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xSUBSTANCE ABUSE TREATMENTReport SummaryState policysupports the useof substanceabuse treatment,although evidenceabout treatmentoutcomes islimited.State policy supports the use oftreatment for individuals withsubstance abuse problems. Forexample, state law says that “theinterests of society are best served byproviding persons who are dependentupon alcohol or drugs with acomprehensive range of rehabilitativeand social services.”1There were nearly 42,000 admissionsof Minnesota residents to substanceabuse treatment in 2004, and 55 percentwere publicly-funded. The main sourceof public funding was the ConsolidatedChemical Dependency Treatment Fund.State appropriations for this fund haveincreased in recent years (reaching 63million in fiscal year 2006), but the2003 Legislature discontinued fundingfor persons with household incomesabove the federal poverty line.Effectiveness Studies Show MixedResults, And Information OnMinnesota’s Community ProgramsIs LimitedBroad claims that treatment is effectiveor ineffective are misleading. There aremany forms of substance abusetreatment, of various lengths andintensities, provided to persons withdifferent needs, and implemented withvarious degrees of skill. Nationalresearch has produced a mix of positiveand negative findings regarding theeffectiveness of substance abusetreatment. A limited number of studieshave isolated the impact of treatmenton clients, apart from other variables.Studies have demonstrated the potentialfor certain counseling-based programsto reduce clients’ chemical use andimprove their social functioning, basedon comparisons to persons who did notundergo treatment or persons in othertypes of programs. Also, there havebeen favorable outcomes for some1Minnesota Statutes 2005, 254A.01.other approaches, such as maintainingheroin addicts on methadone for aperiod of time and having primary careprofessionals conduct briefinterventions with problem drinkers.But there is still much to learn aboutwhich treatments work best in variouscircumstances. There are also certainsubgroups of clients, such asadolescents and methamphetamineusers, for whom there has been alimited amount of rigorous research.The Department of Human Servicesshould develop an inventory of theapproaches used in Minnesota’streatment programs so that it can ensurethat there are appropriate, effectiveplacement options for clientsthroughout the state.In general, research has shown thatpersons who complete their treatmentprograms or remain in programs forlonger periods tend to have betteroutcomes. In Minnesota, 60 percent ofpersons who entered publicly-fundedtreatment in 2004 “completed” theirprograms, while 31 percent left“without staff approval.” The NationalInstitute on Drug Abuse has suggestedthat treatment should generally last forat least 90 days, and there is a growingconsensus that many chemicallydependent persons need extendedperiods of services, even if some areprovided at low levels of intensity.However, the duration of manytreatment episodes in Minnesota isshorter than 90 days, and the averagelength of treatment has been declining.State regulations have variousprovisions that are intended to ensurethat clients receive individualizedtreatment, but many local correctionsand human services officials told usthat programs need to be moreeffectively tailored to meet individualclients’ needs. For example, 96 percentof the directors of community-basedcorrections agencies favored strongeremphasis by substance abuse treatmentprograms on addressing clients’ mentalhealth needs.

SUMMARYCounties are the“gatekeepers” ofMinnesota’spublicly-fundedchemical healthprogram, and theDepartment ofHuman Servicesshould moreclosely monitortheir assessmentand referralpractices.xiLegislators have expressed someconcern about repeated placements ofclients into community-basedtreatment. We found that, amongpersons over age 30 who weredischarged from publicly-fundedtreatment in 2004, 37 percent had noprior episodes of treatment inMinnesota since 1995 and 22 percenthad only one episode, while 20 percenthad at least four prior episodes. Thus,some clients experience frequentreadmissions, but this is not the norm.Existing data do not conclusively showwhether Minnesota’s treatmentprograms are effective. However, theDepartment of Human Services shouldprovide counties and tribes with betterinformation to help them judgeprogram outcomes and quality,including information on programs’client completion rates, clientreadmission rates, compliance withstate regulations, and peer reviews.Use Of Community-BasedTreatment Reflects SignificantVariation In Program AvailabilityAnd Local Referral PracticesPublic funding pays for the substanceabuse treatment of persons who meetstate-prescribed financial and clinicaleligibility criteria. Despite uniformcriteria, there are wide variations in thecounties’ use of publicly-fundedtreatment for low income persons, andthe treatment clients receive dependspartly on where they live. For example,the average number of adult admissionsin 2003-04 to publicly-fundedtreatment per 1,000 adult residents inpoverty ranged from 22 in KittsonCounty to 168 in Mahnomen County.The range among counties in the TwinCities area was from 53 in DakotaCounty to 129 in Anoka County. Inaddition, some counties made most oftheir placements to outpatienttreatment, while other counties reliedmuch more on other types of care.To some extent, these differencesreflect variations in assessmentpractices. Counties and AmericanIndian tribes are “gatekeepers” inMinnesota’s chemical health system,assessing residents and makingreferrals to publicly-funded treatment.Some counties are much more likelythan others to find the clients theyassess to be chemically “dependent”(rather than the less serious diagnosisof chemically “abusive”), and the typesof programs to which clients can bereferred depends partly on thisdetermination. Also, local agencies usea variety of assessment instruments,which differ in how thoroughly theydocument clients’ underlying problems.The Minnesota Department of HumanServices is required by law to monitor“the conduct of [substance abuse]diagnosis and referral services,” but ithas not done in-depth reviews of localpractices for several years. Thedepartment should (1) provide localagencies with information on “bestpractices” in substance abuseassessment, including model protocolsfor assessment of adults andadolescents, and (2) initiate ongoingcompliance monitoring of localassessment and referral practices.Variations in treatment referrals alsoreflect the uneven availability oftreatment programs around the state,and the department should develop astrategy for addressing gaps intreatment services. About 51 percent ofpublicly-funded admissions totreatment in 2004 were at programsoutside of the client’s home county.Local corrections and human servicesofficials expressed concerns about theavailability of treatment in halfwayhouse and “extended care” settings, aswell as treatment and related servicesfor adolescents, persons with dualdiagnoses of mental illness andchemical dependency, persons withcognitive limitations, andmethamphetamine users.In addition, local corrections officialstold us that criminal offenders’

xiiSUBSTANCE ABUSE TREATMENTfinancial eligibility for publicly-funded,community-based treatment hasaffected whether these offenders enrollin treatment. Ineligibility for publicfunding could be one reason whynearly half of the offenders sentencedto probation in 2003 for felony-levelsubstance use or possession did notenter community-based treatment priorto sentencing or during the periodimmediately following their sentencingdate or release from jail.Prisons Need More TreatmentBeds And Better Planning ForServices Following ReleaseMost chemicallydependentinmates do notcompletetreatment inprison or whenthey are released.Persons imprisoned for drug-relatedoffenses now comprise 25 percent ofMinnesota’s prison population, up from9 percent in 1990. In addition, a highpercentage of other types of offendersin Minnesota’s prisons have histories ofsubstance abuse. All but two ofMinnesota’s prisons have programs forinmates with substance-relatedproblems. Some are treatmentprograms, lasting 6 to 12 months andproviding a variety of group andindividual counseling, while others aresubstance abuse education programs,lasting three months or less andoffering no individual counseling.Among chemically dependent inmatesreleased from prison in early 2004, only25 percent participated in substanceabuse treatment prior to release (17percent completed a program andanother 9 percent started a program butdid not complete it). Another 30percent participated only in short-termeducation programs prior to release.Many inmates do not serve enoughtime in prison to complete a treatmentprogram, but there is also a shortage oftreatment beds to meet the needs ofinmates with substance use problems.Among chemically dependent inmatesreleased from prison in 2002, amajority had arrests or convictions fornew offenses within three years(including 36 percent with arrests orconvictions for drug or alcohol crimes).Prisoners who completed the ChallengeIncarceration Program (a boot campwith a chemical dependency treatmentcomponent) and other prison-basedtreatment programs generally had lowerpost-release recidivism rates than thosewho failed treatment or completedshort-term education programs. It isunclear whether the lower recidivismrates for treatment completers wereattributable to treatment rather thanother factors, such as the offenders’motivation to change.When inmates near their dates ofrelease from prison to correctionalsupervision in the community, theDepartment of Corrections andsupervising agency develop plans forhelping the offenders succeed in thecommunity. But prison “release plans”have contained little direction regardingpost-release chemical use assessmentsand programming. In addition, lessthan 10 percent of chemicallydependent inmates released from prisonto community supervision in 2004entered community-based treatment inthe six months following their release.The Department of Corrections shoulddevelop a strategy for improving theavailability of treatment in prisons andensuring that chemically dependentoffenders receive the treatment theyneed following release.

IntroductionAbuse of alcohol and other drugs has widespread impacts. It often leads toreduced personal productivity, harmful health effects, and damaged personalrelationships. In addition, substance abuse can have broader social impacts,contributing to child abuse, welfare dependence, and criminal activity. Thus,interventions that reduce substance abuse may serve important public purposes.Accordingly, Minnesota law declares that it is the state’s policy to providechemically dependent people with rehabilitative services.1But policy makers have asked many questions about substance abuse treatment inrecent years. In April 2005, the Legislative Audit Commission directed ouroffice to evaluate substance abuse treatment in Minnesota communities and stateprisons. Our evaluation addressed the following questions: Are substance abuse treatment programs effective? Is there adequate treatment for chemically dependent criminaloffenders sentenced to prison and probation? To what extent do counties vary in how they assess and referindividuals to community-based substance abuse treatment, andshould policy makers be concerned about these variations? Do public agencies use reasonable methods to determine individuals’needs for substance abuse treatment?We used existing data from the departments of Human Services, Corrections, andPublic Safety to assess outcomes for persons who entered treatment programs.For example, we examined the extent to which chemically dependent inmateswho participated in prison-based treatment programs were arrested and convictedof new crimes following release from prison. For community-based treatment,we examined measures such as program completion rates and rates ofreadmission to treatment following treatment discharge. We recognize thatfactors other than treatment may have contributed to the outcomes we observed,so we also examined findings from previous studies of substance abusetreatment.2We looked at treatment use and availability in Minnesota, including variationamong counties. Local human services agencies play a key role in treatment12Minnesota Statutes 2004, 254A.01.We did not conduct “experimental” research, in which persons are randomly assigned to variousprograms or to no treatment at all. Such studies provide more definitive evidence of treatment’simpacts.

2SUBSTANCE ABUSE TREATMENTplacement decisions, and we conducted site visits to eight counties and contactedsome others by phone.3 Publicly-funded treatment for low-income personsaccounts for more than half of Minnesota’s substance abuse treatmentadmissions, so we gave particular attention to its use. We looked at variationamong counties in the share of treatment costs they bear, but we did not conductan in-depth evaluation of the formula used to allocate state treatment funds tocounties.Because of the close association between substance use and crime, we alsolooked at treatment availability and use among Minnesota’s criminal offenders.Specifically, we examined the extent to which chemically dependent offendersenrolled in treatment programs in prison, after prison, and during probation.Community-based corrections agencies supervise many offenders with substanceabuse problems, so we conducted a statewide survey of the directors of theseagencies to better understand their perceptions about treatment availability andadequacy.4Chapter 1 provides background information on substance abuse treatmentservices in Minnesota communities and prisons. Chapter 2 reviews previousresearch on treatment effectiveness. The next two chapters examine communitybased treatment in Minnesota, including client placements (Chapter 3) andcertain treatment outcomes (Chapter 4). The final two chapters examine prisonbased treatment, including availability (Chapter 5) and rates of post-prisonrecidivism and relapse (Chapter 6).Finally, we often use the terms “substance abuse” and “chemical dependency”interchangeably in this report. Chapter 1 notes the diagnostic distinctionsbetween “abuse” and “dependency,” and Chapter 3 examines differences amongcounties in their diagnoses, but elsewhere in the report we do not differentiatebetween “substances” and “chemicals” or between “abuse” and “dependency.”3We did not review individual clients’ case files during our site visits, such as assessment reportsor treatment plans.4To provide probation services, each Minnesota county (1) participates in the state’s CommunityCorrections Act (CCA) and receives state funds for this purpose, (2) receives “county probationofficer” (CPO) funding from the state, or (3) obtains services from the Minnesota Department ofCorrections (DOC). We surveyed and received responses from all of the 54 directors of CCAagencies, CPO agencies, and DOC’s district offices and supervised release offices.

1BackgroundSUMMARYMinnesota law supports treatment and other rehabilitative services forpeople with substance abuse problems. The state has provided significantfunding for community-based treatment for low income persons, as well asfunding for substance abuse programs in most of the state-operatedprisons. Current state rules that define chemical “dependency” do notreflect diagnostic criteria commonly used by mental health professionals,although changes to the outdated definition are scheduled forimplementation in 2007. Alcohol remains the predominant substanceabused by people entering treatment in Minnesota, but the number ofpeople entering treatment for methamphetamine use grew dramaticallyduring the past decade.Avariety of factors contribute to chemical dependency, including socialinfluences, genetic predispositions, the nature and availability of thesubstances abused, and underlying psychological disorders.1 Substance abuseinvolves voluntary behaviors, at least initially, but it may also evolve intocompulsions and loss of control. Substance abuse treatment takes many forms,and relapses are common. This chapter provides background information onsubstance abuse treatment, and it addresses the following questions: How are substance “abuse” and “dependency” defined? What types of treatment programs are offered in community-basedand prison-based settings? What roles do Minnesota’s state and local governments play inoverseeing substance abuse treatment programs, paying fortreatment, and helping individuals access treatment services? What are the primary substances abused by persons enteringtreatment, and how has this changed in recent years?KEY TERMSSubstance “Abuse” and “Dependency”Definitions of chemical “abuse” and “dependency” are important becauseMinnesota’s administrative rules prescribe the types of publicly-funded treatmentfor which persons are eligible, based partly on whether the person is determined1George E. Vaillant, “Natural History of Addiction and Pathways to Recovery,” in Principles ofAddiction Medicine, 2nd ed., ed. Allan W. Graham and Terry K. Schultz (Chevy Chase, MD:American Society of Addiction Medicine, 1998), 295-308.

4SUBSTANCE ABUSE TREATMENTto be chemically dependent rather than chemically abusive.2 As shown in Table1.1, the rules define chemical abuse as less severe than chemical dependency.3We found that: Minnesota’s criteria for determining who is “chemically dependent”are not consistent with current professional criteria for diagnosingmental health disorders.The Minnesota rules that define “abuse” and “dependency” are based on the 1980edition of the American Psychiatric Association’s Diagnostic StatisticalManual.4 The rules require that dependency be based, in part, on evidence ofTable 1.1: Definitions of Chemical Abuse andDependency in Minnesota RulesStateadministrativerules definesubstance“abuse” and“dependency.”Chemical abuse is a pattern of inappropriate and harmful chemical use which exceedssocial or legal standards of acceptability, the outcome of which is characterized by threeor more of the following indicators: Weekly use to intoxication.Inability to function in a social setting without becoming intoxicated.Driving after consuming sufficient chemicals to be considered legally impaired,whether or not an arrest takes place.Excessive spending on chemicals that result in an inability to meet financialobligations.Loss of friends due to behavior while intoxicated.Chemical use that prohibits one from meeting work, school, family, or socialobligations.Continued use of chemicals by a woman after she has been informed that she ispregnant and that continued use may harm her unborn child.Chemical dependency is a pattern of pathological use accompanied by the physicalmanifestations of increased tolerance to the chemical or chemicals being used orwithdrawal syndrome following cessation of chemical use. “Pathological use” means thecompulsive use of a chemical characterized by three or more of the following indicators: Daily use required for adequate functioning.An inability to abstain from use.Repeated efforts to control or reduce excessive use.Binge use, such as remaining intoxicated throughout the day for at least two daysat a time.Amnesic periods for events occurring while intoxicated.Continuing use despite a serious physical disorder that the individual knows isexacerbated by continued use.Continued use of chemicals by a woman after she has been informed that she ispregnant and

3.5 Examples of Differences in Counties' Substance Abuse Assessment Instruments 47 3.6 Assessment Results of Clients Authorized for Publicly-Funded Treatment, Select Counties, 2003-04 49 3.7 Client "Dimensions" that Substance Abuse Treatment Providers Must Assess 50 3.8 Licensed Substance Abuse Treatment Programs, 2000-05 54