Trends in Access to Substance Abuse Treatment for Women and Men: Jeanne C. Marsh, PhD, Hee-Choon Shin, PhD, Dingcai Cao, PhD University of Chicago Society for Social Work and Research January 2010 Support from NIDA R01-DA THE SCHOOL OF SOCIAL SERVICE ADMINISTRATION THE UNIVERSITY OF CHICAGO SSA/CHICAGO

6/25/20162 PURPOSE: To compare trends in access to substance abuse treatment for women and men between 1995 and 2005 To examne factors related to admission to substance abuse treatment for six substances: alcohol, marijuana, Heroin, cocaine, methamphetamines and prescription pain relievers

6/25/20163 BACKGROUND: Evidence documents significant gender disparities in access to substance abuse treatment services E.G., 6.2% women and 8.3% ment receive treatment for alcoholism; 15% women and 19% of men who need treatment for illicit drugs receive treatment Factors related to these disparities only beginning to be understood e.g., different barriers related to social roles, difference drug preferences EXPAND

6/25/20164 STUDY SAMPLE AND DESIGN: Data collected from National Treatment Improvement Evaluation Study (NTIES) Purposive longitudinal study of substance abuse treatment (SAT) programs and clients Analytic sample of 1812 Blacks, 486 Hispanics, 844 Whites, 1123 women and 2019 men

6/25/20165 BACKGROUND SAT results in decrease in alcohol and drug use for women, men and individuals from different race/ethnic groups. No differences in outcome persist despite differences in severity coming into treatment and differences in utilization patterns.

6/25/20166 BACKGROUND Know very little about race/ethnicity and gender COMBINED as moderator variables in search for distinct PATHWAYS TO TREATMENT SUCCESS. Useful to identify distinct pathways for women and men from different racial/ethnic groups.

6/25/20167 REVIEW: BLACKS AND LATINOS: Enter substance abuse treatment (SAT) with co- occurring problems and limited social and economic resources. Report receiving fewer services and spend less time in treatment. Have few interventions developed to address their special needs. Underserved in relation to health and social service needs.

6/25/20168 REVIEW: WOMEN Enter SAT with more co-occurring problems and more barriers to treatment. Receive more ancillary health and social services in SAT. Spend comparable amounts of time in treatment and have comparable outcomes as men. Differentially benefit from specific services: Women benefit more than men from mental health services; men more than women from staying in treatment.

6/25/20169 SEARCH FOR PATHWAYS CONSISTENT WITH RESEARCH ON SPECIAL SERVICES History of research on special services for women in SAT and growing interest in tailoring services to other groups. Special services research shows women benefit from ancillary health and social services in SAT (Greenfield et al., 2007). Women (and men) benefit from services tailored to specific treatment needs. Overall support for treatment principle of tailoring services to client needs to achieve best outcomes.

6/25/ RESEARCH QUESTIONS: What are race-specific gender differences? What are factors predicting reduced post- treatment drug use for women and men within each race/ethnic group?

6/25/ DEPENDENT VARIABLE: Substance use in 12 month post-treatment completion, specifically, # days in last 30 client used at least one of five most frequently used drugs: marijuana, crack, cocaine powder, heroin or alcohol.

6/25/ INDEPENDENT VARIABLES: ORGANIZATIONAL-LEVEL Accreditation Modality Ownership On-site service availability Counseling frequency

6/25/ INDEPENDENT VARIABLES: CLIENT-LEVEL Services received: access, substance abuse counseling, family and life skills services, health services, mental health services, concrete services Service duration (weeks between 1st and last day of treatment) Client demographics (age, race, education, living with minor child)

6/25/ WHAT ARE RACE/ETHNIC DIFFERENCES IN ADMINISTERS ’ REPORTS OF ORGANIZATIONAL CHARACTERISTICS? Blacks, Hispanics, Whites all benefit from SAT Blacks, Hispanics, Whites served in different treatment organizations Hispanics served in programs with least number of services provided onsite Hispanics served in treatment organizations with lowest frequency counseling schedules

6/25/ Outcome Differences

6/25/ Differences in Organizational Variables: Accreditation

6/25/ Organizational Variable: Onsite Services

6/25/ Organizational Variable: Frequency of Counseling

6/25/ SUMMARY OF RACE/ETHNIC DIFFERENCES IN TREATMENT EXPERIENCE No differences in outcome for Blacks, Hispanics, Whites: All benefit from SAT Blacks, Hispanics, Whites served in different treatment organizations Hispanics served in programs with least number of services provided onsite Hispanics served in treatment organizations with lowest frequency counseling schedules

6/25/ WHAT ARE RACE/ETHNIC DIFFERENCES IN CLIENT REPORTS OF SERVICES RECEIVED? Hispanics receive most access and concrete services Blacks receive most substance abuse counseling services Whites receive most family counseling and mental health counseling services

6/25/ Service Variable: Access

6/25/ Service Variable: Concrete Services

6/25/ Service Variable: Substance Abuse Counseling

6/25/ Service Variable: Family Counseling

6/25/ Service Variable: Mental Health Counseling

6/25/ Service Duration

6/25/ SUMMARY OF SERVICES RECEIVED Hispanics receive most access and concrete services Blacks receive most substance abuse counseling services Whites receive most family counseling and mental health counseling services No difference in time spent in treatment Across all groups and all services, women receive more services than men

6/25/ WHAT ARE RACE/ETHNIC DIFFERENCES IN CLIENT CHARACTERISTICS? Hispanics less likely than Blacks or Whites to have graduated from high school, be working full time, to have prior drug/alcohol treatment experience Hispanics more likely to be embedded in family system and less like to report domestic violence history Hispanics and Blacks greater pre-treatment drug use Whites report greater pre-treatment use of mental health services

6/25/ Client Characteristic: High School Graduation

6/25/ Client Characteristic: Marital Status

6/25/ Client Characteristic: Lives with Child or Pregnant

6/25/ Client Characteristic: Full-time Work

6/25/ Client Characteristic: Ever Beaten

6/25/ Client Characteristic: Prior drug/alcohol treatment

6/25/ Client-characteristic: Payment Source

6/25/ SUMMARY: CLIENT CHARACTERISTIC DIFFERENCES Hispanics less likely than Blacks or Whites to have graduated from high school, be working full time, to have prior drug/alcohol treatment experience Hispanics more likely to be embedded in family system and less like to report domestic violence history Hispanics and Blacks greater pre-treatment drug use; less prior exposure to service system Whites report greater reliance on private insurance/self-pay.

6/25/ DOES GENDER PREDICT OUTCOME FOR ALL RACE/ETHNIC GROUPS? Marsh & Cao (2004) found main effect for gender when all groups analyzed together When gender analyzed separately for specific race/ethnic groups, gender main effect only for Hispanics: After controlling for organizational, service and individuals characteristics, Hispanic women have lower post-treatment drug use than men

6/25/ WHAT OTHER FACTORS PREDICT OUTCOME FOR EACH (OF SIX) GROUPS? Hispanics benefit from receiving services in JCAHO- accredited organizations Hispanics and Hispanic women benefit from having services available onsite Blacks and Black women benefit from substance abuse counseling Blacks and Black men benefit from remaining in treatment White women benefit from receipt of mental health services Whites and White men benefit from receipt of concrete services

Reduced Substance Use Black Samples Women + Men Accreditation Methadone Long-term Residential Private Ownership Onsite Services Frequency of Counseling Substance Abuse Counseling Mental Health Service Concrete Service Treatment Duration Gender Gender x Mental Health Service Gender x Treatment Duration Organizational Variables Service Variables Interactions Women 9.56 Men

Reduced Substance Use Hispanic Samples Women + Men 8.72 Accreditation Methadone Long-term Residential Private Ownership Onsite Services Frequency of Counseling Substance Abuse Counseling Mental Health Service Concrete Service Treatment Duration Gender Gender x Mental Health Service Gender x Treatment Duration Organizational Variables Service Variables Interactions Men Women

Reduced Substance Use White Samples Accreditation Methadone Long-term Residential Private Ownership Onsite Services Frequency of Counseling Substance Abuse Counseling Mental Health Service Concrete Service Treatment Duration Gender Gender x Mental Health Service Gender x Treatment Duration Organizational Variables Service Variables Interactions Women + Men Women Men

6/25/ SUMMARY OF PATHWAYS TO TREATMENT OUTCOME Hispanics benefit from receiving services in JCAHO- accredited organizations Hispanics and Hispanic women benefit from having services available onsite Blacks and Black women benefit from substance abuse counseling Blacks and Black men benefit from remaining in treatment White women benefit from receipt of mental health services Whites and White men benefit from receipt of concrete services

6/25/ OVERALL FINDINGS: Gender and race/ethnic groups have distinct treatment experiences Gender is a significant predictor of treatment success only for Hispanics when groups analyzed separately A distinct set of factors predicts outcome for each group

6/25/ CONCLUSIONS: No gender, race/ethnic disparities in SAT outcomes. Disparities in SAT services received and time spent in treatment. Findings identify service ingredients most likely to contribute to reduced drug use for each group, i.e., specific service pathways to success.