Coerced treatment for methamphetamine abuse : Differential patient characteristics and outcomes

Policymakers have responded to the increase in the prevalence of methamphetamine (MA) use and the associated social costs (such as crime and child abuse and neglect) by mandating a growing number of MA users to substance abuse treatment via the criminal justice system (CJS) and/or child protective service (CPS) agencies. However, empirical evidence remains sparse about treatment outcomes specifically for MA users who report that their treatment admission occurred under such pressures. This analysis uses natural history interview data from 350 clients treated for MA use in Los Angeles County to examine clients' self-reported CJS/CPS pressure to enter treatment, comparing background and treatment characteristics and selected treatment outcomes across groups defined by existence of such perceived pressure and source of pressure. Approximately half the clients reported legal pressure to enter the index (used for sampling) treatment episode. Those reporting pressure were younger, less likely to have received residential treatment, and had longer treatment episodes than those not reporting pressure. Outcomes (treatment completion, relapse within 6 months, time to relapse, and percentage of days with MA use in 24 months following treatment) did not differ significantly in simple comparisons between the pressured and nonpressured groups; however, when client and treatment characteristics were controlled, the short term outcome of relapse within 6 monthswas worse for those reporting legal pressure. Outcomes did not differ by source of pressure.

Keywords: Coerced treatment; methamphetamine; relapse; drug treatment outcomes; child protective services; criminal justice

As substance abuse has grown in diversity and prevalence, policymakers have searched for alternatives to alleviate the social costs associated with drug addiction. One recurring method under prevailing U.S. policies has been to mandate or coerce individuals into substance abuse treatment. Many studies have supported the effectiveness of this approach generally and for some specific drugs. However, little research has focused on patient characteristics and treatment outcomes for methamphetamine (MA) users coerced into treatment through various social service (such as child protective services [CPS]) and criminal justice (CJS) procedures or sanctions, including civil commitment programs, conditions of probation or parole, mandated inmate treatment, drug court supervision, or conditions of child custody. In this article, we examine user characteristics and substance use treatment outcomes for MA users who report legal pressure for their treatment participation through criminal justice (court or probation/parole) or child protective services sources. Findings are particularly relevant at present, as admissions to treatment for MA have increased considerably, particularly in California and other western states.

Increases in MA prevalence in the last decade have generated concern resulting in the development of a national strategy for attacking MA related problems [1]. While long endemic in certain areas, the geographic penetration has expanded from the West Coast to include parts of the Midwest and South [2], [3], [4]. MA has been cited as one of the major drugs of concern by federal, state, and local law enforcement, with 31% of state and local law enforcement agencies now citing MA as the major drug problem [5]. Epidemiological and law enforcement concerns also are reflected in treatment admission data. For example, in 1992 only one state had treatment admission rates for methamphetamine (per 100,000 population) of 24 or more; by 2000, 15 states had rates at least that high [6]. In the California public treatment system, while total admissions increased in capacity only about 17% from 1992 to 2000, admissions for MA tripled [7].

Because of these increases in MA use, the concomitant social problems, and law enforcement concerns, the use of pressure, coercion, or mandate has been suggested as one way to induce MA users into treatment. For example, the Methamphetamine Interagency Task Force [8] recommended coercion as a major law enforcement strategy; and the National Drug Control Strategy has recommended increased use of the child welfare system and drug courts to channel substance users into treatment [1].

Most research on coerced or pressured treatment admission comes from the criminal justice system arena [9], [10]. Because of the demonstrated link between crime and substance abuse and increasingly costly incarceration rates, strategies have been developed to use CJS sanctions to facilitate treatment entry by offenders with substance abuse problems. Such approaches are also sometimes called "mandated," "coerced," "compulsory," or "nonvoluntary" [11]. While there do not appear to be constitutional and other legal barriers to CJS-pressured treatment, there have been conflicting views on the appropriateness of such strategies [12], [13], [14], [15]. Coerced treatment is controversial in part because it may not coincide with professional views of important psychological processes such as motivation, engagement in treatment, or compliance [16], and the common belief that the lack of internal client motivation may preclude positive outcomes [15], [17]. However, it also has been argued that the external motivators (e.g. CJS coercion) may lead to increased internal motivation or interact with it to produce better outcomes [18], [19], [20]. In addition, clients entering treatment under CJS pressure may not necessarily be involuntary [11]. Many studies have shown at least some positive results of coerced treatment for criminal offenders generally and for users of specific drugs such as heroin [9], [21], [22], [23], [24], [25]. There remains a need to extend this evidence to include MA users due to the increasing national impact of this drug.

CJS pressure to enter treatment has been exerted through a variety of agencies and programs. Past programs have included, for example, court-ordered treatment alternatives to prison (e.g., the Civil Addict Program), pretrial diversion programs (e.g., Treatment Alternatives to Street Crime), in-prison treatment programs, and parole/probation programs [9], [21], [23], [26], [27], [28], [29]. A relatively recent addition to CJS approaches (beginning in 1989) has been the drug court movement, involving substance abuse treatment and rehabilitation services coupled with intensive court supervision. Drug courts continue to increase in number because of their reported effectiveness in terms of decreased costs, improved retention in treatment, and decreased recidivism [30], [31], [32], [33], [34]. Yet, there are few data other than anecdotes on drug court outcomes specifically for MA users [35]. Further, the need to examine the impact of CJS-pressured substance abuse treatment for MA users is evident in recent statistics showing that almost half of California offenders eligible for treatment (rather than prison) under the 2000 Substance Abuse and Crime Prevention Act (SACPA) are MA users [36].

The other most common source of pressured treatment admission results from actions of county child protective services (CPS), which identify children at risk for neglect or abuse, and facilitate their safety through intervention with their caregivers or by removing them from unsafe care environments [37]. The high rates of substance-using parents or caretakers of children under CPS jurisdiction have increased the formal interaction between CPS and substance abuse treatment services [10], [38]; estimated rates range from around 20% [39] to as high as 50% [40] and 70% [41]. Unlike CJS-pressured admissions, few evaluation data are available on CPS-coerced drug treatment admission [10], [42]. The scarce research results that have been reported suggest high levels (48% within 6 months) of noncompliance with court-ordered substance abuse or mental health treatment among randomly selected child neglect cases in a large urban southeastern U.S. county [10]. Yet rates of treatment completion were higher for mandated than for voluntary admissions in a California program for women offered treatment as an alternative to incarceration or loss of custody [43]. The present study is able to extend this research to outcomes of CPS-pressured treatment for MA users.

This article assesses the relationship of perceived legal pressure for treatment entry (as self-described by the client) to treatment outcomes for a sample of 350 MA-using clients from a large county publicly-funded substance abuse treatment system. We describe the existence and source of CJS (drug court, other court, probation/parole) and CPS pressure to enter substance abuse treatment as reported by these treated MA users, as well as differences between the pressured and non-pressured subgroups and among reported sources of pressure in terms of selected client and treatment characteristics and treatment outcomes. We also examine the impact of existence and type of legal pressure in predicting treatment outcomes, controlling for selected client and treatment characteristics.

The sample of 350 MA users was obtained by stratified (by gender, ethnicity, and modality) random sampling of records of admission to outpatient or residential treatment for MA use in Los Angeles County from the statewide administrative database for publicly funded service delivery units (California Alcohol and Drug Data System). The majority of sampled admission records were from 1996 (with a few from proximal months in 1995 and 1997 in order to increase the size of underrepresented strata). Service delivery units contacted (or attempted to contact) the former clients associated with the sampled records, inviting them to participate in the study. Interviews were conductedwith these former treatment clients in 1998–2001; for most participants, this interview occurred approximately 2–3 years after their admission to the sampled ("index") treatment episode. A 76% interview rate was achieved from the sampled records for which clients could be located: 365 were interviewed, 88 declined participation, 28 expressed interest but found it impossible to schedule an interview during the study period, 6 had died. Another 151 from the originally sampled records could not be located primarily because of incomplete or no longer existent program records. Fifteen of the 365 interviews were not included in the current analysis because of incomplete or inconsistent data, producing the analysis sample of 350 reported here.

Comparisons of admission record data for those interviewed versus those not interviewed showed no significant differences for an extended array of measurements: gender, ethnicity, education, age of first MA use, age at treatment admission, number of prior treatment episodes, status at admission (employed, homeless, pregnant, or under legal supervision), whether completed treatment, and time in treatment. Such similarity suggests that loss to follow-up was not obviously systematic or nonrandom in nature, thus supporting the representativeness of the sample for this analysis.

Data for this analysis were collected in a larger, longitudinal parent study using the Natural History Interview (NHI). This instrument includes sections on personal and family background, physical and mental health, risk behaviors, substance use, treatment, and crime. Part of the interview allows collection of a "continuous stream" of data on a month-to-month basis from age 14 until the interview, providing histories of substance use and other behaviors. The NHI has acceptable levels of agreement of test-retest self-report, of self-report and urinalysis, and of pattern reliability of latent constructs across time [44], [45], [46]. In the current study, agreement between self-reported recent MA use and urinalysis was 88%. While the study was not designed specifically to examine coerced treatment, data are sufficiently comprehensive to provide a basis for this analysis.

Variables included in the analysis represent perception of existence and source of legal pressure for treatment admission, selected treatment outcome measures, as well as client background and treatment characteristics. Pressure to enter treatment is measured by the respondent's self-report of whether there was legal pressure from CJS or CPS to enter treatment; source of pressure is self-report of drug court, other court, parole/probation, or CPSpressure. Our measure represents the client's perception of pressure and its source, a critical perspective often not included in prior research [47].

We use four MA-use-related treatment outcomes including treatment completion and incidence-related indicators from both harm-reduction and abstinence perspectives [48]. An overall indicator of post-treatment MA-use frequency, covering a moderately long 24-month period, is measured as the percent of days of MA use in the 24 months following the index episode; for the 8% of the subjects who had follow-up periods less than 24 months, their MA-use frequency measure represents the percentage of their actual follow-up days with MA use. Months of continuing abstinence (or "months to relapse") is measured as the number of consecutive months without MA use following discharge from the index treatment episode; full follow-up periods differed somewhat in length with most (81%) 2–4 years (additional detail in Results below). To provide a focus on the early posttreatment period during which the majority of relapse typically occurs, a dichotomous variable was created indicating whether respondent relapsed to MA use during the first 6 months following the index treatment episode.

Research findings have been inconsistent with respect to differences between coerced and noncoerced treatment clients in terms of background characteristics, with most studies finding no major differences [21], but others noting differences in, for example, education and ethnicity [49]. Nevertheless, because such characteristics are sometimes shown as possible influences on treatment outcomes [50], [51], [52], we include them as control variables in assessing effects of existence and source of coercion. Accordingly, several demographic and other client background characteristics are used to further describe pressured versus non-pressured groups and the subgroups by source of pressure and to act as control variables in examining the relationship of legal pressure to treatment outcomes. Gender, ethnicity, and education level are included as basic demographic descriptors. Ethnicity is categorized from self-report into African American, Hispanic, non-Hispanic White, and "other" (including other race/ethnic groups and/or mixed race). Education is represented by a dichotomous variable indicating high school graduate (or GED) versus less. History of psychiatric comorbidity is indicated by self-reported past diagnosis of schizophrenia or bipolar disorder.

Indicators of substance use severity and history have been shown in prior analyses to be related to choice of treatment modality and treatment outcomes [53], [54], [55] and to motivation for treatment [56]; in turn, they also may influence agency decisions about the appropriateness of pressure to enter treatment. Measures of substance abuse severity include two indicators of pretreatment MA-use severity: number of MA related problems (out of 11 types of possible problems: weight loss, paranoia, hallucinations, sleeplessness, violent behavior, skin, dental, high blood pressure, financial, legal, work) and frequency of use (percentage of days with MA use in 24 months prior to index treatment episode). A client's prior treatment history (total number oftreatment episodes for any substance preceding the index treatment), and prior coerced treatment (total number of coerced treatment episodes preceding the index episode) also are included.

Selected treatment characteristics of the index treatment episode also have been included since these may distinguish pressured treatment episodes and/or sources of pressure [49]. Length of treatment has consistently been shown to be related to treatment outcomes [51], [57], [58], [59]; we include number of months in treatment as an indicator. Other treatment-related variables include client age at admission and type of treatment (residential vs. outpatient) [52], [57].

Respondents (along with their index treatment episodes) were initially divided into two groups based on whether they reported any CJS/CPS pressure to enter the index treatment episode or reported no such pressure. These two groups were compared on background, treatment characteristics, and outcome measures using t-tests or chi-square as relevant to distributional characteristics. Pressured episodes were further divided by the source of pressure: drug court, other court, parole/probation, or CPS. These source-of-pressure subgroups were compared using ANOVA or chi-square as relevant to distributional characteristics.

The relationship of pressured treatment entry to treatment outcomes was addressed from a multivariate perspective (controlling for other client and treatment characteristics) using linear regression (for percentage of days of posttreatment MA use), logistic regression (for treatment completion and relapse within 6 months), and Cox proportional hazards models (time to relapse to MA use after the index treatment episode). A two-step modeling approach was used. Estimates were first calculated for models that included as predictors all background and treatment characteristics shown in Table 1. A second step estimated a reduced model for each outcome measure, including only those predictors significant at p <.10 in the (full model) first step. A similar process was used to assess the relationship of source of pressure to treatment outcomes (for pressured episodes only). (Reduced model results are shown in Tables 2 and 3.)

Table 1. Description of sample and comparison by existence of CJS/CPS pressure and by source of pressure

707 aComparisons across 2 groups (non pressured vs. pressured): chi-square for percents, t-tests for means. bComparisons across 4 types of pressure: chi-square for percents, ANOVA for means (note 1 subject reporting pressure did not answer question on source of pressure). cFor total sample of episodes, percents add to 100 across non pressured and pressured for all episodes, and also add to 100 for pressured episodes across 4 sources. (Note, because of rounding, percents may not total exactly 100.) dFor pressure groups and for episodes, percents add to 100 within each column for specified characteristic—e.g., "of nonpressured episodes, 60% are male and 40% are female" (totaling 100%). *p <.05. **p <.01.

Table 2. Multivariate models: relationship of legal pressure to selected treatment outcomes (n = 350 index episodes)

708 NA = "not applicable," not significant at p <.10 in full model thus not included in reduced model. aLogistic regression odds ratios (> 1 means greater likelihood of outcome). bCox regression hazard ratios (> 1 means greater risk of relapse, shorter time). cLinear regression coefficients (negative means less MA use). dLikelihood Ratio (df) for logistic regression and Cox reg.; F (df), R2 for reg. *p <.05. **p <.001.

Table 3. Multivariate models: relationship of type of legal pressure to selected treatment outcomes (n = 182 index episodes with reported pressure)

709 NA = "not applicable," not significant at p <.10 in full model thus not included in reduced model. aLogistic regression odds ratios (> 1 means greater likelihood of outcome). bCox regression hazard ratios (> 1 means greater risk of relapse, shorter time). cLinear regression coefficients (negative means less MA use). dLikelihood Ratio (df) for logistic regression and Cox reg.; F (df), R2 for reg. *p <.05. **p <.001.

Table 1 shows selected sample characteristics. The sample is 56% male, 44% female. The largest group is non-Hispanic White (47%), and 30% areHispanic. About one-fifth (19%) reported a history of schizophrenia or bipolar disorder. As would be expected, participants reported considerable MA use and related problems prior to the index treatment episode. They reported using MA on average 33% of days in the 24 months prior to treatment) and reported experiencing an average of 6.5 out of the 11 possible MA-related problems listed in the interview protocol. The sample also has considerable treatment history: 39% reported at least one substance use treatment episode prior to the index episode, and 22% reported a pressured treatment episode prior to the index episode. [Additional sample description and detail on MA-related behaviors appear in Brecht et al. [60].]

Average age at entry to the index treatment episode was 29 years. Sixty-two percent of index treatment episodes were residential. The average number of months in the index episode was 3.7.

Approximately one-half (54%) did not complete the index treatment episode. Percentage of days of MA use in the 24 months following the index treatment episode averaged 13% (approximately 94 days) across the sample. Notwithstanding an overall positive effect of treatment (e.g., decrease to average 13% of days in 24 months following treatment from an average of 33% of days in 24 months prior to treatment), approximately half (54%) had relapsed to MA use within 6 months of index treatment discharge. A total of 70% had relapsed by their follow-up interview (by an average of 4.2 months after leaving treatment for those who relapsed); the remaining 30% reportedcontinuing abstinence of averaging 33.9 months. Across all subjects (including those still abstinent at follow-up interview), the average length of abstinence was 13.3 months.

About one-half (52%) the respondents reported legal pressure to enter the index treatment episode (see Table 1, two columns under heading "Legal Pressure"). A slightly greater percentage of females (56%) report legal pressure for the index treatment compared to males (48%), but this difference was not significant. Similarly, ethnicity was not significantly related to legal pressure (p =.10), although Hispanics and non-Hispanic Whites were slightly more likely to report legal pressure than were African Americans and other/mixed ethnicity groups. Overall, those reporting pressure were significantly less likely to also report a history of major mental illness (12% vs. 20% for those not pressured) and were more likely to have entered prior treatment with legal pressure (30% vs. 14% for those not pressured). Pressured and nonpressured groups were not significantly different in terms of other personal background characteristics (p >.45).

Some significant differences are demonstrated between pressure groups in treatment-related characteristics. Clients reporting pressure were younger (average 28.5 years) at admission to the index treatment episode than were those not reporting pressure (30.3 years). Pressured episodes were less likely to be residential (44% vs. 76% of nonpressured). Respondents reporting pressure had longer stays in treatment (average 4.3 months compared to 3.1 months for nonpressured).

No statistically significant differences were seen on outcome measures between pressured and non-pressured treatment. However, a somewhat greater percentage of respondents relapsed within 6 months of pressured treatment (59% vs. 49% for nonpressured, p =.08).

The most common type of legal pressure reported was "other court" (37%) followed by probation/parole (30%), child protective services (28%), and drug court (4%). Source of pressure was significantly related to gender: Probation and Other Court sources were predominantly male (81% and 75%, respectively), while Child Protective Services was predominantly female (84%). Respondents reporting Drug Court or Other Court pressure also reported more frequent pretreatment MA use, 55% and 41% of pretreatment months, respectively, compared to 26% and 28% for Probation and CPS. Significant differences were not seen for other personal background characteristics.

Respondents reporting CPS pressure were least likely to have been in residential treatment (24% vs. 50% or more for CJS sources), likely due in part to lack of child care resources in many residential programs; and, typical of the predominant outpatient modality, those with CPS pressure had longer treatment durations (5.9 months vs. 3.5–4.1 months for CJS sources of pressure).

There were not significant differences among source groups on outcome measures. However, those reporting drug court pressure had the highest rates of completion, but also the highest rates of early relapse; these differences were not significant in part because of the small number of drug-court pressured cases in this study.

Table 2 shows the reduced-form multivariate models of the relationship of existence of reported pressure to treatment outcome variables, controlling for other selected characteristics. For three outcomes (treatment completion, posttreatment MA use, and time to relapse), there is no significant effect of CJS/CPS pressure, controlling for ethnicity, education, pretreatment MA use, type of treatment, number of months in treatment, and number of hours in treatment. However, the odds of relapse within six months are significantly (1.7 times) higher for those reporting legal pressure than those reporting no such pressure.

Among control variables, time in treatment is significantly related to all outcomes (longer treatment associated with better outcomes). Treatment completion is also related to type of treatment, with odds of completion 2.4 times greater for residential than for outpatient treatment. Lower posttreatment MA use is also related to being African American or other/mixed ethnicity (compared to non-Hispanic White), high school (or more) education, and lower pretreatment MA use. Note, however, that in spite of a significant model and predictors, the model accounted for only 10% of the variability in posttreatment MA use, suggesting that additional predictors should be considered in future work.

Considering only pressured episodes, source of pressure is not significant in predicting treatment outcomes, controlling for other selected characteristics (Table 3). Results for other predictors are, for the most part, similar to those described above.

Just over onehalf of the MA users interviewed for this study reported pressure by CJS or CPS sources to enter treatment. Pressure to enter treatment did notsignificantly differ by gender or ethnicity, but the source of pressure differed by gender, with women more likely to report CPS pressure and men more likely to report pressure through parole/probation. The pressured group was less likely to have had histories of major mental illness; this may suggest that those with psychiatric-drug use comorbidity may be routed by CJS and CPS to services other than publicly-funded drug treatment programs. Those reporting pressure were younger, suggesting that the agency pressure may bring MA users into treatment sooner than would occur without such pressure. They also were more likely to be in outpatient treatment and stay longer in treatment; this longer time in treatment is consistent with the typically longer program length for outpatient treatment than for residential and is similar to that found in studies of the broader California treatment system [49].

As has been shown in studies of coerced treatment for users of other drugs, moderate levels of positive outcomes are seen for MA users reporting pressure, for the most part similar to outcomes of those not reporting legal pressure [61]. For the sample overall, and for all coercion subgroups, the percentage of days of MA use is less after treatment than before—by more than one-half [see also Brecht et al. [54], and almost one-third of these MA users report continuing abstinence. While not significant, the direction of the relationship of reported legal pressure to treatment completion is positive, similar to results found by Joe et al. [19] and Berkowitz et al. [43]. Early relapse, however, appears to be a greater problem among those reporting legal pressure; but this difference in early outcomes evens out when frequency of MA use is considered over a longer 24-month period. The strongest predictor of all four treatment outcome measures, from among the variables used in this analysis, is number of months in treatment, with longer time in treatment associated with more positive outcomes. This is consistent with results for users of other substances [51], [57], [58], [59] and supports a need for longer rather than shorter treatment programs even when admission is pressured through CJS/CPS sources. Source of pressure was not significantly related to outcomes for MA users reporting legal pressure.

Such results offer optimism for individuals and socially-beneficial outcomes of the growing policy emphasis for substance abuse treatment of MA and other drug users through drug court and other CJS jurisdictions. An example of such pressure is the California Substance Abuse and Crime Prevention Act of 2000 (SACPA), which allows certain nonviolent adult offenders to receive drug treatment instead of prison. The first year of SACPA implementation showed that greater than half of SACPA clients were MA users [36]. Moreover, the prevalence of MA has been increasing among arrestees nationwide; for example, data from the Arrestee Drug Abuse Monitoring (ADAM) show an overall steady increase in percent of arrestees testing positive for MA; in year 2000, 9 of the 27 sites had 17–27% of the arrestee sample who tested positive for MA [62]. These localities mayespecially benefit from CJS/CPS linkages to substance abuse treatment for MA use.

However, results also suggest areas for continuing improvement of interventions. Rates of relapse within the first few months after treatment were higher for those reporting legal pressure (when other characteristics were controlled), supporting a need for continuing care to bridge this period of particular vulnerability. It may be that more programmatic efforts are needed to secure the cooperation and engagement of pressured clients in order to retain them beyond the threshold recommended for effective treatment.

This analysis relies on a self-report measure of perceived legal pressure by CJS or CPS sources. Further research considering both the level of perceived pressure and its relationship to the structure and process of actual agency pressure as well as type of alternative consequences for non-compliance may yield a deeper understanding of how pressure to enter treatment interacts with other influences on treatment outcomes [11], [26], [61], [63]. A direct measure of internal motivation for treatment was not available for in this study, but further study on this topic is recommended; study of its relationship to both external coercion and treatment outcomes is still needed for MA users. Although external coercion has been shown to be unrelated to internal motivation for users of substances other than MA [64], it also has been shown to be negatively related to therapeutic involvement, which in turn is predictive of selected treatment outcomes [19]. In addition, while models allowed focus on differences by existence and source of legal pressure, these models were not optimal in predicting outcomes; future work should examine additional predictors including, for example, a broader range of client characteristics, specific treatment services, aftercare participation, and alternative consequences and supervision of coercion. In the current article we have focused only on selected treatment outcomes including completion and posttreatment MA use. Further study is suggested on additional outcomes of treatment for MA use including crime, retention of children, and employment in order to more comprehensively reflect CJS and CPS agency objectives and the potential personal and social benefit thereby derived.

[25].

This research was supported by a grant from the National Institute on Drug Abuse (R01-DA11020). We thank L. Greenwell, Ph.D. and T.-H. Lu, Ph.D.for data preparation, C. von Mayrhauser, Ph.D. for project management, and P. Sheaff, L. Guzman, R. Lua, M. Frias, and L. Rodriguez for fieldwork.