Broad claims—positive or negative—about the effectiveness of substance abuse treatment are misleading. Research has produced mixed evidence, with some studies showing that certain types of treatment can achieve positive client outcomes, while others have little evidence of effectiveness.
The Department of Human Services has not provided enough oversight of county practices to ensure that clients are placed in appropriate treatment, nor has it done enough to foster the development of sufficient treatment options to effectively meet clients’ needs statewide.
Despite uniform placement criteria, there is wide variation in counties’ use of publicly-funded substance abuse treatment for low income persons, and the treatment clients receive depends partly on where they live.
Inmates who complete substance abuse treatment programs in prison have lower overall arrest and conviction rates following release than (1) inmates who complete short education programs, and (2) untreated inmates. However, Minnesota prisons do not have enough capacity in their substance abuse treatment programs to serve all of the inmates who need treatment.
The Department of Human Services should (1) strengthen its oversight of local assessment and referral practices; (2) develop strategies to increase the availability of effective treatment options; (3) improve placement decisions by providing counties with more information on treatment program outcomes and quality; and (4) assess options for improving the equity of state laws governing county obligations to pay for treatment costs.
State policy supports the use of treatment for individuals with substance abuse problems. For example, state law says that “the interests of society are best served by providing persons who are dependent upon alcohol or drugs with a comprehensive range of rehabilitative and social services.” 1
State policy supports the use of substance abuse treatment, although evidence about treatment outcomes is limited.
There were nearly 42,000 admissions of Minnesota residents to substance abuse treatment in 2004, and 55 percent were publicly-funded. The main source of public funding was the Consolidated Chemical Dependency Treatment Fund. State appropriations for this fund have increased in recent years (reaching $63 million in fiscal year 2006), but the 2003 Legislature discontinued funding for persons with household incomes above the federal poverty line.
Broad claims that treatment is effective or ineffective are misleading. There are many forms of substance abuse treatment, of various lengths and intensities, provided to persons with different needs, and implemented with various degrees of skill. National research has produced a mix of positive and negative findings regarding the effectiveness of substance abuse treatment. A limited number of studies have isolated the impact of treatment on clients, apart from other variables.Studies have demonstrated the potential for certain counseling-based programs to reduce clients’ chemical use and improve their social functioning, based on comparisons to persons who did not undergo treatment or persons in other types of programs. Also, there have been favorable outcomes for some other approaches, such as maintaining heroin addicts on methadone for a period of time and having primary care professionals conduct brief interventions with problem drinkers. But there is still much to learn about which treatments work best in various circumstances. There are also certain subgroups of clients, such as adolescents and methamphetamine users, for whom there has been a limited amount of rigorous research. The Department of Human Services should develop an inventory of the approaches used in Minnesota’s treatment programs so that it can ensure that there are appropriate, effective placement options for clients throughout the state.
In general, research has shown that persons who complete their treatment programs or remain in programs for longer periods tend to have better outcomes. In Minnesota, 60 percent of persons who entered publicly-funded treatment in 2004 “completed” their programs, while 31 percent left “without staff approval.” The National Institute on Drug Abuse has suggested that treatment should generally last for at least 90 days, and there is a growing consensus that many chemically dependent persons need extended periods of services, even if some are provided at low levels of intensity. However, the duration of many treatment episodes in Minnesota is shorter than 90 days, and the average length of treatment has been declining.
State regulations have various provisions that are intended to ensure that clients receive individualized treatment, but many local corrections and human services officials told us that programs need to be more effectively tailored to meet individual clients’ needs. For example, 96 percent of the directors of community-based corrections agencies favored stronger emphasis by substance abuse treatment programs on addressing clients’ mental health needs.
Legislators have expressed some concern about repeated placements of clients into community-based treatment. We found that, among persons over age 30 who were discharged from publicly-funded treatment in 2004, 37 percent had no prior episodes of treatment in Minnesota since 1995 and 22 percent had only one episode, while 20 percent had at least four prior episodes. Thus, some clients experience frequent readmissions, but this is not the norm.Existing data do not conclusively show whether Minnesota’s treatment programs are effective. However, the Department of Human Services should provide counties and tribes with better information to help them judge program outcomes and quality, including information on programs’ client completion rates, client readmission rates, compliance with state regulations, and peer reviews.
Public funding pays for the substance abuse treatment of persons who meet state-prescribed financial and clinical eligibility criteria. Despite uniform criteria, there are wide variations in the counties’ use of publicly-funded treatment for low income persons, and the treatment clients receive depends partly on where they live. For example, the average number of adult admissions in 2003-04 to publicly-funded treatment per 1,000 adult residents in poverty ranged from 22 in Kittson County to 168 in Mahnomen County. The range among counties in the Twin Cities area was from 53 in Dakota County to 129 in Anoka County. In addition, some counties made most of their placements to outpatient treatment, while other counties relied much more on other types of care.
Counties are the “gatekeepers” of Minnesota’s publicly-funded chemical health program, and the Department of Human Services should more closely monitor their assessment and referral practices.
To some extent, these differences reflect variations in assessment practices. Counties and American Indian tribes are “gatekeepers” in Minnesota’s chemical health system, assessing residents and making referrals to publicly-funded treatment. Some counties are much more likely than others to find the clients they assess to be chemically “dependent” (rather than the less serious diagnosis of chemically “abusive”), and the types of programs to which clients can be referred depends partly on this determination. Also, local agencies use a variety of assessment instruments, which differ in how thoroughly they document clients’ underlying problems.
The Minnesota Department of Human Services is required by law to monitor “the conduct of [substance abuse] diagnosis and referral services,” but it has not done in-depth reviews of local practices for several years. The department should (1) provide local agencies with information on “best practices” in substance abuse assessment, including model protocols for assessment of adults and adolescents, and (2) initiate ongoing compliance monitoring of local assessment and referral practices.Variations in treatment referrals also reflect the uneven availability of treatment programs around the state, and the department should develop a strategy for addressing gaps in treatment services. About 51 percent of publicly-funded admissions to treatment in 2004 were at programs outside of the client’s home county. Local corrections and human services officials expressed concerns about the availability of treatment in halfway house and “extended care” settings, as well as treatment and related services for adolescents, persons with dual diagnoses of mental illness and chemical dependency, persons with cognitive limitations, and methamphetamine users.
In addition, local corrections officials told us that criminal offenders’ financial eligibility for publicly-funded, community-based treatment has affected whether these offenders enroll in treatment. Ineligibility for public funding could be one reason why nearly half of the offenders sentenced to probation in 2003 for felony-level substance use or possession did not enter community-based treatment prior to sentencing or during the period immediately following their sentencing date or release from jail.
Persons imprisoned for drug-related offenses now comprise 25 percent of Minnesota’s prison population, up from 9 percent in 1990. In addition, a high percentage of other types of offenders in Minnesota’s prisons have histories of substance abuse. All but two of Minnesota’s prisons have programs for inmates with substance-related problems. Some are treatment programs, lasting 6 to 12 months and providing a variety of group and individual counseling, while others are substance abuse education programs, lasting three months or less and offering no individual counseling.Among chemically dependent inmates released from prison in early 2004, only 25 percent participated in substance abuse treatment prior to release (17 percent completed a program and another 9 percent started a program but did not complete it). Another 30 percent participated only in short-term education programs prior to release. Many inmates do not serve enough time in prison to complete a treatment program, but there is also a shortage of treatment beds to meet the needs of inmates with substance use problems.
Among chemically dependent inmates released from prison in 2002, a majority had arrests or convictions for new offenses within three years (including 36 percent with arrests or convictions for drug or alcohol crimes). Prisoners who completed the Challenge Incarceration Program (a boot camp with a chemical dependency treatment component) and other prison-based treatment programs generally had lower post-release recidivism rates than those who failed treatment or completed short-term education programs. It is unclear whether the lower recidivism rates for treatment completers were attributable to treatment rather than other factors, such as the offenders’ motivation to change.
Most chemically dependent inmates do not complete treatment in prison or when they are released.When inmates near their dates of release from prison to correctional supervision in the community, the Department of Corrections and supervising agency develop plans for helping the offenders succeed in the community. But prison “release plans” have contained little direction regarding post-release chemical use assessments and programming. In addition, less than 10 percent of chemically dependent inmates released from prison to community supervision in 2004 entered community-based treatment in the six months following their release. The Department of Corrections should develop a strategy for improving the availability of treatment in prisons and ensuring that chemically dependent offenders receive the treatment they need following release.
Summary of Agency Response
In a letter dated February 7, 2006, Commissioner of Human Services Kevin Goodno said that his department “supports the key recommendations of the report.” He said that some variation in counties’ use of publicly-funded treatment may reflect underlying variation in the extent of substance abuse, but he agreed that his department should strengthen its oversight of county practices. The Commissioner also said that his agency should provide counties with more data on treatment outcomes, but—contrary to a recommendation in the report—he questioned whether treatment program peer reviews should be made available to counties.
In a letter dated February 8, 2006, Commissioner of Corrections Joan Fabian said that the report contains “a good summary of the current challenges and important recommendations for reform.” She said that her department is working on ways to improve offender assessment and treatment. She said: “With greater collaboration among agencies, and improved access to the Consolidated Treatment Fund, we believe that better outcomes are within reach.”
1 Minnesota Statutes 2005, 254A.01.
The Program Evaluation Division was directed to conduct this study by the Legislative Audit Commission in April 2005. For a copy of the full report, entitled "Substance Abuse Treatment," 117 pp., published in February 2006, please call 651/296-4708, e-mail Legislative.Auditor@state.mn.us, write to Office of the Legislative Auditor, Room 140, 658 Cedar St., St. Paul, MN 55155, or go to the webpage featuring the report. Staff who worked on this project were Joel Alter (project manager), Valerie Bombach, and Kelly Lehr.