 

Leukefeld, 2001). According to these definitions, rural areas are areas not considered 

urban. The problem with this dichotomy 

is that it leaves a large gray area often not 

captured when this definition is used for 

individuals living in areas with populations 

of more than 2,500 but fewer than 50,000 

inhabitants. This omission is important, 

as rural residents represent about onefourth of the total U.S. population (Bureau 

of the Census, 1993) and one-third of the 

country’s poor (Rural Clearinghouse, 1993). 

About a decade ago, in an effort to be more 

inclusive of rural populations, Leukefeld 

and colleagues (1992) applied a very conservative definition to the term rural, which 

they termed “very rural” (p. 103). In their 

research on rural drug use, based on the 

1985 National Household Survey on Drug 

Use, “rural” was defined as “unincorporated areas of under 2,500 residents” (p. 

103). More recently, Warner and Leukefeld 

(2001) examined differences in substance 

use and treatment use among prisoners 

within rural populations. They defined 

“rural” as places with a 1990 population of 

2,500–49,999 not within an urbanized area; 

“very rural” was defined as places with populations of less than 2,500 persons outside a 

census-defined urbanized area (p. 269).

Like the rest of the United States, rural 

America is multiethnic. Although they are 

heterogeneous in ethnic composition, rural 

Americans share common characteristics, 

such as individualism (associated with feelings of self-sufficiency and strong ties to 

family and clan), isolation (associated with 

limited access to role models for individual 

and group behavior and meeting community needs), intense religiosity (providing 

rigid norms and the potential for normative 

conflict), conservatism (in a form that is, 

however, tolerant of bizarre behavior that 

fits into the community framework), distrust toward newcomers (anyone who might 

challenge their way of life by introducing 

new ideas or new technologies), and economic deprivation (a consequence of labor 

market trends and technological advances) 

(Beltrome, 1978). These characteristics represent research barriers in rural areas, and 

they are common to these populations. In 

the context of substance abuse, issues such 

as isolation (as a function of location) and 

limited employment opportunities (due to 

accessibility) may contribute to problems, 

such as mental health problems, as well as 

increased poverty (Leukefeld et al., 1992). 

To be more specific, people living in rural 

areas represent a multitude of ethnic and 

cultural traditions, ranging from Native 

Americans to Hmong tribespeople from 

Southeast Asia in rural Iowa and to 
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African Americans in the rural South 

(Conger, 1997). As a function of this diverse 

background, rural America is characterized 

by varying histories of discrimination, disadvantage, and cultural practices, which, in 

turn, can affect attitudes toward the use of 

illegal substances and alcohol. 

Using data from the 1985 National Household Survey on Drug Abuse, Leukefeld and 

colleagues (1992) pointed out that across 

all age groups, marijuana and cocaine use 

in “truly” rural areas was at lower levels 

than in large metro, small metro, or nonmetro areas. Although they found that rural 

drug use was extensive and that alcohol 

use in rural areas was similar to that in 

urban areas, they indicated rural residents’ 

reported illegal drug use, while lower than 

their urban counterparts’, was at an unacceptable level.

Other studies have examined drug use preferences among urban and rural substance 

abuse treatment populations. These studies revealed that the drugs of choice for 

clients in rural treatment programs were 

marijuana, amphetamines, and sedatives 

and for urban clients, opiates (Brown et al., 

1977; NASADAD, 1991). A recent study by 

Leukefeld and colleagues (2002) showed 

that use of marijuana and sedatives was 

more frequently reported by rural respondents, and use of cocaine by urban respondents. On the basis of these studies, alcohol 

use was clearly identified as the substance 

of choice (Leukefeld et al., 1992, 2002).

The current study uses data from drug 

users entering treatment to contribute to 

the limited knowledge on rural drug use. 

Specifically, we compare drug use patterns 

between rural and very rural drug users 

entering substance abuse treatment in 

Kentucky—a predominantly rural State. 

Along with providing a more comprehensive 

understanding of rural drug use in general, differentiating between rural and very 

rural clients could have important implications for identifying factors associated with 

risk for substance abuse as well as with 

the success of substance abuse treatment 

programs in rural locations. This study 

therefore examines: (1) demographic and 

other selected background characteristics 

between rural and very rural drug users 

admitted to substance abuse treatment, (2) 

lifetime drug use patterns, (3) current drug 

use, (4) age of first drug use, (5) whether 

drug use is recognized as a problem, and 

(6) correlates of drug use behavior to identify potential predisposing factors. The 

study’s hypothesis is that drug users from 

very rural areas are more sheltered and the 

severity of involvement with drug use is 

lower than in drug users from rural areas.

Method

Participants for this study were recruited 

into a Center for Substance Abuse Treatment (CSAT)-sponsored cooperative agreement project titled Treatment Outcomes and 

Performance Pilot Studies Enhancement

(TOPPS II). Participants were drug users 

admitted to publicly funded treatment 

programs in three regions in Kentucky. 

Between November 15, 1999, and January 

31, 2001, data were collected in face-to-face 

interviews by trained data collectors using 

a structured questionnaire. Interviews 

were held in three geographic regions of 

Kentucky (N = 604): Eastern Kentucky (n 

= 206) and South Central Kentucky (n = 

165)—both considered rural (N = 371)—and 

Western Kentucky (N = 233)—which is considered more urban. Although the majority 

of subjects (N = 199, 85 percent) from the 

urban programs were admitted to residential treatment, the majority of participants 

(N = 273, 74 percent) from the rural sites 

were admitted to outpatient treatment 

facilities.

The current study includes drug users who 

were admitted to one of the three participating treatment centers and who agreed to 

participate in the TOPPS II study. 
Substance Abuse Among Rural and Very Rural Drug Users at Treatment Entry

63

Eligibility criteria included (1) having been 

admitted to substance abuse treatment, 

(2) being at least 18 years of age, (3) not 

being admitted only for education purposes 

(e.g., for driving under the influence), and 

(4) not being admitted only for mental 

health or mental retardation treatment. 

Dual diagnosis with substance abuse was 

an acceptable criterion for eligibility. 

Baseline data were collected through 

face-to-face structured interviews lasting 

an average of 30 minutes (with a range 

between 10 and 67 minutes). The Addiction 

Severity Index (ASI) Lite (modified) was 

used as the baseline questionnaire. The 

ASI Lite was modified to meet the needs 

of the CSAT cooperative agreement. The 

questionnaire included measures from the 

ASI (McLellan et al., 1980; McLellan et 

al., 1992), the TOPPS II Core Data Items, 

as well as the Treatment Event Data Set 

Items. In addition to demographic and other 

relevant background information, data 

were collected on the following six domains: 

medical status, employment/support status, 

alcohol/drug use, legal status, family/social 

status, and psychiatric status. Demographic 

locator data, including the city and county 

that participants considered their “home 

base,” were also obtained to allow for a 

series of followup interviews after their 

treatment episodes had ended.

Measures

Rural and Very Rural

The definition of urban and rural is somewhat ambiguous. Although some define 

rural simply as non-metropolitan areas, 

others define rural as places having a population of fewer than 20,000 people; still 

others describe as rural areas having fewer 

than 2,500 people (Bureau of the Census, 

1993; Edwards, 1997; Luekefeld et al., 

1992; Robertson & Donnermeyer, 1997). 

Recently, a case has been made for using 

an urban–rural continuum instead of the 

rather crude urban–rural dichotomy, which 

does not seem to capture urban–rural differences adequately (Conger, 1997; Patton, 

1989; Hewitt, 1999). A recognized research 

practice for defining such a continuum is 

the application of rural–urban continuum 

codes (Beale & Johnson, 1995; Butler & 

Beale, 1994). This classification scheme 

distinguishes metropolitan counties by size 

and non-metropolitan counties by degree of 

urbanization and proximity to metro areas. 

The standardized Office of Management 

and Budget metro and non-metro categories have been subdivided into four metro 

and six non-metro categories, resulting in a 

10-part county codification (Ricketts et al., 

1998). As Leukefeld and colleagues (2002) 

pointed out, this differentiation has limited 

utility for practitioners and policymakers. 

Therefore, the intent of this study was to 

define further the rural dimension. For this 

purpose, we applied Beale codes to county of 

residence, which was identified by participants as their “home base,” captured in the 

question: “What town, county, and State do 

you consider your home base or permanent 

residence?”

Because the focus of this study was to 

examine and describe differences in substance abuse as a function of rurality, the 

total sample (N = 604) was reduced to those 

participants with a home county that was 

classified by the rural–urban continuum 

codes of Beale and Johnson (1995), ranging 

from 6 to 9 (N = 478). The selection criteria for the Rural group (N = 310) included 

home county codes of 6 and 7, representing 

a population of between 2,500 and 19,999. 

The selection criteria for the Very Rural 

group (N = 168) included home county codes 

of 8 and 9, representing a completely rural 

population of fewer than 2,500 people in an 

area. Thus, drug users at substance abuse 

treatment entry from rural areas (population more than 2,500 but less than 20,000) 

were compared with those from very rural 

areas (population less than 2,500).
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Table 1. Characteristics of a Rural Population Entering Substance Abuse Treatment

Variables Rural

(n = 310)

Very Rural

(n = 168)

Total (N = 478)

Percent df c2 or F Sig (p)

Program Modality 1 1.534 .216

Residential 45% 39% 43%

Outpatient 55% 61% 57%

Average Age (Range 18–74) in Years

Median Age in Years

32.69

32

34.60

33

33.36

32

1 4.130 .043

Male 75% 77% 75% 1 .302 .583

Race/Ethnicity 2 7.053 .029

White 94% 94% 94%

Black 5% 2% 4%

Other 1% 4% 2%

Religious Preference 2 4.807 .090

Protestant/Catholic 33% 24% 30%

Other 19% 21% 19%

None 48% 55% 51%

Marital Status 2 .308 .857

Married/Remarried 27% 29% 27%

Widowed, Separated, Divorced 40% 40% 40%

Never Married 33% 31% 33%

High School or Above 57% 49% 54% 1 2.178 .140

Not Employed 57% 70% 61% 1 7.722 .005

Average Current Nonemployment

Income (Range $0–$10,000)

$440 $551 $479 1 1.732 .189

Median $230 $324 $280

Admission Suggested by Criminal

Justice System

65% 63% 64% 1 .102 .750

Had Prior Substance Abuse

Treatment

58% 49% 55% 1 2.954 .086

Prescription Medication for Psychological/Emotional Problems: Lifetime

45% 39% 43% 1 1.372 .242

Has Chronic Medical Problems 31% 32% 32% 1 .037 .848

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

Sample

Demographic and other relevant background characteristics of the study participants are summarized in table 1. More than 

one-half of the participants were admitted to outpatient treatment (57 percent). 

The majority of participants were male 

(75 percent), were white (94 percent), had 

no religious preference (51 percent), had 

been referred to treatment by the criminal 

justice system (64 percent), and had a history of prior substance abuse treatment (55 

percent). Although 54 percent had a high 
Substance Abuse Among Rural and Very Rural Drug Users at Treatment Entry

65

school education or more, 61 percent were 

not employed. The median age of the study 

population was 32 (ranging from age 18 to 

age 74), and the median current nonemployment income was $280 per month (ranging 

from $0 to $10,000 per month).

Dependent Variables

Because most treatment-seeking models 

suggest that the severity of the problem is 

an important outcome predictor (Andersen, 

1995; Anderson & Newman, 1973; Hartnoll, 1992), the dependent measures used 

in this study were the number of years any 

drugs had been used, drug use in the 30 

days prior to treatment entry, the age at 

which drug use was initiated, and problem 

recognition.

Lifetime Drug Use

To examine lifetime drug use, we asked 

participants how many years they had 

ever used 1 or more of 11 substances and 

substance categories as well as about how 

many years they drank alcohol to the point 

of intoxication (key for intoxication: females 

= 2 or more drinks, males = 4 or more 

drinks). Lifetime drug use was assessed 

asking the question: “In your lifetime, how 

many years did you use [specific drug] at 

least 3 times a week?” This question was 

repeated for alcohol, heroin, methadone, 

other opiates/analgesics, barbiturates, other 

sedatives/hypnotics/tranquilizers, cocaine/

crack, amphetamines, marijuana/hashish/

THC, hallucinogens, and inhalants.

Current Drug Use

To examine current drug use, participants 

were asked about their use of the 11 substances and substance categories listed 

above during the previous 30 days and 

whether they had used multiple substances 

per day, including alcohol. Current drug use 

was assessed by asking the question: “In 

the past 30 days, on how many days did you 

use [drug]?”

Age at First Drug Use

To examine the age of drug use initiation, 

participants were asked: “How old were you 

when you first used [drug]?” This question 

was repeated for alcohol, opiates, tranquilizers/sedatives, cocaine/crack, stimulants, 

marijuana, hallucinogens, and inhalants.

Problem Recognition

To examine problem recognition, participants were asked whether they had 

experienced (1) alcohol and (2) drug problems, whether these problems troubled 

or bothered them, whether they thought 

they needed treatment for these problems, 

and how often had they recently attended 

self-help groups. Problem recognition 

was assessed asking the questions: “How 

many days in the past 30 days have you 

experienced (1) alcohol, (2) drug problems?”; “How troubled or bothered have 

you been in the past 30 days by these (1) 

alcohol, (2) drug problems?” (0 = not at all, 

1 = slightly, 2 = moderately, 3 = considerably, 4 = extremely); “How important to 

you now is treatment for these (1) alcohol, 

(2) drug problems?” (0 = not at all, 1 = 

slightly, 2 = moderately, 3 = considerably, 

4 = extremely); and “How many days have 

you attended self-help groups (Alcoholics Anonymous, Narcotics Anonymous, 

Cocaine Anonymous) in the past 30 days?” 

The effects of rurality were examined by 

entering a dummy variable “very rural” (0 = 

rural, 1 = very rural). Internal consistency 

reliability for this problem recognition index 

was good (Cronbach’s Alpha = .77).

Other Variables

To gain a better understanding of participants’ life circumstances, which may have 

either protective or facilitating effects on 
NRADAN Awards for Excellence 2004

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substance abuse among rural and very 

rural drug users, we analyzed variables 

related to demographic characteristics, 

economic stresses, substance abuse treatment availability and utilization, health, 

and criminal justice system involvement. 

To examine demographic characteristics, 

we included the following variables: age: 

median split (0 = younger than age 32, 1 

= age 32 or older); gender (0 = female, 1 = 

male); race (0 = white, 1 = black); religion

(0 = has no religious affiliation, 1 = has 

religious affiliation); marital status (0 = not 

single, 1 = single, never married); education

(0 = less than high school, 1 = high school 

or above). To examine economic stresses, we 

included the following variables: employment (0 = not employed, 1 = full- or parttime employed); nonemployment income. 

To examine substance abuse treatment 

availability and utilization, the following 

variables were included: treatment modality

(0 = residential, 1 = outpatient); substance 

abuse treatment history (0 = had no prior 

substance abuse treatment, 1 = had prior 

substance abuse treatment). To examine health, the following variables were 

included: chronic medical problems (0 = no, 

1 = yes); prescribed medications regularly 

for physical and/or psychological problems: 

lifetime (0 = no, 1 = yes). To examine criminal justice system involvement, the following 

variable was included: admission suggested 

by criminal justice system (0 = no, 1 = yes). 

To identify the effects of being either from 

rural or very rural areas, a dummy variable 

was included (rural = 0, very rural = 1).

Analytic Plan

Differences in demographic and other background characteristics between rural and 

very rural drug users were identified by 

using chi-square analyses for categorical 

variables and by using analysis of variance (ANOVA) for continuous variables. 

Ordinary Least Squares regressions were 

performed to further explore the impact 

of rurality on (1) substance abuse problem 

recognition and (2) drug use. Dependent 

variables were determined by conducting independent t-tests on all relevant 

substance abuse variables and comparing 

rural and very rural areas. Those variables 

which produced significant differences were 

then entered as dependent variables in the 

regression model. This was the case for 

lifetime use of methadone, other opiates, 

sedatives, cocaine/crack, marijuana, or multiple drugs; treatment for drug abuse; and 

attendance at self-help groups in the last 30 

days.

Results

Demographic Characteristics

Examination of demographic and other 

background characteristics of participants 

from rural and very rural areas showed that 

participants from both areas were similar in 

terms of the proportions of program modality, gender, marital status, religious preference, education, admission suggested by the 

criminal justice system, substance abuse 

treatment history, taking any prescription medication for psychological/emotional 

problems, and chronic medical problems. 

However, African-American subjects were 

significantly (p <.05) more likely to be from 

rural areas (5 percent vs. 2 percent), and 

those of “other” racial or ethnic background 

were more likely to be from very rural areas 

(1 percent vs. 4 percent). Also, significantly 

more subjects who were unemployed were 

from the very rural areas (57 percent vs. 

70 percent). On average, subjects from very 

rural areas tended to be significantly older 

(34.60 years) than those from rural areas 

(32.69 years).

Substance Abuse Among Rural and

Very Rural Drug Users

Tables 2 and 3 summarize differences in 

drug use prevalence—expressed in percent—of lifetime as well as of current (last 
Substance Abuse Among Rural and Very Rural Drug Users at Treatment Entry

67

30 days before the interview) drug use 

between rural and very rural drug areas. 

Table 2 shows that very rural lifetime drug 

users were significantly less likely to report 

using other opiates (39 percent vs. 27 percent), cocaine/crack (34 percent vs. 20 percent), marijuana (61 percent vs. 46 percent), 

and multiple drugs (57 percent vs. 42 percent). Furthermore, very rural lifetime drug 

users were marginally less likely to report 

using methadone (6 percent vs. 2 percent), 

barbiturates (9 percent vs. 4 percent), and 

amphetamines (23 percent vs. 16 percent).

Table 3 shows that for current drug use, 

participants from very rural areas were 

significantly less likely to be using cocaine/

crack (10 percent vs. 3 percent). Although 

no statistically significant differences were 

found between the two groups in the use of 

other types of drugs examined, it is interesting that current use of alcohol, barbiturates, and inhalants was marginally higher 

in very rural areas.

Differences in Age of First Drug Use

Among Rural and Very Rural Drug

Users

Table 4 shows that participants from very 

rural areas were older when they first used 

drugs (except for inhalants). This difference in the age of drug use initiation was 

significant for those who used tranquilizers 

or sedatives (rural: age 20.66 vs. very rural: 

age 22.95) and for those who used cocaine/

crack (rural: age 20.63 vs. very rural: age 

22.36).

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

Variables

Rural

(n = 310)

Percent

Very Rural

(n = 168)

Percent

Total

(N = 478)

Percent df c2 Sig

Fisher’s

Exact

(2-Sided)

Alcohol 81 86 83 1 1.711 .191

Alcohol to Intoxication 73 78 75 1 1.409 .235

Heroin 4 2 3 1 1.952 .162

Methadone* 6 2 4 1 3.717 .054

Other Opiates 39 27 35 1 6.507 .011

Barbiturates* 9 4 7 1 3.403 .065

Other Sedatives 30 23 28 1 3.235 .072

Cocaine/Crack 34 20 29 1 9.819 .002

Amphetamines† 23 16 20 1 3.426 .064

Marijuana 61 46 56 1 8.922 .003

Hallucinogens 14 9 12 1 2.496 .114

Inhalants‡ 3 3 3 1 .002 .964 1.000

Multiple Drug Use 57 42 52 1 9.450 .002

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

†Borderline significance. ‡1 cell (25%) has expected count less than 5. The minimum expected count is 4.92.
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Table 3. Current Drug Use: Rural vs. Very Rural

Variables

Rural

(n = 310)

Percent

Very Rural

(n = 168)

Percent

Total

(N = 478)

Percent df c2 Sig

Fisher’s

Exact

(2-Sided)

Alcohol 31 35 32 1 .631 .427

Alcohol to Intoxication 24 27 25 1 .649 .420

Heroin 0 0 0 – – –

Methadone† 1 .6 1 1 .509 .476 .661

Other Opiates‡ 21 14 19 1 3.498 .061

Barbiturates¶ 2 4 3 1 .710 .399 1.000

Other Sedatives 15 12 14 1 .788 .375

Cocaine/Crack* 10 3 7 1 7.210 .007

Amphetamines 5 4 5 1 .112 .738

Marijuana 27 22 25 1 1.142 .285

Hallucinogens** .6 .6 .6 1 .004 .947 1.000

Inhalants*** 0 .6 .2 1 1.849 .174 .351

Multiple Drug Use 22 19 21 1 .464 .496

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

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

‡Borderline significance.

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

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

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

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

Variables

Rural

(n = 310)

Mean

Very Rural

(n = 168)

Mean

Total

(N = 478)

Mean df F Sig

Alcohol 15.34 15.76 15.49 1 1.096 .296

Opiates 22.74 23.36 22.95 1 .340 .560

Tranquilizers, Sedatives* 20.66 22.95 21.45 1 5.647 .018

Cocaine/Crack* 20.63 22.36 21.16 1 4.810 .029

Stimulants 19.78 19.88 19.81 1 .018 .892

Marijuana 15.56 15.98 15.70 1 .938 .333

Hallucinogens 18.46 19.56 18.77 1 2.509 .115

Inhalants 14.50 14.00 14.38 1 .170 .681

*Items in bold are significant at the .05 level.
Substance Abuse Among Rural and Very Rural Drug Users at Treatment Entry

69

Substance Abuse Problem Recognition

Among Rural and Very Rural Drug

Users

Table 5 examines substance abuse problem 

recognition among drug users from rural

and very rural areas. The relationship was 

significant (b = .520, p<.001) between the 

number of days participants reported currently having alcohol problems and the 

degree to which they were troubled by 

them. The relationship was also significant 

(b = .641, p<.001) between the number of 

days participants reported currently having 

drug problems and the degree to which they 

were troubled by them. However, the model 

revealed no significant relationships in the 

degree participants thought treatment for 

alcohol or drugs was important, their recent 

attendance of self-help groups, or rurality. Overall, in terms of recognition of their 

substance abuse problems, the variation for 

alcohol (27 percent) and drug (41 percent) 

problems was explained by the degree to 

which participants were troubled by them.

Correlates of Substance Abuse Among

Rural and Very Rural Drug Users at

Treatment Entry

To gain a more comprehensive understanding of the impact of rurality on substance 

abuse, the variables age, gender, religion, 

marital status, education, employment, 

income, substance abuse treatment history, 

admission by criminal justice system, taking prescription drugs, and having chronic 

medical problems were included in a model 

to examine demographic characteristics, 

economic stresses, substance abuse treatment availability and utilization, health, 

and criminal justice system involvement. 

Table 6 shows that, for these rural and very 

rural drug users, admission to substance 

abuse treatment suggested by the criminal 

justice system (b = –.104, p<.05) and being 

from very rural areas (b = –.092, p<.05) 

were negative correlates for any methadone use. Being employed full or part time 

(b = –.094, p<.05) and admission to substance abuse treatment suggested by the 

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

Dependent Variables Had Alcohol Problems

(No. of Days Last 30 Days)

Had Drug Problems

(No. of Days Last 30 Days)

Independent Variables Beta Beta

Troubled by Recent Alcohol Problems* .520† .077

Troubled by Recent Drug Problems* .210 .641†

Importance of Treatment for Recent

Alcohol Problems*

.177 –.096

Importance of Treatment for Recent

Drug Problems*

.148 –.192

Recent Attendance at Self-Help Groups

(No. of Days in Last 30 Days)

–.040 .217

Very Rural .067 –.017

Overall Model Statistics

df 1 1

F 17.078 32.092

Sig .000 .000

R2 .271 .411

*Cronbach’s Alpha = .7732.

†Items in bold are significant at the .001 level.
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criminal justice system (b = –.143, p<.01) 

were negative correlates for any opiate 

use, while taking prescribed medications 

regularly for physical and/or psychological 

problems (b = .128, p<.01) was a positive 

correlate. Having had any prior substance 

abuse treatment (b = .117, p<.05) and taking prescribed medications regularly for 

physical and/or psychological problems (b = 

.139, p<.01) were positive correlates for any 

use of sedatives, and being from very rural 

areas (b = –.094, p<.05) was a negative correlate. Having had any prior substance 

abuse treatment (b = .186, p<.001) was a 

positive correlate for any cocaine/crack use, 

but being from very rural areas (b = –.119, 

p<.01) was a negative correlate. Being 

treated as an outpatient (b = –.133, p<.01) 

was a negative correlate for any marijuana 

use, and being male (b = .123, p<.01) and 

having had any prior substance abuse treatment (b = .158, p<.001) were positive correlates. Being treated as an outpatient (b = 

–.220, p<.001) was a negative correlate for 

any multiple drug use, while being age 32 

or older (b = .109, p<.05), having had any 

prior substance abuse treatment (b = .158, 

p<.001), and taking prescribed medications 

regularly for physical and/or psychological 

problems b = .096, p<.05) were positive correlates. Being employed full or part time 

(b = –.106, p<.05), admission to substance 

abuse treatment suggested by the criminal 

justice system (b = –.115, p<.01), and being 

from very rural areas (b = –.114, p<.05) 

were negative correlates for having been in 

any treatment for drug abuse, whereas having had prior substance abuse treatment (b

= .300, p<.001) and having chronic medical 

problems (b = .109, p<.05) were positive 

correlates. Having a religious affiliation (b

= .105, p<.05), having had prior substance 

abuse treatment (b = .146, p<.01), and having chronic medical problems (b = .118, 

p<.05) were positive correlates for recent 

attendance at self-help groups. No relationship was found between race/ethnicity, 

marital status, education, nonemployment 

income, and any of the examined drug use 

variables.

Discussion

Study participants from the very rural 

areas were more likely to be older and 

unemployed. This finding supports other 

studies (Brody et al., 1994; Conger et al., 

1984; Kessler et al., 1994; McLoyd et al., 

1994; Wilson, 1996; Wagenfeld & Wagenfeld, 1981) which refer to the effects of 

economic stresses on rural populations. 

Overall, however, drug users in this study 

from rural and very rural areas are more 

alike than different in their sociodemographic background. Their demographic characteristics are similar to those 

described by Davidson (1996) as representing the “new rural ghetto.” Davidson 

maintains that since the farm crisis in the 

1980s, many rural areas have been confronted with problems similar to those in 

inner-city areas. Citing the 1971 work of 

Bender, Green, and Campbell, he adds that 

an initial economic crisis, like the farm 

crisis of the 1980s, sets in motion a process that is influenced by some of the same 

social forces that affect the inner city. These 

forces include intergenerational poverty, 

class-selective migration—out-migration 

of more prosperous and younger residents, 

leaving behind aging communities characterized by more concentrated poverty—and 

an accelerated downward spiral resulting in 

“ghetto-like” conditions (Davidson, 1996).

In Kentucky, the effect of the farm crisis 

was magnified because “it came on the 

heels of the mining crisis” (Warner & 

Leukefeld, 2001, p. 276). As farming and 

mining are among the main income sources 

in rural Kentucky, this study shows some 

pronounced consequences of these two 

economic setbacks among persons admitted to substance abuse treatment in very 

rural areas. On average, these participants 

were older and—as one might expect—their 

unemployment rate was significantly higher 

than among participants in rural areas.

In the context of overall drug use, the 

findings from this study are similar to an 
Substance Abuse Among Rural and Very Rural Drug Users at Treatment Entry

71

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

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

Variables

Use in Lifetime (Beta values) Attendance at

Self-Help Groups

in Last 30 Days

(Beta values)

Methadone Other Opiate Sedative Cocaine/ Crack Marijuana Multiple Drugs Treatment for Drug Abuse

Outpatient –.133† –.220‡

Age 32 or Older .109*

Male .123†BlackHas a Religious Affiliation .105*SingleHigh School or AboveIs Employed Full or Part Time –.094* –.106*

Nonemployment IncomeAdmission Suggested by Criminal Justice System –.104* –.143† –.115†

Had Prior Substance Abuse

Treatment

.117* .186‡ .158‡ .158‡ .300‡ .146†

Takes Prescribed MedicationsRegularly for Physical and/orPsychological Problems

.128† .139† .096*

Chronic Medical Problems .109* .118†

Very Rural –.092* –.094* –.119† –.114†

Overall Model Statistics

df 2 3 3 2 3 4 5 3F 4.444 9.047 7.787 12.514 11.153 13.650 17.861 9.074Sig .012 .000 .000 .000 .000 .000 .000 .000R2 .019 .056 .049 .052 .068 .108 .164 .057

*p<.05,

p†<.01,

p‡<.001
NRADAN Awards for Excellence 2004

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earlier observation by Calahan and 

colleagues (1969), that drug abuse in rural

areas is a relatively new problem compared 

to alcohol use, which is both older and growing. We found that any alcohol use—including use to the point of intoxication—was 

higher in the very rural areas. This finding 

could be an artifact of social norms—alcohol is a legal substance and readily available, whereas illegal drugs are relatively 

expensive (Conger, 1997). Illegal drug use 

in this study was higher in the rural areas. 

Current barbiturate and inhalant use were 

exceptions. Drug use in rural areas also 

reflects age at drug use initiation, with the 

exception of inhalant use, which was higher 

in very rural areas.

Participants were significantly troubled or 

bothered by their current alcohol and drug 

abuse problems. Although the data are not 

significant, alcohol users were more likely 

than drug users to view treatment for their 

recent alcohol and drug problems as important. Alcohol users had attended fewer selfhelp groups than drug users, neither rural

nor very rural areas were significantly correlated with recent alcohol or drug use.

An examination of correlates of drug use 

and related issues, such as treatment for 

drug abuse and recent self-help group 

attendance, revealed that drug users from 

very rural areas were less likely than those 

from rural areas to use any methadone, 

sedatives, and cocaine/crack and were less 

likely to have received any drug abuse 

treatment. These negative correlates (see 

table 2) may be an indication that being 

from very rural areas is somewhat protective for certain drug use. However, the negative relationship between very rural and 

treatment for drug abuse is open and warrants additional research on the availability 

of treatment programs in very rural areas, 

their accessibility, referrals, and drug users’ 

problem recognition. With respect to substance abuse treatment, users of sedatives, 

cocaine/crack, marijuana, and multiple 

drugs were likely to have a substance abuse 

history with repeated treatment episodes. 

This history evokes the image of a revolving door and leads to the questions, “How 

successful are current substance abuse 

treatment approaches?” and “How can we 

change the status quo?” Specifically, participants who were employed, referred by 

the criminal justice system, and came from 

very rural areas were more likely to have 

had fewer treatment episodes. Those with 

chronic medical problems were likely to 

have had more treatment episodes. Older 

subjects (32 years or older), those who had 

a substance abuse treatment history, and 

those who took prescription drugs regularly 

were more likely to have used multiple 

drugs. On the other hand, subjects who 

were in outpatient treatment were less 

likely to have used multiple drugs. Male 

subjects and those who had a substance 

abuse treatment history were more likely 

to have used marijuana. As with our findings for multiple drug use, participants 

who were in outpatient treatment were less 

likely to have used marijuana.

We believe that our findings are of value 

to substance abuse treatment providers in 

rural and very rural areas. Providers can 

use these results for assessing specific drug 

abuse treatment needs in rural locations. 

For example, a better understanding of the 

effects of “rurality,” not only on drug use 

patterns and on substance abuse problem 

recognition, but also on the heterogeneity 

of rural populations (Edwards, 1997; Oetting, et al., 1997), will enable providers and 

policymakers to improve currently existing 

substance abuse treatment programs and/or 

to develop new programs. Our study shows 

that further research is needed to define 

specific needs so they may be implemented 

in new treatment approaches. In particular, 

“successful treatment” may need to be redefined. Completion of repeated treatment 

episodes does not fit the bill. When funding 

dollars are to be awarded, policymakers 

need to notice, and be willing to act on, the 

fact that one treatment approach may be 

too narrow.
Substance Abuse Among Rural and Very Rural Drug Users at Treatment Entry

73

Limitations associated with this study 

include its size. Because the sample for this 

study was not randomly selected, and data 

were collected only in one State (Kentucky), 

generalizability is limited. However, we 

wish to point out that firm adherence to the 

research protocol greatly reduced—if not 

eliminated—any chance for bias. We feel 

confident that our findings can be applied to 

other rural places. The data presented here 

were self-reported. Subjects consented to 

the study and were assured strictest confidentiality; thus we were not able to validate 

the self-reported data. As a group, drug 

users who are admitted to substance abuse 

treatment in rural facilities may not be 

representative of all substance abuse treatment seekers.

In conclusion, our findings indicate that 

being from very rural areas may have some 

sheltering properties, as indicated by lower 

current drug use and the generally older 

age at drug use initiation. 

Although no differences were found in alcohol use among subjects from both rural and 

very rural areas, alcohol is the most commonly used substance both currently and 

over a lifetime.

Cocaine use, on the other hand, was three 

times higher in rural areas than in very 

rural areas. While not markedly different in both areas, illegal drug use remains 

at unacceptably high levels. More than a 

decade ago, Leukefeld and colleagues (1992) 

reported similar findings. Subsequently, 

little has changed. However, participants 

in this study recognized they had substance 

abuse problems and were considerably 

bothered by those problems. Interestingly, 

participants were more bothered by their 

drug-related problems than by their 

alcohol-related problems. This difference 

is another indication that, despite the fact 

that it is the most used substance in both 

rural areas, alcohol is thought to be less 

problematic. These findings are important 

because they contribute to the very limited 

body of literature on substance abuse differences among rural populations. With a better understanding of the effects of “rurality” 

on different drug use patterns and on substance abuse problem recognition, providers 

and policymakers will be able to use data to 

improve currently existing substance abuse 

treatment programs and/or to develop new 

programs.

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77

Making the Addiction Severity Index 

User Friendly: An Electronic Display 

of Client Outcomes Using Shareware*

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

James Elzey, CMA

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

Contact information:

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

School of Accountancy

Daniels College of Business

University of Denver

2101 South University Boulevard

Denver, CO 80208

Phone: (303) 871–2028 

Fax: (303) 871–2016

E-mail: jsorense@du.edu

James Elzey, CMA

Bureau for Behavioral Health and Health

Facilities, WV Department of Health

and Human Resources

350 Capitol Street

Charleston, WV 25301–3702

Phone: (304) 558–3627

Fax: (304) 558–1008

E-mail: jelzey@wvdhhr.org

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

Bureau for Behavioral Health and Health

Facilities, WV Department of Health 

and Human Resources

350 Capitol Street

Charleston, WV 25301–3702

Phone: (304) 558–5540

Fax: (304) 558–1008

E-mail: faithstuart@wvdhhr.org

*Funding for this project was provided by the Substance Abuse and Mental Health Services Administration through 

a data information grant to the West Virginia Department of Health and Human Resources.

Area of focus: Addiction Severity Index (ASI) Microsoft® Access software for calculating and 

displaying the ASI over multiple time periods, clients, and settings.

Abstract

Rural and frontier alcohol and other drug abuse clinicians need assistance in calculating 

and displaying the multimeasure Addiction Severity Index (ASI) over multiple time periods 

and for multiple clients and multiple settings. Clinicians and program managers need to be 

able to report:

• Individual client ASI outcomes

• Clinician’s clients’ ASI outcomes (aggregates all clients of a clinician for a given time 

period)
NRADAN Awards for Excellence 2004

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

unit or area)

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

In addition, clinicians and program managers need to be able to summarize ASI program 

results periodically in terms of the quantities and percentages of clients who show improvement, maintenance, and regression. The current version of the ASI Microsoft® Access software program developed for the Bureau for Behavioral Health and Health Facilities, West 

Virginia Department of Health and Human Resources, meets all of these requirements, 

provides a user-friendly format, and is recommended for all ASI users. The program was 

developed at the Southern Highlands Community Mental Health Center in Princeton, West 

Virginia, and has undergone beta testing at the Appalachian Community Mental Health 

Center in Elkins, West Virginia. The ASI Access program is shareware and is available 

upon request. The current Access Database uses only Interview Severity Ratings and, as 

the addendum reveals, the ASI Access Database will be modified to include ASI Composite 

Scores because these measures offer greater reliability and validity.

Introduction

Rural and frontier alcohol and other drug 

abuse (AODA) programs face many challenges. Funding methods are shifting as 

Medicaid expenditures grow and Federal 

funds to States and local governments 

are concurrently cut. Rural areas suffer 

from a lack of healthcare resources (existing resources are often underfunded and 

understaffed) and an absence of integrated 

healthcare systems. New service systems 

are developing with a shift from providercentered to client-centered services. Pressures are increasing for assessment of client 

and program outcomes and effectiveness. 

Demands are also increasing for more 

organized and efficient services, all resulting in a thrust toward managed care 

(Broskowski, 1991; Feldman, 1992; Woodward, 1992; Wagenfeld, Murray, Mohatt, 

& DeBruyn, 1994; Van Hook & Ford, 1995; 

Minden & Hassol, 1996; Manderscheid & 

Henderson, 1997; “Study Finds Mental 

Health Spending Cut,” 1998; Heflinger & 

Northrup, 2000; Dorfman & Smith, 2002). 

Service settings grow more complex when a 

client has a dual diagnosis—mental health 

and substance abuse or mental health 

and developmental disabilities (Alterman, 

McLellan, & Shifman, 1993; Solomon, 

Zimberg, & Schollar, 1993; Woody, 

McLellan, Luborsky, & O’Brien, 1995; 

NASDDDS & HSRI, n.d.).

Coping with these constraints and opportunities in a rural or frontier service setting 

requires a focus on client outcome and program accountability. Albrecht (1992) stated 

that in the customer-value paradigm, “the 

primary focus of measurement is on outcomes” The basic question is, “How do we 

know whether we have succeeded in meeting the demands for both person-centered 

outcomes and increased accountability?” 

(Schalock, 1999). This paper focuses on how 

to enable the effective use of the widely 

known Addiction Severity Index (ASI) by 

rural and frontier AODA clinicians and 

program managers within a developing 

managed care environment.

Research Description

This project attacked a root problem in the 

use of outcome instruments: the inability 

to conveniently summarize and display 

client outcomes (Sorensen, Brackman, 

Sayers, Akers, Bell, & Elzey, 2000). The 

Microsoft® Access called the “Access 

Client Outcome Software” suite was 

designed to incorporate seven outcome 
79

instruments used in the West Virginia 

behavioral health system:

• Adult MH/SA Functional Assessment 

Instrument—Consumer/Staff, Version 5, 

Office of Behavioral Health Services, 3/97

• Child and Adolescent Functional 

Assessment Scale (CAFAS) (Subscales) 

ages 7–18, Version 5, Office of Behavioral 

Health Services, 3/97

• Preschool and Early Childhood Functional 

Assessment Scales (PECFAS) (Subscales) 

ages 4–7, Version 5, Office of Behavioral 

Health Services, 3/97

• Brief Psychiatric Rating Scale–Anchored 

(BPRS–A), Version 5, Office of Behavioral 

Health Services, 3/97

• WV Brief Psychiatric Rating Scale for 

Children (BPRS–C), Version 5, Office of 

Behavioral Health Services, 3/97

• Addiction Severity Index (ASI), Version 5, 

Office of Behavioral Health Services, 3/97

• Adaptive Behavior Scale—Residential and 

Community (ABS–RC:2), Version 5, Office 

of Behavioral Health Services, 3/97

In this paper, only the software for reporting ASI outcomes is illustrated, but the 

entire suite of programs is available from 

the Bureau for Behavioral Health and 

Health Facilities, West Virginia Department of Health and Human Resources, 

State of West Virginia, Charleston, West 

Virginia. The software was developed to be 

in the public domain and is available upon 

request.

Purpose

The project objective was to develop userfriendly software using Microsoft® Access 

programming that will display and print 

the results of client outcome instruments 

used in the West Virginia behavioral health 

system. The software was expected to display progression, regression, or no change 

status for the domains of an instrument for 

up to three time periods (to display three 

time periods requires four data points). 

The input form would employ a tabledriven design so that outcome data could 

be extracted easily from any of the existing 

behavioral health information systems. In 

addition, clinicians and program managers needed to be able to summarize ASI 

program results periodically in terms of 

the quantities and percentages of clients 

who show improvement, maintenance, and 

regression or the “Access Client Outcome 

Software.”

Barriers/Problems Encountered 

and Solutions

The original project was started in 1999, 

and the software development was completed in November 2000. As the project 

approached the beta testing phase, the 

State governorship changed parties in 

the November 2000 election. This event, 

in turn, led to changes in the West Virginia Department of Health and Human 

Resources as well as in the Bureau for 

Behavioral Health and Health Facilities. 

The beta testing phase was not resumed 

until fall 2003 and after several changes in 

the leadership of the Bureau for Behavioral 

Health and Health Facilities. The current 

leadership now believes that the software 

could be a valuable resource for clinicians 

and program managers and, as a result, has 

funded the beta testing that was concluded 

by March 2004. 

Methods

Addiction Severity Index

The ASI is a semistructured interview 

designed to assess patient problems in 

seven content areas of substance-abusing 

patients: medical status, employment and 

support, drug use, alcohol use, legal status, 

family/social status, and psychiatric status 

(see National Institute of Alcohol Abuse 

Making the Addiction Severity Index User Friendly
NRADAN Awards for Excellence 2004

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and Alcoholism, www.niaaa.nih.gov/

publications/asi.htm; McLellan, Luborsky, O’Brien, & Woody, 1980; McLellan et 

al., 1992). In 1 hour, a skilled interviewer 

can gather information from a client on 

recent (past 30 days) and lifetime problems 

in all seven areas. The ASI collects information on problems in personal and social 

functioning common among substance abusers, not just information on problems with 

drugs and alcohol. It has been used with 

psychiatrically ill, homeless, pregnant, and 

prisoner populations, but its primary use 

has been with adults seeking treatment for 

substance abuse problems.

The ASI has been used extensively for 

treatment planning and outcome evaluation. Reliability studies have been done 

(namely, test-retest, split-half, and internal 

consistency), and measures of validity have 

been derived (namely, content, criterion 

[predictive, concurrent, “postdictive”], and 

construct). The instrument is in the public domain because its development was 

supported by grants from the Veterans 

Administration and the National Institute 

on Drug Abuse. There are no costs and 

only minimal charges for photocopying and 

mailing the ASI, and it can be acquired 

from A. Thomas McLellan, Ph.D., Treatment Research Institute, 600 Public Ledger 

Building, 150 S. Independence Mall West, 

Philadelphia, PA 19106 (phone 215–399–

0980, fax 215–399–0987, or e-mail 

tmclellan@tresearch.org).

Dynamic Assessment of Client

Progression or Regression

Accountability for client outcomes is now 

another responsibility of AODA service providers. Assessment of client outcomes must 

be comprehensive, dynamic, user friendly, 

and relatively inexpensive. Simple gain 

scores (viz., time 1 – time 2) are subject to 

extensive criticism. The results have to be 

interpreted with caution since those with 

higher initial scores can be expected to 

improve at a higher rate than those with 

lower scores. Relating the actual gain to a 

potential gain is more defensible. The analysis uses the form

x 100 = %

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

base:

 x 100

In this analysis, the denominator includes 

(Maximum Score + 1) and shifts from the 

older score (for progression) to the newer 

score (for regression) to keep the progression and regression percentages parallel, to 

weight more dramatic changes with higher 

percentages, and to avoid a potential division by zero.

The percentage is a dynamic expression of 

change and is anchored to the beginning 

level of performance (which may be shifting 

over time also). For example, if a 5-point 

scale were used, with 5 = highly dysfunctional and 1 = highly functional, and a client progressed from a score of 3 to a score of 

1, then the change of 2 would be:

 x 100 = 

 x 100 = = 0.67 x 100 = 67%

showing a 67% progression (or improvement).

Likewise, if a 5-point scale were used, with 

5 = highly dysfunctional and 1 = highly 

functional, and a client regressed from a 

score of 1 to a score of 3, the change of 

2 would be:

[Older Score] – [Newer Score]

[Ideal] – [Older Score]

[Older Score] – [Newer Score]

[Maximum Score + 1] – [Older Score]

[Older Score] – [Newer Score]

(5 + 1) – [Older Score]

[3] – [1]

[6] – [3]

2

3
81

 x 100 = 

 x 100 = = – 0.67 x 100 = – 67%

showing a 67% regression. If the client 

regressed from a score of 1 to a score of 4, 

then the computations would be:

 x 100 = x 100 = 

– 1.50 x 100 = – 150%

revealing a 150% regression. Note that a 

shift of 3 points (150 percent) is weighted 

more heavily than a shift of 2 points 

(67 percent).

Report Interpretations

In general, in all calculations used by this 

program (“Access Client Outcome Software”), the denominator has the greatest 

influence on the equation. The purpose is 

to represent a scale score change to a more 

severe level as more significant than a 

change to a less severe level. Consequently, 

a less dramatic change will result in a less 

dramatic score, namely, percentage change. 

The following analysis will address each of 

the client outcome software programs written in Access specifically and will provide 

illustrative examples with sample outcomes 

and sample computations.

The same principles and descriptions of ASI 

outcomes apply to all levels of reporting. 

Using the Access Client Outcome software, 

reports may be generated for

• Individual client ASI outcomes

• Clinician’s clients’ ASI outcomes 

(aggregates all clients of a clinician for a 

given time period)

• Reporting unit ASI outcomes (aggregates 

all clients assigned to a given organizational unit or area)

• Total program ASI outcomes (aggregates 

all clients in a designated program)

Scoring the Addiction Severity Index

The ASI instrument is separated into seven 

categories and scored on a scale of 0–9. Categories are medical problems, employment 

and support problems, alcohol problems, 

drug problems, legal problems, family and 

social problems, and psychological problems. For this instrument, a lower score 

(severity scores only) means improvement, 

whereas a higher score indicates decline. 

This means that zero is the best possible 

score and nine is the worst possible score. 

For this example, only three categories of 

scores are shown in detail; all categories, 

however, follow the same pattern.

Regression Formula

 x 100

Progression Formula

 x 100

Table 1 is a set of illustrative scores.

Clinical Interpretation of Illustrative

Scale Scores

Medical, Alcohol, and Family/Social scales 

are illustrated. Medical problems seem to 

increase during time periods A and B but 

return to an improved state in time period 

C (percent change –12.5%, –14.28%, and 

+28.571%). Alcohol consumption appears 

high initially (level of 8) but was reduced 

[Older Score] – [Newer Score] 

(5 + 1) – [Newer Score]

[1] – [3]

[6] – [3]

–2

 3

[1] – [4]

[6] – [4]

–3

 2

Making the Addiction Severity Index User Friendly

[Older Score] – [Newer Score] 

10 – [Newer Score]

[Older Score] – [Newer Score] 

10 – [Older Score]
NRADAN Awards for Excellence 2004

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during time period A (down to a 6), 

maintained at that level during time period 

B, and again was reduced in time period C 

(down to a 5). Alcohol is still a major issue. 

The Family/Social scale regressed initially 

(–33%), improved (+16%) in time period B, 

but has regressed in the most recent time 

period C by moving from a 3 to a 6 (–75%).

Computations

The regression formula can be illustrated using the Medical category for time 

period A, over which the client’s condition 

regressed from 1 to 2. Specifically:

= = – .125

When the –.125 is multiplied by 100, the 

percentage change equals –12.5 percent.

The progression formula can be illustrated 

using the Medical category for time period 

C, over which the client’s condition progressed from 3 to 1. Specifically:

= = .28571

When the .28571 is multiplied by 100, the 

percentage change equals +28.571 percent.

Graphics

The complete results for a client summary 

ASI are displayed in figure 1.

Using Access Client Outcome 

Software

Setting Up Text Documents

The Access programs that have been 

designed for the user’s organization interpret data from text documents (*.txt). The 

user’s organizational personnel must generate these text documents. If the data are 

not set up properly, the Import Text Wizard within Access will generate inaccurate 

fields and the programs will not work or 

will produce inaccurate information.

In the source data files, all the information pertaining to an individual client must 

appear in a single row. The information 

must appear in the following order for 

import to the software’s database:

• Case Manager ID 

• Case Manager Name (first and last name, 

preferably with the last name appearing 

first)

• Program Reporting Unit

• Client ID

Table 1. Illustrative Addiction Severity Index Scores

Category Time Period Older Score Newer Score Percent

Change

Medical A

B

C

1

2

3

2

3

1

–12.5%

–14.285%

+28.571%

Alcohol A

B

C

8

6

6

6

6

5

+100%

0%

+25%

Family/Social A

B

C

2

4

3

4

3

6

– 33.333%

+16.666%

– 75%

(1 – 2)

(10 – 2)

–1

 8

(3 – 1)

(10 – 3)

2

7
83

Figure 1. Client Summary ASI

• Client Last Name

• Client First Name

• Oldest Test Date

• Raw Score for Symptom 1 (Oldest Test 

Date)

• Raw Score for Symptom 2 (Oldest Test 

Date)

• [Continue list of scores for other 

symptoms as needed]

• Second Oldest Test Date

• Raw Score for Symptom 1 (Second Oldest 

Test Date)

• Raw Score for Symptom 2 (Second Oldest 

Test Date)

• [Continue list of scores for other 

symptoms as needed]

• Third Oldest Test Date

• Raw Score for Symptom 1 (Third Oldest 

Test Date)

• Raw Score for Symptom 2 (Third Oldest 

Test Date)

• [Continue list of scores for other 

symptoms as needed]

• Most Recent Test Date

• Raw Score for Symptom 1 (Newest Test 

Date)

• Raw Score for Symptom 2 (Newest Test 

Date) 

• [Continue list of scores for other 

symptoms as needed]

Making the Addiction Severity Index User Friendly

(100)

(80)

(60)

(40)

(20)

0

20

40

60

80

100

120

Medical Emp/Sup

TP C: 7/8/98 to 7/29/99

TP B: 6/5/98 to 7/8/98

TP A: 5/5/98 to 6/5/98

Alcohol Drugs Legal Fam/Soc Psych

 28.6 12.5 25.0 14.3 0.0 -75.0 10.0

-14.3 -28.6 0.0 16.7 0.0 16.7 0.0

-12.5 0.0 100.0 20.0 0.0 33.3 11.1

% Improvement (Regression)

Major

regression in

family/social

Major

improvement in 

use of alcohol
NRADAN Awards for Excellence 2004

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Basic Program Operation

Once the data have been imported into 

the custom Access software, the program 

is ready to run. First, the user clicks the 

Run Program control button on the welcoming screen, which takes the user to the 

program’s main menu (figure 2). The main 

menu provides the user access to all of the 

program’s outputs. The main menu will look 

similar to figure 2 (details vary depending 

on the instrument). The screen illustrated 

in figure 2 is for functional assessments, 

but the operations for any of the various 

programs, including the ASI, are identical. 

The callout boxes on the figure describe 

various operations. (The Southern Highlands Community Mental Health Center in 

Princeton, West Virginia was the software 

developmental site for this example.)

Problems

Discharged Clients Report

The Discharged Clients Report compares 

the most recent score for each symptom 

against the oldest corresponding score, 

for each client in the database. Each client is then classified as having improved, 

regressed, provided insufficient data, or 

made no change for each symptom. A client 

is classified as having insufficient data if 

there is only one score recorded for a symptom (as showing improvement or regression demands a comparison of two scores). 

The report function then totals the number 

of clients who fit into each category and 

graphs the data. The user can print a copy 

of the report with or without the graph by 

using the print buttons on the top, left-hand 

side of the screen.

A client does not need to have been tested 

in the most recent time period to be 

included in the report. The program automatically sorts through all the scores and 

determines which are the oldest and most 

recent scores.

The Discharged Clients Report does not 

distinguish between ongoing clients and 

discharged clients. The report function classifies and counts every client who is entered 

into the database. Therefore, if active and 

discharged clients are entered in the same 

database, all the clients will be considered 

as if they have been discharged. Therefore, 

only clients who have truly been discharged 

should be entered into the reporting database to produce a report that shows only 

clients who have been discharged. The 

report is titled “Discharged Clients Report” 

because reporting the status of discharged 

patients is the practical function of the 

report. A report showing the same results 

for active clients may be processed using a 

database containing only active clients.

Findings and Conclusions

Developmental Site

The developmental site, the Southern Highlands Community Mental Health Center 

in Princeton, West Virginia, tested the ASI 

program (along with others in the developed software suite) with positive results 

from the viewpoints of clinicians, program 

managers, and information systems staff. 

Staff responded positively to the visual displays that enabled clinicians (and clients) 

to review past results and set new goals in 

light of past progress (or maintenance or 

regression).

Beta Testing

The results of the beta test at a site different from the developmental site, the 

Appalachian Community Mental Health 

Center in Elkins, West Virginia, are now 

being reviewed, but the initial findings are 

promising. Information systems required 

to meet the new Health Insurance Portability and Accountability Act legislation have 

slowed the progress of the beta testing.
85

Making the Addiction Severity Index User Friendly

To view an individual 

reporting unit’s chart, 

first select the desired 

reporting unit from the 

drop-down menu and 

then click the View RU 

Report button.

To print a report that 

averages all clients 

in the program, click 

the Print Program 

Report button. Click the Print 

All RU Reports

button to print a 

separate report 

for each reporting 

unit entered into 

the database.

Click the Print 

All Case Mngr 

Reports button 

to print a separate report for 

each case manager entered into 

the database.

To view an individual 

client’s progress over 

time, first select the 

desired client from the 

drop-down menu and 

then click the View 

Client Report button.

To view an individual 

case manager’s report, 

first select the desired 

case manager from 

the drop-down menu

and then click the 

View Case Manager 

Report button.

Click the Data Import 

Instructions button 

for information on how 

to load data from text 

files into the database.

The Exit Program

button closes 

the program and 

shuts down Microsoft Access.

Click the View Discharged 

Clients Report button to 

view a chart that tallies the 

status of clients upon being 

discharged from program. 

(Be sure to see page 15 for 

further details. Special client 

data files must be loaded 

for the report to provide an 

accurate count.)

Click the Print All Client 

Reports button to print 

a separate report for 

each client entered into 

the database. (To print 

an individual client’s 

report, call up the 

client’s record and use 

the print button available in the upper lefthand corner of that 

form.)

To view a report 

that averages all 

the clients in the 

program, click the 

View Program 

Report button.

SOUTHERN HIGHLANDS

Community Mental Health Center

View Program

Report

Print Program

Report

View RU Report Print All RU Reports

ViewCaseManagerReport PrintAllCaseMngrReports

View Client Report

Select Reporting 

Unit

Select Case

Manager

Select Client

Data

Import

Instructions

Exit

Program

View

Discharged

Clients Report

Figure 2. Client Outcome Software Main Menu

Print All Client Reports
NRADAN Awards for Excellence 2004

86

Conversion to Access 2002

The current version of the ASI program is 

written in Access 97 and can be run only 

on Access 97. A contract is under negotiation to update the ASI program software to 

Access 2002. Microsoft has made substantial changes and improvements in recent 

versions of Access and, as is so often the 

case, the newer versions cannot process 

programs produced under older versions, 

unless converted properly.

Tests of Statistical Significance

One additional feature to be added to the 

software suite is a test of statistical 

significance. After calculating the changes, 

the results will be subjected to a nonparametric statistical test to determine if the 

changes are significant.

Addition of Composite Scores in the

Revision of the ASI Database

While clinicians in the demonstration site 

indicated a preference for the Interview 

Severity Ratings in the qualitative interview phase of the database design, scores 

that are better suited for comparison over 

time are (1) the ASI Composite Scores 

and (2) analysis of specific item variables 

according to the literature (Carise, 2004; 

McLellan, Kushner, Metzger, Peters, Smith, 

et al., 1992; McLellan et al., 1985). With 

new funding to update a suite of client outcome databases, the ASI Composite Scores 

will be added so a clinician (or other user) 

may use the interview severity ratings, 

composite scores, or both.

Recommendations

Meeting the Needs of AODA Clinicians

and Managers

Rural and frontier AODA clinicians need 

assistance in calculating and displaying 

the multimeasure Addiction Severity Index 

over multiple time periods and for multiple 

clients and multiple settings. Clinicians 

and program managers need to be able to 

report:

• Individual client ASI outcomes

• Clinician’s clients’ ASI outcomes 

(aggregates all clients of a clinician for a 

given time period)

• Reporting unit ASI outcomes (aggregates 

all clients assigned to a given organizational unit or area)

• Total program ASI outcomes (aggregates 

all clients in a designated program)

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

improvement, maintenance, and regression. 

The current version of the ASI software 

program, Access Client Outcome Software, 

meets all of these requirements, provides a 

user-friendly format, and is recommended 

for all ASI users. The software is accompanied by a user manual. It can be operated 

with a laptop computer or within a full 

workstation computer or computer network and can be easily adapted to a local 

environment.

Software Availability

The ASI Access program developed for the 

Bureau for Behavioral Health and Health 

Facilities, West Virginia Department of 

Health and Human Resources, is shareware 

and is available upon request. 

Additional Resources

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

• The ASI-MV is an interactive, audio/

video CD-ROM program that allows for 

client self-administration of the widely 
87

used Addiction Severity Index. More 

information is available at www.asimv.

com.

• The Treatment Research Institute Web 

site is a nonprofit research group founded 

and directed by A. Thomas McLellan, 

the lead researcher and developer of the 

ASI. The following materials (and many 

others) are available at www.tresearch.

org/resources/instruments.htm.

– Addiction Severity Index—5th Edition 

– Addiction Severity Index—5th Edition 

(Spanish) 

– Addiction Severity Index—5th Edition 

(for use with Native Americans) 

– Addiction Severity Index Lite 

– Addiction Severity Index—5th Edition 

Clinical Training Version 

– Addiction Severity Index—Lite: Clinical 

Trials Network Version—Part 1 

– Addiction Severity Index—Lite: Clinical 

Trials Network Version—Part 2 

– Treatment Services Review—14 Day 

– Treatment Services Review—30 Day 

References

Albrecht, K. (1992). The only thing 

that matters: Bringing the power 

of the customer into the center 

of your organization. New York: 

HarperBusiness.

Alterman, A. I., McLellan, A. T., & Shifman, 

R. B. (1993). Do substance abuse 

patients with more psychopathology 

receive more treatment? Journal of 

Nervous and Mental Disease, 181(9), 

576–582.

Broskowski, A. (1991). Current mental 

health care environments: Why 

managed care is necessary. Professional 

Psychology: Research & Practice, 22(1), 

6–14.

Carise, D. (2004). [Review of the manuscript 

Making the Addiction Severity Index 

(ASI) user friendly: An electronic display 

of client outcomes using shareware.] 

Rockville, MD: American Institutes for 

Research, Performance Management 

Technical Assistance Coordinating 

Center. 

Dorfman, S. L., & Smith, S. A. (2002). 

Preventive mental health and 

substance abuse programs and services 

in managed care. The Journal of 

Behavioral Health Services & Research, 

29(3), 233–258.

Feldman, S. (Ed.). (1992). Managed mental 

health services. Springfield, IL: Charles 

C. Thomas.

Heflinger, C., & Northrup, D. (2000). What 

happens when capitated behavioral 

health comes to town? The transition 

from the Fort Bragg demonstration to 

a capitated managed behavioral health 

contract. The Journal of Behavioral 

Health Services & Research, 27(4), 390–

405.

Manderscheid, R. W., & Henderson, M. J. 

(1997). Federal and State legislative and 

program directions for managed care. In 

E. J. Mullen & J. L. Magnabosco (Eds.), 

Outcomes measurement in the human 

services: Cross-cutting issues and 

methods (pp. 113–123). Washington, 

DC: NASW Press.

McLellan, A. T., Carise, D., & Kleber, H. 

D. (2003) Can the national addiction 

treatment infrastructure support 

the public’s demand for quality care? 

Journal of Substance Abuse Treatment

25, 117–121.

McLellan, A. T., Kushner, H., Metzger, D., 

Peters, R., Smith, I., Grissom, G., et al. 

(1992). The fifth edition of the Addiction 

Severity Index. Journal of Substance 

Abuse Treatment, 9(3), 199–213.

McLellan, A. T., Luborsky, L., Cacciola, J., 

Griffith, J., Evans, F., Barr, H. L., et 

al. (1985). New data from the Addiction 

Severity Index: Reliability and validity 

in three centers. Journal of Nervous and 

Mental Diseases, 173, 412–423.

Making the Addiction Severity Index User Friendly
88

McLellan, A. T., Luborsky, L., O’Brien, C. 

P., & Woody, G. E. (1980). An improved 

diagnostic instrument for substance 

abuse patients: The Addiction Severity 

Index. Journal of Nervous and Mental 

Diseases, 168, 26–33.

Minden, S., & Hassol, A. (1996). Final 

review of available information on 

managed behavioral health care. 

Rockville, MD: U.S. Center for Mental 

Health Services.

National Association of State Directors of 

Developmental Disabilities Services 

(NASDDDS) & Human Services 

Research Institute (HSRI). (n.d.). 

National Core Indicators project. See 

www.hsri.org/nci. 

Schalock, R. L. (1999). A quest for quality: 

Achieving organizational outputs and 

personal outcomes. In J. F. Gardner & 

S. Nudler (Eds.), Quality performance in 

human services: Leadership, values, and 

vision (pp. 55–80). Baltimore, MD: Paul 

H. Brookes Publishing Co.

Solomon, J., Zimberg, S., & Schollar, E. 

(1993). Dual diagnosis: Evaluation, 

treatment, training, and program 

development. New York: Plenum 

Publishing Corp.

Sorensen, J. E., Brackman, K., Sayers, P., 

Akers, J., Bell, S., & Elzey, J. (2000). 

Client outcome instruments user’s 

manual. Charleston, WV: Bureau 

for Behavioral Health and Health 

Facilities, West Virginia Department of 

Health and Human Resources.

Study finds mental health spending cut in 

half over last decade (1998, May 7). The 

Wall Street Journal, p. B1.

Van Hook, M. P., & Ford, M. (1995). 

Linking mental and primary health 

care in rural areas. Administration and 

Policy in Mental Health, 22(6), 633–641. 

Wagenfeld, M. O., Murray, J. D., Mohatt, 

D. F., & DeBruyn, J. C. (1994). 

Mental health and rural America: 

1980–1993; An overview and annotated 

bibliography. NIH Publication No. 94–

3500. Washington, DC: Office of Rural 

Health, Health Resources and Services 

Administration and Office of Rural 

Mental Health Research, National 

Institute of Mental Health.

Woodward, A. (1992). Managed care 

and case management of substance 

abuse treatment. In R. S. Ashery 

(Ed.), Progress and issues in case 

management (pp. 34–53). NIDA 

Research Monograph No. 127. Rockville, 

MD: National Institute on Drug Abuse, 

U.S. Department of Health and Human 

Services.

Woody, G. E., McLellan, A. T., Luborsky, L., 

& O’Brien, C. P. (1995). Psychotherapy 

in community methadone programs: A 

validation study. American Journal of 

Psychiatary, 152(9), 1302–1308.

Addendum

With a useful review by and suggestions from Deni Carise, Ph.D., Treatment 

Research Institute (dcarise@tresearch.

org), the authors intend to update the ASI 

Database to include ASI Composite Scores. 

Improved reliability and validity are available for the ASI Composite Scores. The 

recent financing by the Bureau of Behavioral Health and Health Facilities, West 

Virginia Department of Health and Human 

Resources, Charleston, West Virginia of 

an update of several outcome databases 

(including this ASI Database) will enable 

the software to be updated to Access 2002–

2003 versions and to add ASI Composite 

Scores. An early review of the client 

database submissions by West Virginia 

treatment providers has identified preexisting data elements for ASI Composite Scores. It is not clear without further 

research if the scores are computed or if the 

scores need to be computed. In any event, 

the revised ASI Database could include an 

option for the computation of the scores 

if not computed. This additional feature, 

as an aside, may widen the application of 

the software to users who do not have a 

ready capability to calculate ASI Composite 

Scores. The computation of ASI Composite 

Scores can be accomplished without any 

user (or license) fees (Carise, 2004). When 

the ASI Database is updated, a new manuscript describing all of its features will be 

created.

NRADAN Awards for Excellence 2004
89

Resources on Rural Substance Abuse 

Issues

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

Contact information:

P.O. Box 40 

Tony, WI 54563-0040 

Phone: (715) 532–9030 

Fax: (715) 532–9030

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

Description: 

NRADAN is a private, nonprofit foundation that promotes networking between rural 

programs, and professionals along with providing liaisons to key Federal and State 

government agencies and private resources.

The National Rural Health Association (NRHA)

Contact information:

521 East 63rd Street

Kansas City, MI 64410-3329

Phone: (816) 756–3140

Fax: (816) 756–3144

Web Site: www.nrharural.org

Description:

NRHA is a national nonprofit membership organization with more than 10,000 members 

that provides leadership on rural health issues. The association’s mission is to improve the 

health and well-being of rural Americans and to provide leadership on rural health issues 

through advocacy, communications, education, research, and leadership. 

Rural Assistance Center (RAC)

Contact information:

P.O. Box 9037

Grand Forks, ND 58202

Phone: (800) 270–1898

Fax: (800) 270–1913

E-mail: info@raconline.org

Web Site: www.raconline.org

Description:

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

human services to rural residents.
NRADAN Awards for Excellence 2004

90

Substance Abuse Facility Locator

Contact information:

Web Site: dasis3.samhsa.gov

Description: 

A searchable database that provides assistance with locating drug and alcohol abuse 

treatment programs (including in rural areas).

2-1-1 Resource Line

Contact information:

Web Site: 211.org/status.html

Description: 

2-1-1 is an easy to remember telephone number that, where available, connects people with 

important community services and referral agencies in their areas. This is a nationwide 

program with services varying State-by-State. 

National Hotline Call Center for Alcohol and Drug Abuse 

Contact information:

Phone: (800) 784–6776

Web Site: www.addictioncareoptions.com

Description: 

The National Hotline Call Center for Alcohol and Drug Abuse provides accurate information 

about alcohol and drug abuse and offers alternatives and suggestions to anyone looking 

for answers and assistance. Staff is on duty 24 hours a day, 7 days a week. They provide 

in-depth information about court orders, family interventions, detoxification, treatment, 

rehab programs, insurance, and anything that is related to alcohol and drug abuse. Services 

are free of charge.

Selected Publications on Rural Substance Abuse Issues

Center for Substance Abuse Treatment. (1997). Bringing Excellence to Substance Abuse 

Services in Rural & Frontier America: 1996 Award for Excellence Papers. Technical 

Assistance Publication (TAP) number 20. Rockville, MD: Substance Abuse and Mental 

Health Services Administration. Available from the National Clearinghouse for 

Alcohol and Drug Information at www.ncadi.samhsa.gov.

Center for Substance Abuse Treatment. (1998). Rural Issues in Alcohol and Other Drug 

Abuse Treatment. Technical Assistance Publication (TAP) number 10. Rockville, MD: 

Substance Abuse and Mental Health Services Administration. Available from the National 

Clearinghouse for Alcohol and Drug Information at www.ncadi.samhsa.gov.

Robertson, E. B., Sloboda, Z., Boyd, G. M., Beatty, L., and Kozel, N. J. (Eds.). (1997). Rural 

Substance Abuse: State of Knowledge and Issues. NIDA Research Monograph 168. NIH 

Publication No. 97-4177. Rockville, MD: National Institute on Drug Abuse.
Other Technical Assistance Publications (TAPs) include:

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

PHD580

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

Adolescents PHD581

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

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

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

PHD584

TAP 6 Empowering Families, Helping Adolescents: Family-Centered Treatment of Adolescents with 

Alcohol, Drug Abuse, and Mental Health Problems BKD81

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

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

TAP 9 Funding Resource Guide for Substance Abuse Programs BKD152

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

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

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

State Agencies PHD666

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

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

BKD175

TAP 15 Forecasting the Cost of Chemical Dependency Treatment Under Managed Care: The Washington 

State Study BKD176

TAP 16 Purchasing Managed Care Services for Alcohol and Other Drug Abuse Treatment: Essential 

Elements and Policy Issues BKD167

TAP 17 Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas BKD174

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

TAP 19 Counselor’s Manual for Relapse Prevention With Chemically Dependent Criminal Offenders 

PHD723

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

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

Practice BKD246

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

Purchasers BKD252

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

TAP 24 Welfare Reform and Substance Abuse Treatment Confidentiality: General Guidance for 

Reconciling Need to Know and Privacy BKD336

TAP 25 The Impact of Substance Abuse Treatment on Employment Outcomes Among AFDC Clients in 

Washington State BKD367

TAP 26 Identifying Substance Abuse Among TANF-Eligible Families BKD410

TAP 27 Navigating the Pathways: Lessons and Promising Practices in Linking Alcohol and Drug 

 Services with Child Welfare BKD436

TAP 28 The National Rural Alcohol and Drug Abuse Network Awards for Excellence 2004, Submitted 

and Award-Winning Papers BKD522

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

Information (NCADI), (800) 729-6686 or (301) 468-2600, TDD (for hearing impaired), (800) 487-4889.
DHHS Publication No. (SMA) 06-4183

NCADI Publication No. BKD552

Printed 2006