Substance Abuse Treatment
Compliance of Drug Offenders
in Philadelphia
Sameena Azhar
July 25, 2007
University of Pennsylvania
Graduate Program in Public Health Studies
Problem Identification



More than 6 million people are under
criminal supervision (prisons/jails/
parole/probation).
~4 million people in the criminal justice
system are drug offenders, of which only
1/4 are receiving treatment
77% of those who are arrested are under
the influence of drugs or alcohol at the
time of arrest.
Broad Objective
To compare treatment compliance
for two subgroups of clients
receiving substance abuse
treatment at a Philadelphia site:
court-stipulated drug offenders and
non-court stipulated clients.
Specific Aims


To evaluate whether court stipulation is
a promoter of treatment compliance.
To evaluate whether mental health
diagnosis is a confounder to treatment
compliance.
Conceptual Framework
CourtStipulation
Predictor
Mental Health
diagnosis
Moderating Variable
Court-Stipulation
x Mental Health
Diagnosis
Predictor x Moderating
Variable
Treatment
Compliance
Capstone Overview
Identify
discharge charts
of courtstipulated drug
offenders
Identify
discharge
charts of
voluntary
clients
Create de-identified
database of clients’
information
Analyze database
information for
differences
between treatment
groups
Distribute
information to
administrators,
therapists and
FIR/treatment
court case
managers for
program
restructuring
Methods


Utilization of Northeast Treatment Centers
(NET) in Philadelphia as a case study for
substance abuse treatment
Completion of retrospective cohort study
comparing court-stipulated drug offenders and
non-court stipulated clients by reviewing
charts for:
1)
2)
3)
4)
Court stipulation status
Demographic data (age, race)
Compliance (# of completed weeks in treatment)
Mental health diagnosis if applicable
(DSM-IV Axis I Dx)
Methods
Inclusion Criteria

Male

Has an Axis I diagnosis of chemical dependency

Has been admitted for intensive outpatient substance
abuse treatment at Northeast Treatment Centers

Has been discharged from treatment between Jan &
July 2007
Exclusion Criteria

Females

Individuals who have been assessed by Northeast
Treatment Centers and were found to require an
inpatient level of treatment care
Methods

Sample size calculation using the first 20
reviewed charts assuming:

t-tests for independent samples




power=0.8
m=5
=6 weeks in treatment
=3.43
 α = .05


At least 3 subjects would be needed to detect
a difference in 6 weeks of completed
treatment between stipulated clients and nonstipulated clients.
N for study = 120 clients
Methods
Subject
No.
Court
Stipulation
Race
(Yes=1/No=2)
Age
MH Presence?
(Years)
(Yes=1/No=2)
MH Dx
TX Compliance
(# of weeks)
1
1
W
21
1
Schizophrenia, Anxiety D/O
4
2
2
W
36
2
3
2
B
55
1
4
2
B
36
2
4
5
2
B
39
2
13
6
2
W
26
2
10
7
2
W
23
1
2
Depressive Disorder
Depressive D/O, Panic D/O
5
3
Community Partners

Northeast Treatment Centers (NET)
Mission of NET’s substance abuse
treatment program: To provide
comprehensive assessment, treatment, and
aftercare services for clients with chemical
dependency and coexisting mental health
issues.
Timeline



September 2006 - May 2007:
Development of Research Protocol,
Database, IRB Application
June - July 2007: Data
Collection/Analysis
Late July 2007: Presentation of Capstone
Project
Ethical Issues

Risks: Negligible risk of loss of protection of
confidentiality of drug offenders as all personal
health information was de-identified in
database.

Benefits: Potential benefits to clients receiving
substance abuse treatment in the future at NET.
Societal benefits of improved drug offender
programming via better understanding of client
needs.
Results
Baseline Sample Characteristics
Variable
Court-Stipulated
(N=60)
Not Court-Stipulated
(N=60)
Age
34.0 (SD=8.8)
39.1 (SD=8.3)
40.0%
53.3%
6.7%
0%
0%
63.3%
30.0%
3.3%
1.7%
1.7%
Race
African American
White
Hispanic
Asian
American Indian
Mental Illness
Schizophrenia
Depressive Disorder
Bipolar Affective Disorder
Anxiety Disorder
Panic Disorder
Cyclothymic Disorder
PTSD
40.0%
6.7%
11.7%
16.7%
5.0%
1.7%
0.0%
3.3%
3.3%
36.7%
3.3%
21.7%
10.0%
3.3%
1.7%
0.0%
1.7%
6.7%
More than one Mental Illness
Treatment Compliance
12.7 weeks
8.8 weeks
Results
Correlations
Tx
Compliance
Drug
Offender
Age
MH
Presence
Race
Pearson
Correlation
Sig. (1-tailed)
Tx Compliance
.
.015
.290
.320
.316
Drug Offender
.015
.
.001
.427
.012
Age
.290
.001
.
.109
.284
MH Presence
.320
.427
.109
.
.470
Race
.316
.012
.284
.470
.
N=120
Results
Regression Model
Model
1
R
R Square
.260(a)
Adjusted R
Square
.067
Std. Error of the
Estimate
.027
9.85598
N=120
Coefficientsa
Model
1
(Constant)
CourtStipulation
Race
Age
MHPresence
CourtStipulationandMH
Unstandardized
Coefficients
B
Std. Error
2.705
4.717
5.660
2.506
-1.755
1.916
.164
.111
1.919
2.657
-3.268
3.774
a. Dependent Variable: TxCompliance
Standardized
Coefficients
Beta
.285
-.088
.145
.094
-.129
t
.573
2.259
-.916
1.480
.722
-.866
Sig.
.567
.026
.362
.142
.472
.388
Results
3.9 week difference in means of court-stipulated
clients and non-court-stipulated clients
•
• The only predictor showing a statistically significant
p-value for treatment compliance is court stipulation
status.
•When other variables are controlled for, this
difference is not statistically significant. Running an Ftest from the sum of squares of the regression yields
an insignificant p-value of 0.153.
Feasibility & Limitations



Obtaining high number of cases and
controls (n=120) was feasible due to
high turn-over within agency.
Limitations: Generalizability of data from
local rehabilitation program
Generalizability of sample that included
large cross-section of court-stipulated
clients
Limitations



Control and sample populations largely
differ in terms of race and age.
Sampling method was inconsistent.
Sample collected only from Spring &
Summer months (Jan – July 2007)
Analysis


Though court stipulation to a substance
abuse treatment facility may significantly
reduce recidivism, it may not increase the
likelihood of completion of treatment.
Internal motivation to seek treatment plays
a significant role in treatment compliance.
Analysis


Study results do not support the hypothesis
that court-stipulation for drug offenders
promotes substance abuse treatment
compliance.
Results also do not support the hypothesis
that mental illness is a modifier to treatment
compliance.
Analysis


Current substance abuse treatment
modalities do not promote compliance
for drug offenders.
More research most focus on how to
overcome treatment resistance in
forensic clients.
Public Health Implications



Creating better understanding of client
needs
Providing evidence for the necessity of
further evaluation of substance abuse
treatment in Philadelphia
Helping assist in improving existing
treatment programs for drug offenders in
Philadelphia, such as NET
References
Bourgois, P. (2003). In Search of Respect: Selling Crack in El Barrio. New York:
Cambridge University Press.
Bureau of Justice Statistics. (1997). Substance Abuse and Treatment, State and
Federal Prisoners, Special Report, p3, Table 1.
Harrison, L.D. (2001). The Revolving Door for Drug-Involved Offenders:
Challenges and Opportunities. Crime & Delinquency, 47(3), July 2001, 462285. Sage Publications.
Leukefeld, C.G.; Tims, F. & Farabee, D. (Eds.). (2002). Treatment of Drug
Offenders. New York: Springer Publishing Company.
Pennsylvania State Police. (2003). Crime in Pennsylvania: Annual Uniform Crime
Report 2003. Available from: LexisNexis™ Congressional (Online Service).
Bethesda, MD: Congressional Information Service.
Sindelar, J. L. & Fiellin, D.A. (2001). Innovations in Treatment for Drug Abuse:
Solutions to a Public Health Problem. Annual Review of Public Health 22, 249272).
References
United States Department of Health and Human Services (HHS). National
Household Survey on Drug Abuse: Main Findings 1997. Washington, DC: HHS.
United States Department of Justice. (2005). National Criminal Justice Service,
U.S. Department of Justice, Drug-Courts and Figures. Retrieved online from:
www.ncjrs.gov/spotlight/ drug courts/facts.html
United States Government Accountability Office (GAO). (02/2005). Adult Drug
Courts: Evidence Indicates Recidivism Reductions and Mixed Results for Other
Outcomes. Washington, DC: GAO.
World Health Organization (WHO). Drug Abusers in Prisons: Managing their
Health Problems. Copenhagen: World Health Organization.
Young, D; Fluellen, R. & Belenko, S. (2004). Criminal recidivism in three models
of mandatory treatment. Journal of Substance Abuse Treatment 27 (2004)
313-323.