Masters thesis differential effectiveness of substance abuse treatment by j fuller
1. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 1
Differential Effectiveness of Substance Abuse Treatment
For Drug Traffickers vs. Substance Users
By
Joyce Julianne Fuller
A thesis submitted in partial fulfillment of the requirements
for the degree of
Master of Science in Psychology
Kaplan University
2013
2. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 2
KAPLAN UNIVERSITY
Abstract
Differential Effectiveness of Substance Abuse Treatment
For Drug Traffickers vs. Substance Users
By Joyce Julianne Fuller
Study considered the differential effectiveness of standard substance abuse treatment for persons
with actual histories of drug use vs. those who have been arrested for drug trafficking,
possession, dealing, delivery, manufacture, or sale. Dataset contained 1,348 subjects who had
completed drug and alcohol treatment. Mean age was 33; 2/3 of subjects were male, 1/3 female;
ethnic mix was well rounded. The researcher identified 77 outcome variables within 12 outcome
categories. Of the 77, 64 trended as predicted, suggesting poorer outcomes for drug traffickers
vs. substance users. A Chi Square was computed on trend data and was highly statistically
significant. A MANOVA was then computed, considering each of the 64 outcome variables,
with two covariates: 1) number of days during the three months post treatment that the individual
was in a controlled environment; and 2) severity of alcohol and drug abuse at time of treatment
commencement. The overall MANOVA was highly statistically significant, indicating that drug
trafficking has a pure effect on poorer treatment outcomes. ANOVAs were computer to contrast
drug traffickers vs. substance users on each of the 64 individual outcome variables, using a
Bonferroni corrected alpha level. In five of 12 outcome categories, one or more outcome
measures differed significantly between traffickers and users. The five categories with
significantly different outcomes were Continued Alcohol/Drug Use, Reinstitutionalization,
Environmental Issues, High Risk Sexual Behaviors, and Relationship Issues. Why drug
3. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 3
traffickers are receiving treatment designed for substance users, and treatment alternatives for
drug traffickers along with costs and policy implications are considered.
Keywords: substance use, drug trafficking, treatment, outcomes, substance abuse
4. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 4
Table of Contents
List of Tables...............................................................................................................................4
Introduction.................................................................................................................................6
Literature Review ..................................................................................................................6
Hypotheses/Research Questions ...........................................................................................13
Method......................................................................................................................................14
Participants..........................................................................................................................14
Procedures...........................................................................................................................14
Results ......................................................................................................................................18
Discussion.................................................................................................................................21
Findings ..............................................................................................................................22
Limitations ..........................................................................................................................25
References.................................................................................................................................26
Appendix A: Tables...................................................................................................................29
5. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 5
Acknowledgments
The author wishes to express sincere appreciation to the Research Associates and Data Analysis
Teams of Chestnut Health Systems and the addiction recovery programs that provided the data
for this study. Without their support, this thesis would not have been possible. The author also
thanks her Thesis Adviser, Dr. Edward Cumella PhD, and her Thesis Committee members, Dr.
John Burke and Dr. Alyssa Gilston. Thank you for all your help in completing this research!
6. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 6
The United States (US) war on drugs has been in effect since 1971 (Vulliami, 2011).
Since its inception, Americans have seen stronger and more punitive sentencing laws which have
filled the jails and prisons with offenders incarcerated for drug-related charges and fueled the
prison industry and prison building boom across the nation (Bewley-Taylor, Hallam, & Allen,
2009; Mauer, 2010; Muftić & Bouffard, 2008). Many authors have documented growing
disappointment in the lack of changes these greater sentences have had on recidivism rates for
the population of drug offenders (Bewley-Taylor, Hallam, & Allen, 2009; Mauer, 2010; Muftić
& Bouffard, 2008). As greater focus has been placed on sentencing laws, less attention has
focused on the needs for specific forms of treatment in relation to a person’s frequency and
severity of substance abuse. This paper therefore explores the effectiveness of mandated
substance abuse treatment in relation to the frequency and severity of substance use. Muftić and
Bouffard (2008) speak of alternative options to prison overcrowding using intermediate
sanctions. Intermediate sanctions are strategies imposed by Probation and Parole (P&P)
departments to intervene in offenders’ destructive patterns of behavior. Intermediate sanctions
utilize methods such as drug court, substance abuse treatment programs, electronic monitoring,
and other interventions prior to offenders being sentenced to incarceration. These sanctions
attempt to control the overcrowding of an overburdened criminal justice system, as well as
reduce recidivism rates.
In an article titled, “Beyond the Fair Sentencing Act”, Mauer (2010) addresses issues
within the Fair Sentencing Act and mandatory sentencing provisions that have eventuated in the
incarceration of the majority of ethnic minority offenders. The Fair Sentencing Act, enacted by
Congress and signed into law by President Barack Obama in 2010, was initiated as an attempt to
create fairer sentencing laws for cocaine and crack cocaine users. Mauer describes the Act as a
7. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 7
method to “scale back the harsh and racially disparate mandatory sentences for federal crack
cocaine offenses” (Mauer, 2010, p. 1). Mauer (2010) identifies that the problem lies within the
sentencing and advocates for more drug treatment within communities as well as fairer
sentencing laws. However, both Muftić and Bouffard (2008) and Mauer (2010) fail to note that
many of those sentenced for drug sales or trafficking may not be in need of drug treatment at all,
as they do not necessarily use substances themselves.
Studies of substance abuse treatment outcomes among incarcerated drug felons often
fail to differentiate the portion of the population that does not meet the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (American Psychiatric
Association, 2000) criteria for addiction. This potentially important failure to differentiate
recipients of treatment is a notable factor in a recent Department of Justice report regarding the
lack of effective tracking of grant programs aimed at reducing recidivism from drug related
crimes using re-entry programs (Anonymous, 2010). Williams’ (2008) article, titled “Whose
Responsibility is Substance Abuse Treatment?” provides evidence that admissions to drug
treatment programs have increased by 35% between 1995 and 2005. During this same time
period, federal spending for drug treatment increased by 15%. Yet there has been insufficient
accountability regarding how these dollars have been spent, partly related to the use of substance
abuse treatment for criminals who do not meet criteria for a substance abuse or dependence
disorder.
Programs have been initiated throughout the US to provide substance abuse education
and treatment within the criminal justice system. These programs include modalities of
treatment such as outpatient drug treatment, using peer discussion groups, counselor led groups,
vocational therapy, and cognitive therapy. Programs also include 12-step meetings, relapse
8. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 8
prevention, and aftercare in various multimodality designs, of which a recent focus is on
transition classes and re-entry programs (Center for Substance Abuse Treatment [CSAT], 2005).
There is literature to support a measure of success with these substance abuse programs in
assisting drug users; however, almost no data reports how successful these modalities of
treatment have been for those offenders who have never or only rarely used illegal drugs. One
recent study of a small sample (N=30) of women mandated into drug treatment suggests that
60% did not have a DSM-IV-TR drug abuse or dependence diagnosis; some of these women
were satisfied with drug treatment at time of discharge, but many were not (Shaw, 2012). Yet no
post-discharge follow-up data were available on this sample.
Meanwhile, the incarcerated offender population continues to face major challenges as
there is no specific curriculum or identified modality to address criminal thinking behaviors
(Simpson, 2008; Williams, 2008). In short, there appears to be no specific criteria or specialized
treatment components designed to meet the needs of those incarcerated individuals who are: 1)
sentenced as drug traffickers, 2) identified as non-users, or 3) mandated to receive substance
abuse treatment for a range of drug-related crimes apart from drug use itself.
US and state agencies, such as the Department of Corrections (DOC), place offenders in
drug treatment simply due to the presence of any drug related charge. Many of these individuals
return to prison perhaps because their underlying needs have not been addressed through their
participation in treatment designed only for those who abuse drugs. Furthermore, empirical
research suggests that punitive prison sentences, programs aimed at shocking youthful offenders
with the harsh reality of the jail/prison environments, such as Scared Straight, and military and
disciplinary styled behavior modification programs, often called boot camps, may result in
increased rather than decreased recidivism rates (Serin, Caleb, & Hanby, 2012). Thus, those
9. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 9
with drug related crimes apart from substance abuse may not be receiving the assistance they
need through other programs they are encountering while in the criminal justice system. In
discussion of methods in separate areas within the same system regarding corrections and re-
entry, Serin et al. (2012, p. 56) state, “In reality, little is known regarding their relative and
combined contributions to offender success and crime desistance. Moreover, an overarching
conceptual model that integrates these literatures is presently and noticeably absent.” This is
also true of available and accurate reports of currently used assessment methods, in regard to
success rates of those who engage in drug sales as a form of employment.
Placing individuals who do not use drugs in substance abuse treatment due to their drug
related charge of drug trafficking, sales, manufacturing, delivery, or possession may be
unethical, costly, and ineffective (Shaw, 2012). In an article titled “Downsizing Prisons: Should
Non-violent Inmates be Incarcerated”, Katel (2011) discusses the high costs associated with
placing inmates in substance abuse treatment within the prison system. This cost includes many
who may not need or benefit from such treatment, but would rather benefit from a different
modality of treatment that better addresses their criminal thinking and behaviors. Johnson
(2012), in his article titled “Prisoners facing long waits for drug rehab”, laments the lack of
available treatment for those who truly need it, caused in part by the use of treatment for those
who do not abuse substances.
Although greater attention has been paid to the male offender population, the problem is
not limited to males. Female offenders who have no evidence of actual drug use are also
mandated into substance abuse treatment programs (Mares, 2011). The Women’s Prison
Association reports:
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In 1977, the U.S. imprisoned 11,212 women; by 2004, that number had ballooned to
96,125, a 757% increase. In 1977, the United States imprisoned 10 women per 100,000
female residents; in 2004, the rate had grown to 64 per 100,000 (Jacobs & From, 2006,
para. 1).
Authors Greene & Pranis (2011) shed light on the growing numbers of women engaging in drug
trafficking in an article entitled “HARD HIT: The Growth in the Imprisonment of Women”,
suggesting that “Women were described as responding to the same social and economic
dynamics that drove increased levels of violence among men, making gender a ‘less salient
factor’” (Greene & Pranis, 2011, p. 21).
Andrea Mares (2011) uses the term femicide to describe the mass killing of women
occurring among Latin American women. In her article titled “The Rise of Femicide and
Women in Drug Trafficking”, the author contends that the 400 percent increase in women
incarcerated in Mexico since 2007 is directly linked to organized crime, specifically related to
women’s increased participation in drug trafficking . Mares speaks to the accessibility of
financial gain and lavish lifestyles women are afforded to provide for their children and families,
stating, “women are probably drawn to the excitement, mystery and power of drug trafficking.
By way of narcotic smuggling, some women are able to attain opulent lifestyles”. It is suggested
that this same dynamic, so evidence in Mexico and various other Latin American nations, is also
impacting women’s increased involvement in drug trafficking in the US. In a study conducted
on US women in New York State, Shaw (2012) reports similar economic factors as driving the
increased number of women convicted of drug related crimes, but also reports other influences as
well. Shaw summarizes that “many [women] appear to be placed in treatment environments
meant for different populations”. Thus, whether male or female, it would seem prudent to focus
11. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 11
attention on providing appropriate treatment to the offender population of drug traffickers, and to
free up scarce drug treatment resources for those who truly have an addiction in need of
treatment (Mares, 2011; Shaw, 2012).
Realizing that there is a potentially significant difference between the user and the dealer
is not a new concept. Many authors have linked the differences to the criminogenic thinking and
lifestyles of the latter group (Simpson, 2008; Williams, 2008). Simpson expresses that,
“offenders engage in crime as a means to obtain money, sex, material possessions and status”
(Simpson, 2008, p. 71). Simpson goes on to explain that the use of drugs for this offender
population is “not the primary focus of their lives; rather, drugs are viewed as a means to support
their criminal enterprise” (Simpson, 2008, p. 71). In fact, the drug dealer who does not use drugs
may have a more serious issue than the typical drug user. Many dealer come from communities
that condone their criminal behaviors (Simpson, 2008). Their behaviors are deeply rooted in a
psychological, cultural, and spiritually flawed belief system. In some communities where quality
education and access to jobs are limited, these offenders are seen as neighborhood role models
who are able to provide food and shelter for their families.
There are many works of fiction that depict the hero worship of the criminal lifestyle
associated with drug trafficking, such as Drama City, Soul Circus, and Hard Revolution, all by
George Pelecanos. Movies such as American Gangster, In Too Deep, and Scarface all portray
the affluent and destructive lifestyles associated with drug sales and culture. Although often
published and created to educate about the evils of this lifestyle, offenders often glorify and
attempt to identify with and mimic the behaviors of the fictional characters. One such book of
fiction is by Sister Souljah, titled The Coldest Winter Ever. The author gives a clear and accurate
picture of this criminal lifestyle, the hero worship of the community, and the egotistic and
12. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 12
narcissistic values that are inherent in this culture. The author also gives a realistic view of the
issues of women involved in the drug dealing culture and the consequences thereof, namely the
problematic legacy to the children growing up in this environment, in which the criminal culture
is inculcated.
Once drug users stop using and engage in a recovery program, their lifestyle often
improves (CSAT, 2005; Wexler, 1995). On the other hand, when drug dealers stop dealing, they
may be faced with what they believe to be a lesser quality of life due to financial and community
esteem losses (Williams, 2008). Much of society may believe that these individuals are lazy or
unintelligent, when much to the contrary they are often intelligent and work diligently in their
trade (Mares, 2011). For instance, US authorities have estimated the business of drug trafficking
as profitable and lucrative, with “between USD [United States Dollar] 18 and USD 35 billion in
drug earnings per year” (Mares, 2011). When a dealer can make thousands of dollars in one day
and is then faced with the very real possibilities of earning minimum wage to meet his needs and
those of his family, it is self-evidence that his value system may have to change to accept such a
drastic change in lifestyle.
Certain behavior modification modalities, such as Therapeutic Communities, have
demonstrated success with the incarcerated population of drug dealers (Wexler, 2011).
Providing drug education, accountability, character building, and stress coping techniques, the
success of this modality has been primarily attributed to dimension of community accountability.
However, many drug users have also been enrolled in programs of this type, and the research has
not differentiated between the outcomes associated with users vs. dealers.
Several authors have acknowledged the need for separation in treatment between drug
users and dealers (Fitzgerald, 2009; Simpson, 2008; Snipes 2011). In the article titled,
13. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 13
“Identifying the Proper Drug-Abuse Treatment for Offenders”, Simpson (2008) states, “While
drug abuse is considered one such criminogenic need, psychological interventions that focus
solely on offenders' drug use and do not attempt to address their criminal behavior will likely
show limited success in impacting recidivism”. Their criminal behaviors are often influenced by
grandiosity, narcissism, power and control issues, spirituality issues, co-dependency, and
underlying anger (Simpson, 2008), some of which are not addressed routinely within chemical
dependency treatment programs.
In an online article, titled “Drug Dealing as an Addiction”, Snipes (2011) expresses that
specialized treatment for drug dealers is just as vital as for drug users. For example, Snipes
(2011) notes that, “Long-winded groups on pharmacology and deficit based instruction are only
going to irritate this [drug dealing] patient”. Snipes notes similarities between drug dealers and
those with problem gambling in an effort to identify treatment needs and how counselors can
address the needs of the non-using offender by focusing on career and employability skills. The
need for separate treatment for drug traffickers vs. users is also discussed by Fitzgerald (2009).
Fitzgerald (2009) emphasizes the need for harm reduction modalities among drug dealers
because studies reflect a high level of habitual violence in this population, fueled in part by
disputes in competition among rival drug dealers for customers and territorial power (Ward,
Mann, & Gannon, 2006).
Clearly, an emerging literature suggests that many professionals in the field of substance
abuse and in the criminal justice system recognize that the need for education and treatment for
the drug dealer is as important as it is for the drug user, and that the modalities of treatment for
drug users are not necessarily helpful for drug dealers (Simpson, 2008). This recognition leads
to a range of questions, such as: What percentage of criminals enrolled in drug treatment due to
14. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 14
drug related charges have no evidence of drug use? Is the drug dealing population large enough
to justify the costs of exploring and developing separate treatments? What are the assessment
tools necessary to reliably differentiate drug users from dealers? What are the treatment
outcomes for drug users vs. dealers who complete current substance abuse treatment programs
designed primarily for users? What is the recidivism rate of those with the same charges who
did not attend drug treatment programming? In standard drug treatment programs, what types of
rehabilitative efforts are being offered to those with sentences of drug trafficking, sales,
manufacturing, delivery, possession, or distribution? What would specialized treatment for drug
dealers include? What additional training would be necessary for addiction professionals to
provide treatment for drug dealers?
The present study isolates one of these research questions: What is the differential
effectiveness of standard substance abuse treatment for persons with actual histories of drug use
vs. those without these diagnoses who have been arrested for drug trafficking, possession,
dealing, delivery, manufacture, or sale, but who may not evidence actual drug use? It is
hypothesized that outcomes for the latter population will be significantly lower than for those
with actual drug abuse or dependence diagnoses.
Method
Participants
This study utilized data from inpatient substance abuse treatment programs that were
grantees of the Offender Re-Entry Programs (ORP) funded by the Center for Substance Abuse
Treatment (CSAT) through the Substance Abuse and Mental Health Administration (SAMHSA)
and monitored through Chestnut Health Systems. The data were collected by the use of the
Global Assessment of Individual Needs (GAIN), which was administered at intake; three month
15. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 15
follow-up, six month follow up, and 12 month follow up. A discharge assessment was also
utilized at the completion of the four to six month outpatient treatment time for those clients who
successfully completed the program. The GAIN assessment and follow-ups were provided for
every client admitted to treatment facilities, whether they completed treatment or dropped out for
any reason. The GAIN assessment and follow ups were given to patients by trained Re-Entry
Care Coordinators, as part of a series of routine intake paperwork. Staff administered the
assessments online, with data maintained in a database at Chestnut Health Systems. Comments
of Care Coordinators and observations were entered at the end of each section of the assessment.
The researcher was not present at the time of data collection. The data covers all clients admitted
between January 1, 2010 through October 31, 2012. The research question of this thesis was not
framed at the time of data collection; as such, there are not expected to be observer effects.
The participants were anonymous in this study as there was no individually identifiable
information available in the database and the subject code had been de-identified such that it
does not link back in any way whatsoever to the client or client records. All results were
presented in aggregate form to further protect subjects’ identities.
Inclusion criteria specified adults aged 18 years and over who attended ORP community
based substance abuse treatment programs during the target dates in 2010-2012, and who had
completed the GAIN Assessment. Data are missing for several reasons that are unlikely to bias
the representativeness of the sample. Most missing data were due to administrative recording
errors and oversights, or for clients who did not meet the substance abuse diagnostic criteria.
Some missing data were due to client refusal to complete paperwork. The dataset consisted of
1,323 individuals, age 18-60 who met inclusion criteria. The dataset included basic
16. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 16
sociodemographic data, but given its national scope, these sociodemographics were insufficient
to identify any particular subjects.
Research Design
The GAIN includes many questions on substance abuse and dependence, including those
needed to suggest a DSM-IV-TR diagnosis and additional questions about each drug and alcohol,
amount used, frequency of use, physical, social, criminal, and economic consequences, and
treatment history. Among these variables is an indicator of whether or not the individual self
reports drugs trafficking, sale, or transport during the past year. This will serve as the
independent variable to divide the subjects into “traffickers” vs. “users”. The dataset contains
150 traffickers and 1,173 abusers.
All subjects in the GAIN database have been enrolled in an appropriate form of alcohol
or drug treatment based on the severity of their substance use. Variables in the dataset include
arrest data, ongoing drug and alcohol use, and measures that have been collapsed to create the
following 12 outcome categories post-discharge:
1. Continued Alcohol/Drug Abuse
2. Reinstitutionalization
3. Illegal Activity
4. Environmental Issues
5. Employment Issues
6. Risky Sexual Behaviors
7. Suicidality/Homicidality
8. Psychiatric Issues
9. Financial Instability
17. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 17
10. Relationship Issues
11. Irresponsible Parenting
12. Continued Aftercare
In the GAIN database, the researcher identified 77 individual outcome variables that could be
used as measures of these 12 outcome categories; see Table 2. Each of these 77 variables
measures outcome for the three month period following discharge from substance abuse
treatment. Means of these variables were reviewed, and it was determined that, of the 77, 64
trended as predicted--i.e., suggesting poorer outcomes for drug traffickers vs. substance users.
These 64 variables will therefore be entered into further analysis.
A MANOVA will be computed, considering each of the 64 outcome variables in relation
to drug trafficking vs. alcohol or drug abuse. A power analysis indicates that the MANOVA and
individual ANOVAs will have sufficient power to detect even small effect sizes (Cohen, 1988).
The alpha level for the ANOVA for each dependent variable will be adjusted using the
Bonferroni method to correct for family-wise error in significance testing; p = .05/64 = .001. In
the MANOVA, two variables will be controlled as covariates: 1) number of days during the three
months post treatment that the individual was in a controlled environment (i.e., jail, prison, or
treatment), since days in a controlled environment impacts access to drugs and alcohol and other
behavioral indicators of potential treatment success; and 2) severity of alcohol and drug abuse at
time of treatment commencement, since severity also affects treatment outcome. With these two
factors controlled, the MANOVA will be able to detect the pure effect of drug trafficking on
treatment outcome.
During this study, only the thesis chair and the student researcher will have access to the
data. The data are stored on the two computers owned by these individuals. The data have been
18. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 18
placed in a separate Windows folder on each computer, segregated from any other files that are
not related to the data set. The two computers are locked by strong Windows passwords, known
only to the computer owners. Following completion of the research, the data set and related files
will be retained by the researcher for a minimum of seven years in case questions arise about the
analyses. The data set and related files will be transferred to any future computer owned by the
researcher until the seven years have expired. Throughout the study and subsequent seven years,
the researcher will implement a weekly backup plan wherein the data set and related files are
backed up using a secure online data backup system. The current system used is Qwest Personal
Digital Vault. Details of this service’s security policy can be found at this link:
https://digitalvault.qwest.com/help.aspx. Once the seven years are over, the researcher will
destroy the electronic dataset using an economical method recommended by Department of
Defense Data Destruction Standards.
Results
The final dataset contained 1,348 subjects who had completed drug and alcohol
treatment. Table 1 presents their sociodemographic information. Their mean age was 33 years;
2/3 was male and 1/3 female. The dataset represents a well rounded ethnic mix, with 46% of
subjects being White and the remainder members of other minority groups. However, Hispanics
were over-represented in the dataset and Asian-Americans were under-represented. Most, 56%,
had not completed high school, and only 10% had some form of college. Only 18% were married
or in a committed relationship, with more than half never married.
In the GAIN database, the researcher identified 77 individual outcome variables that
could be used as measures of the 12 outcome categories. Each of these 77 variables measured
outcome for the three month period following discharge from substance abuse treatment. Means
19. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 19
of these variables were reviewed, and it was determined that, of the 77, 64 trended as predicted--
i.e., suggesting poorer outcomes for drug traffickers vs. substance users. A 1 x 1 Chi Square was
computed on these trend data and was highly statistically significant, indicating that, even
without statistical controls, drug traffickers appeared to have poorer treatment outcomes than
substance users; X2
= 33.78, df = 1, p < .001.
A MANOVA was then computed, considering each of the 64 outcome variables that
trended as predicted in relation to drug trafficking vs. substance use. In the MANOVA, two
variables were controlled as covariates: 1) number of days during the three months post
treatment that the individual was in a controlled environment (i.e., jail, prison, or treatment),
since days in a controlled environment impacts access to drugs and alcohol and other behavioral
indicators of potential treatment success; and 2) severity of alcohol and drug abuse at time of
treatment commencement, since severity also affects treatment outcome. With these two factors
controlled, the MANOVA was able to detect the pure effect of drug trafficking on treatment
outcome.
The overall MANOVA was highly statistically significant; Pillai’s Trace = 0.991,
F(66,174) = 293.44, p < .001. This indicates that, overall, there is a highly significant outcomes
difference between drug traffickers vs. substance users. ANOVAs were computer to contrast
drug traffickers vs. substance users on each of the 64 individual outcome variables. The alpha
level for the ANOVAs was adjusted using the Bonferroni method to correct for family-wise error
in significance testing; p = .05/64 = .001. Table 2 presents means and standard deviations for the
64 drug and alcohol treatment outcome variables, organized by 12 major categories, along with
the F statistic from each individual ANOVA.
20. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 20
In five of the 12 outcome categories, one or more outcome measures differed
significantly between traffickers and users. The five categories with significantly different
variables were: Continued Alcohol/Drug Use, Reinstitutionalization, Environmental Issues, High
Risk Sexual Behaviors, and Relationship Issues.
In the category of Continued Alcohol/Drug Use, eight of 11 outcome measures were
significantly different between traffickers and users. This category is critical, since it measures
the most essential target outcome of alcohol and drug treatment--abstinence. The fact that eight
of 11 variables were statistically significantly different between traffickers and users, even with
statistical controls and a stringent Bonferroni corrected alpha level, appears to suggest a clear
difference in abstinence between the two groups.
In the category of Reinstitutionalization, the one available measure, days in a controlled
environment, was significantly different between traffickers and users. The mean days in a
controlled environment in the past 90 days, 35 vs. 28, suggest that traffickers spent seven more
days in a controlled environment than users.
In the category of Environmental Issues, one out of three outcome measures was
significantly different between groups. The significant variable was the Environmental Strengths
Index, a composite of several measures of environmental stressors and supports. The difference
indicated that, overall, traffickers had less environmental strength than users.
In the category of High Risk Sexual Behaviors, one out of three measures was
significantly different between groups. The variable that was significant was the Sexual Risk
Scale, a composite of several measures of risky sexual practices. This indicated that, overall,
traffickers were engaging in more high risk sexual behaviors than users.
21. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 21
In the category of Relationship Issues, two out of eight variables were significantly
different between groups. Traffickers had more housemates who engaged in illegal activity and
who were frequently intoxicated.
Discussion
The present study asked the following research question: What is the differential
effectiveness of standard substance abuse treatment for persons with clear histories of drug use
vs. those who have been arrested for drug trafficking, possession, dealing, delivery, manufacture,
or sale? It was hypothesized that outcomes for the latter population would be significantly lower
than for those with drug abuse or dependence diagnoses. Results suggested that 64 of 77
outcome measures trended as hypothesized; a Chi Square on the trend data indicated that this
difference was highly statistically significant. MANOVA results also suggested that this
difference was highly significant, even when days post-treatment in a controlled environment
and substance use severity were controlled. Thus, the MANOVA suggested that there is a strong,
pure effect of drug trafficking on poorer treatment outcome. As such, the hypothesis of this study
appears to be well confirmed.
The effect of drug trafficking on poorer treatment outcomes is evident across all 12
outcome categories; see Table 2. The effect is particularly strong in five of the 12 outcome
categories where one or more outcome measures differed significantly between traffickers and
users even with multiple statistical controls from two covariates and the remaining outcome
variables. These five outcome categories are: Continued Alcohol/Drug Use,
Reinstitutionalization, Environmental Issues, High Risk Sexual Behaviors, and Relationship
Issues. With this in mind, the question arises as to why drug traffickers are routinely being
enrolled in treatment programs designed for substance users. This question is explored below.
22. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 22
The results of this study will likely not be surprising to substance abuse counselors who
work within the prison system. Psychosocial assessments, GAIN assessments, and a variety of
other assessments have been created to identify, diagnose, and aid in treating substance users.
When used with drug traffickers, these assessments may falsely flag the individuals as
potentially having the diagnosis of substance abuse, because several criteria of the DSM-IV-TR
substance abuse diagnosis are vague enough that they may apply to drug traffickers who do not
use substances regularly. These criteria include: recurrent substance related legal problems;
recurrent use resulting in failure to fulfill major role obligation at work, home, or school; and
recurrent use in physically hazardous situations. These items, especially “recurrent substance
related legal problems”, are readily endorsed by drug traffickers as they capture the
circumstances of drug trafficking fairly well.
The majority of treatment funding sources, state and federal, during incarceration and
after incarceration, require that a person enrolled in treatment have a DSM-IV-TR substance
abuse or dependence diagnosis. There is no DSM-IV-TR diagnosis for drug dealing. With
funding being harder and harder to obtain, treatment providers often diagnose this population
with substance abuse in an attempt to meet the requirements that those receiving treatment have
a DSM-IV-TR substance use diagnosis. It is possible to justify the diagnosis of substance abuse
in these persons, for several reasons. First, some of the drug traffickers do sometimes use
substances. Second, the DSM-IV-TR criteria for substance abuse include these items: recurrent
substance related legal problems; recurrent use resulting in failure to fulfill major role obligation
at work, home, or school; and recurrent use in physically hazardous situations. These items,
especially “recurrent substance related legal problems”, can apply to drug traffickers even if they
do not use substances regularly. Third, persons involved with substances are known to be in
23. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 23
denial and to misrepresent their substance use. As such, there is an element of clinical judgment
with a drug trafficker which may allow a counselor to make the substance abuse diagnosis
without unequivocally clear evidence of substance abuse. If this is what is needed to obtain
treatment for the person, it may seem like an attractive and even ethical option. This is
particularly the case because there is no alternative for treatment of drug trafficking, and thus the
drug trafficker will likely remain in the same unproductive cycle of repeated incarcerations.
There is no current known assessment to identify, diagnose, and aid with treatment of
drug traffickers. Drug trafficking is not even conceptualized by many as a disorder. Should this
issue be identified as a mental disorder? Should it be identified as a behavioral disorder? What
are the symptoms and how are they identified, measured, and diagnosed? How could treatment
for this population be funded to reduce their recidivism? The results of this study suggest that
there is a need for these questions to be answered. Drug dealers/traffickers are returning to
society with inadequate treatment, despite the attempts of federal, state, and local programs,
DOC Re-Entry programs, transitional programs, and post release treatment. The results of this
study indicate that, after their completion of standard substance abuse treatment, there is little
change in the people they socialize and live with, how they resolve disagreements, and their
ability to condone risky sexual behavior as an inherent part of that culture. Thus, they would
appear to remain at significant risk of recidivism.
There are no easy answers or solutions. To address these issues would change the entire
process of assessment and diagnosis in the penal system. However, it is suggested that just as
there is federal and state funding for the users, there is a need to identify federal and state
funding targeted to the specific population of drug traffickers. Let us keep in mind that these
dollars are already being spent on these clients because they are being sent to standard substance
24. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 24
abuse treatment, but with poorer outcomes. Creating a different modality of treatment and
segregating the populations could provide appropriate treatment for the appropriate clients.
Furthermore, many substance users are in need of treatment that is obviously being directed to
drug traffickers who do not benefit much from the current treatment methods.
Pilot programs initiated within the criminal justice system should present minimal
additional costs, as the clients’ treatment is already being paid for. The greatest issue lies with
the DOC and other criminal justice agencies which now receive funding from federal and state
sources that require a DSM-IV-TR diagnosis and evidence-based treatment. This issue would
need to be addressed by a coalition of clinicians, policymakers, mental health and behavioral
health professionals, and social scientists. For policy makers on both the federal and state levels
to adjust methods of funding, it may be as simple as moving already existing funding in another
direction.
The researcher has been working with these clients for many years, using what may be
inappropriate methods to address their needs. The problem will not resolve itself. If we as
clinicians continue to utilize inappropriate treatment options with this population simply because
we have no alternatives, this is an ethical dilemma. We must create these alternatives by
addressing the issue openly and with good science. This present research is intended to draw
attention to this issue to promote an open dialogue.
This study entails several limitations. First, although the data are based on a reliable and
valid instrument, the GAIN, GAIN data derive from client self-reporting. All self-reporting,
especially when it involves persons with alcohol and drug abuse or criminality, is subject to
some degree of distortion. Second, the outcome measures used were obtained at three months
following end of treatment. Longer periods of time post treatment should be considered to
25. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 25
determine if the differences found remain over time. Third, although drug traffickers clearly are
evidencing lower outcomes at three months post treatment, their status on these measures before
treatment was not assessed. It is possible that drug traffickers have more risk factors and
dysfunctional behaviors pre treatment, and that treatment is having an impact on these issues.
Thus, pre treatment to post treatment change scores should be examined for a deeper
understanding of the effects of standard substance abuse programs on drug traffickers.
26. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 26
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29. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 29
APPENDIX A
Tables
Table 1
Sociodemographic Characteristics of the Sample
Measure All Subjects
N 1,323
Age 32.5 (10.5) RANGE: 20-59
Ethnicity
White
African-American
Asian-American
Native-American
Hispanic
45.6%
19.5%
0.7%
4.8%
29.3%
Gender
Male
Female
67.7%
32.3%
Education
Less than high school
High school completed/GED
College
Graduate school
34.1%
55.9%
9.4%
0.6%
Relationship Status
Married/In Committed Relationship 17.8%
31. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 31
Table 2
90 Day Treatment Outcomes for Drug/Alcohol Users vs. Drug Traffickers
Measure
Users
Mean (SD)
Traffickers
Mean (SD) F (df=2)
N 1,173 150
Continued Alcohol/Drug Use
Days Abstinent 57.03 (38.59) 39.60 (37.97) 373.29*
Denial/Misrepresentation Scale .36 (.53) .69 (.59) 9.62*
% Used Alcohol in Past 90 Days 23 (42) 35 (48) 17.10*
% Using AOD most of day 20 (40) 37 (48) 17.01*
Mental Denial & Misrepresentation Rating .20 (.52) .57 (.75) 3.76
Outcome in Recovery (0-1 scale) .57 (.50) .33 (.47) 45.20*
Days Used AOD 6.39 (18.38) 18.90 (31.42) 6.75*
Substance Abuse Index .08 (.32) .26 (.58) 6.96*
Substance Dependence Scale (past month) .06 (.31) .19 (.56) 4.38
Substance Problem Scale (past month) .16 (.43) .36 (.68) 5.68
Substance Severity Measure (past month) 2.15 (.58) 2.42 (.97) 7.04*
Reinstitutionalization
Days in Controlled Environment 27.59 (37.64) 34.98 (37.89) 1407.71*
Illegal Activity
Times sold/distributed/made illegal drugs 0.18 (2.18) 1.87 (10.05) 0.97
Days in any activities you thought illegal 1.12 (7.84) 5.54 (18.73) 0.78
32. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 32
% Any Illegal Activity 07 (26) 20 (40) 2.79
Total # of Arrests .06 (.31) 0.88 (8.91) 1.27
Illegal Activity Scale 1.03 (.33) 1.10 (.47) 1.15
Days of Illegal Activity to get AOD .42 (4.38) 2.36 (12.30) 1.10
How many times arrested .08 (.39) .34 (2.34) 2.79
General Crime Scale .06 (.28) .20 (.49) 2.25
Environmental Issues
Number of Days Homeless 5.08 (18.84) 7.92 (22.57) 0.11
Environmental Risk Scale 1.00 (.37) 1.22 (.49) 4.26
Environmental Strengths Index-Reversed 1.12 (.67) .93 (.75) 8.48*
Employment Issues
Days Worked .78 (.84) .50 (.75) 0.80
Employment Activity Scale .84 (.88) .57 (.83) 0.61
Vocational Risk Index 1.61 (.61) 1.72 (.52) 1.56
Risky Sexual Behaviors
Number of Male Sex Partners .22 (.89) .25 (.65) 1.25
Any High Risk Sex .08 (.27) .19 (.40) 5.90
Sexual Risk Scale .43 (.50) .50 (.57) 19.25*
Suicidality/Homicidality
Thought About Committing Suicide .03 (.17) .03 (.16) 0.10
# Suicidal/Homicidal Attempts/Thoughts .06 (.24) .09 (.29) 0.31
Thought About Killing or Hurting Someone .04 (.20) .06 (.24) 0.80
33. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 33
Homicidal Suicidal Thought Scale .06 (.27) .10 (.33) 0.35
Psychiatric Issues
Conduct Disorder Scale .20 (.78) .47 (1.21) 0.93
Days with Psychiatric Problems .56 (.83) .84 (.87) 0.23
Anxiety/Fear Symptom Scale .37 (.60) .57 (.71) 0.39
Emotional Problem Scale .57 (.65) .75 (.69) 0.64
General Mental Distress Scale .65 (.88) .91 (.95) 0.95
Internal Mental Distress Scale .28 (.56) .53 (.71) 0.38
High Mental Distress .27 (.44) .40 (.49) 0.57
Strength Self-Efficacy Index-Reversed .65 (.65) .61 (.66) 0.04
Days Cut, Burned or Hurt Self on Purpose .10 (1.71) .13 (.92) 0.95
Financial Instability
Financial Instability Scale .13 (.15) .18 (.19) 2.20
Days with Money Problems (0-1) .14 (.31) .23 (.37) 0.47
Financial Instability Scale .37 (.64) .59 (.74) 2.06
Financial Problem Scale .24 (.54) .52 (.73) 2.46
Past Month School/Work .53 (.50) .40 (.49) 0.23
Work Full Time 22.90 (30.80) 14.54 (27.10) 1.82
Relationship Issues
People Lived with Shout, Argue, Fight .29 (.80) .50 (1.05) 5.27
No Family Problems .88 (.33) .83 (.38) 2.33
Housemates Engaged in Illegal Activity 2.87 (4.65) 3.12 (5.16) 7.26*
34. DIFFERENTIAL EFFECTIVENESS OF SUD TREATMENT 34
% Peers Weekly Intoxication 14 (35) 29 (46) 9.09*
Days Housemates Used Alcohol 2.67 (11.60) 10.89 (25.61) 4.48
Days Housemates Used Drugs 2.35 (11.84) 10.59 (25.00) 2.65
General Social Support Index-Reversed .30 (.59) .39 (.69) 0.47
Social Environmental Risk Index 9.70 (4.36) 11.72 (5.83) 2.26
Irresponsible Parenting
Day had Children in Foster Care 2.48 (14.75) 3.88 (18.36)
0.94
Continued Aftercare
Times in Support Recovery Meetings 1.22 (3.56) 1.06 (3.41) 4.94
General Continuing Care Adherence .62 (.74) .54 (.71) 1.00
Days Attended Groups 19.55 (31.14) 16.63 (27.14) 0.32
Treatment Resistance Index .59 (.64) .83 (.61) 0.18
% Weekly Self-Help 32 (47) 31 (46) 0.36
% Weekly Aftercare 27 (45) 15 (36) 1.59
Spiritual Social Support Index-Reversed .90 (.71) 1.23 (.73) 0.45