Substance Abuse Treatment in Correctional versus Non-Correctional Settings: Analysis of Racial/Ethnic and Gender Differences

1 Substance Abuse Treatment in Correctional versus Non-Correctional Settings Pro et al. Journal of Health Disparities Research and Practice Volume 12, Issue 3, Fall 2019, pp. 1-20 © 2011 Center for Health Disparities Research School of Community Health Sciences University of Nevada, Las Vegas Substance Abuse Treatment in Correctional versus NonCorrectional Settings: Analysis of Racial/Ethnic and Gender Differences George Pro, Northern Arizona University Ricky Camplain, Northern Arizona University Samantha Sabo, Northern Arizona University Julie Baldwin, Northern Arizona University Paul A. Gilbert, University of Iowa Corresponding Author: George Pro, ABSTRACT Background: Alcohol and drug abuse are widespread in the US. Substance abuse treatment services are effective, but utilization of services is low, particularly among African Americans, Hispanics, and women. Substance abuse is strongly associated with incarceration, and African Americans and Hispanics make up a disproportionate percentage of individuals with substance abuse problems involved in the criminal justice system. High treatment need, low treatment uptake, and the association between substance abuse and incarceration have led, in part, to correctional institutions filling the treatment gap by increasingly providing safety-net treatment services. We sought to better understand racial/ethnic and gender differences in determinants of treatment location (jail or prison versus non-correctional settings) among treatment-seeking adults. Methods: We used repeated cross-sectional data from the National Survey on Drug Use and Health (2002-2016) to identify White, African American, and Hispanic past-year substance abuse treatment participants (n=6,435). We tested the modifying roles of race/ethnicity and gender on the association between several exposure variables and treatment locus using multiple logistic regression. Results: Ten percent of treatment participants utilized treatment services in a jail or prison, which varied by race/ethnicity (9% of Whites, 15% of African Americans, 12% of Hispanics) and by gender (11% of men, 9% of women). In our fitted models, we found that educational attainment and past-year employment status varied in effect size between African Americans and Whites. The associations for both variables were strongest among African Americans (Any college vs. Less than high school – adjusted Odds Ratio [aOR] = 0.23, 95% Confidence Interval [95% CI] = 0.08, 0.70; Ever unemployed vs. Never unemployed in the past year – aOR = 5.32, 95% CI = 1.94, 14.60). Health insurance status was significantly associated with treatment in a jail or prison only Journal of Health Disparities Research and Practice Volume 12, Issue 3, Fall 2019 http://digitalscholarship.unlv.edu/jhdrp/ Follow on Facebook: Health.Disparities.Journal Follow on Twitter: @jhdrp 2 Substance Abuse Treatment in Correctional versus Non-Correctional Settings Pro et al. among Whites (Private vs. No insurance – aOR = 0.37, 95% CI = 0.19, 0.69). Co-occurring mental health diagnosis was significant only among African Americans (Any mental health diagnosis vs. none – aOR = 3.91, 95% CI = 1.38, 11.09). Employment and health insurance status were significant only among men (aOR = 2.18, 95% CI = 1.26, 3.77; aOR = 0.39, 95% CI = 0.22, 0.70, respectively). Conclusion: We identified modifying roles for race/ethnicity and gender in the relationship between several factors and treatment utilization in a jail or prison versus non-correctional treatment settings. More numerous factors and stronger effect sizes were identified among African Americans and men in particular. Health promotion interventions promoting the uptake of substance abuse treatment should tailor services to align with the needs of those with the highest risk for incarceration. Keywords: disparities Substance abuse, treatment services utilization, criminal justice, health INTRODUCTION Alcohol and illicit drug use are responsible for considerable physical, social, and public health burdens (Grant et al., 2015; Grant et al., 2016; Sacks, Gonzales, Bouchery, Tomedi, & Brewer, 2015). Treatment for substance use disorders (SUDs) is effective, but treatment utilization is low; only 10-20% of adults with alcohol or drug problems receive any treatment (Alvanzo et al., 2014; Mojtabai, 2005). In general, a higher likelihood of entering treatment is associated with older age, male gender, lower levels of education, and the co-occurring use of alcohol and illicit drugs (Cohen, Feinn, Arias, & Kranzler, 2007). Furthermore, underrepresented racial/ethnic groups (particularly African Americans) who initiate treatment often have characteristics which are associated with poor treatment outcomes, including lower income, less education, and a family history of substance use (Le Fauve, Lowman, Litten, & Mattson, 2003). Treatment utilization varies between races/ethnicities, such that some racial/ethnic groups with alcohol or drug problems are significantly less likely than Whites to receive treatment (Alvanzo et al., 2014; Mojtabai, 2005; Perron et al., 2009; Wells, Klap, Koike, & Sherbourne, 2001). Treatment service utilization also differs by gender. In general, women are less likely to utilize substance abuse treatment services compared to men (Green, 2006). When women do enter treatment, their substance abuse diagnoses tend to be more severe than their male counterparts (Green, Polen, Dickinson, Lynch, & Bennett, 2002). In addition, racial/ethnic disparities in alcohol treatment service utilization are much stronger among women than among men (Zemore, 2014). Despite marked differences in treatment utilization between racial/ethnic and gender groups, treatment service utilization remains low across all groups. Correctional health services are slowly filling the treatment-need gap by providing health and substance abuse safety net services (Huh, Boucher, McGaffey, McKillop, & Schiff, 2018). Compared to their civilian counterparts, individuals entering jail or prison have poorer health (Binswanger, Krueger, & Steiner, 2009; Massoglia, 2008b), demonstrate a higher prevalence of SUDs (Condon, Gill, & Harris, 2007; Feucht & Gproerer, 2011), and come from poorer and more disadvantaged backgrounds (Rabuy & Kopf, 2015). Racial/ethnic groups with SUDs are less likely than their White counterparts to be offered alternatives to incarceration such as drug and alcohol courts (O'Hear, 2009). This imbalance may contribute, in part, to the overrepresentation of African Journal of Health Disparities Research and Practice Volume 12, Issue 3, Fall 2019 http://digitalscholarship.unlv.edu/jhdrp/ Follow on Facebook: Health.Disparities.Journal Follow on Twitter: @jhdrp 3 Substance Abuse Treatment in Correctional versus Non-Correctional Settings Pro et al. Americans and Hispanics being sentenced to jails and prisons (Carson & Anderson, 2016; Dumont, Allen, Brockmann, Alexander, & Rich, 2013; Nellis, 2016; Western & Petti (...truncated)